Page content transcription
If your browser does not render page correctly, please read the page content below
La domanda nasce spontanea….
L’ospedale invecchiaIl 23.5% degli accessi in PS ha più di 75 anni Il 51% dei ricoverati ha più di 75 anni Il 23% dei ricoverati ha più di 85 anni
for many older people the ED is themain portal of entry to urgent care. Clinical Medicine 2017 vol 18 n4 350-3
Emerging data from the Nuffield Trust indicate about20% of all those aged 75+ account for 85% of beddays and 85% of readmission or deaths within 90 daysof an urgent care episode. Clinical Medicine 2017 vol 18 n4 350-3
Siamo inadeguati
Hospitals are very bad places for old, frail peopleSir David Nicholson, Chief Executive NH Commissioning Board BMJ 2013;346:f453
During hospitalization, patients are commonly deprived ofsleep, experience disruption of normal circadianrhythms, are nourished poorly, have pain anddiscomfort, confront a baffling array of mentallychallenging situations, receive medications that canalter cognition and physical function, and becomedeconditioned by bed rest or inactivity.Krumholz HM, NEJM 2013 368(2):100-102
Post-Hospital Syndrome — An Acquired,Transient Condition of Generalized Risk N Engl J Med 2009;360:1418-28.
EMERGENCY DEPARTMENT M Bo, J Am Ger Soc 2016 May 1114-1119
Finally, we need to reject the bogus distinctionbetween the medical-diagnostic model andessential nursing care. Oliver D. Clinical Medicine 2012, 12; 3: 230–34
Assessment medical psychological functional ability social circ*mstances environment
Prompt recognition and diagnosis Elderly or frail patients, especially those with risk factors, should be systematically evaluated for the presence of signs or symptoms of delirium on their arrival at the hospital. Linee di Indirizzo Intersocietarie 2017AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
Sincope cardiogena (bradicardia, BAV 1, BBdx, EAS)Cardiopatia ischemico-ipertensiva con PM bicameraleInfrazione VIII e IX costa con versamento pleurico (poche settimane prima)Encefalopatia mista vascolare degenerativa, demenza, parkinsonismoDM II, panvasculopatia, dislipidemia, IRC lieveAnemia macrocitica, MGUSBPCO, OSAS Terapia cronica: Levodopa/carbidopa, amlodipina, ramipril, bisoprololo, trazodone, asa
Paziente fragile vs paziente robusto Inouye S.K., Charpentier P.A. JAMA 1996; 275: 825-57
Acute Brain Dysfunction
Health care providers who treat patients at high risk fordelirium should know and use screening tools such as 4AT scale. Linee di Indirizzo Intersocietarie 2017 AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
1] VIGILANZA 2] AMT4Sopore/agitazione-iperattività durante test. Osservare il paziente. Se dorme, provare a risvegliarlo, Età, data di nascita, luogo (nome dell’ospedale e richiamandolo, o con un leggero tocco sulla spalla. dell’edificio), anno corrente Chiedere al paziente di ripetere il proprio nome e l’indirizzo della propria abitazione. 4AT 3] ATTENZIONE 4] CAMBIAMENTO ACUTO/FLUTTUAZIONI Chiedere al paziente: “per favore, mi dica i mesi dell’anno in ordine contrario, partendo da dicembre” Per aiutare la comprensione della Dimostrazione di un evidente cambiamento o di un domanda, è consentito inizialmente questo decorso fluttuante relativamente suggerimento: “qual è il mese prima di dicembre? all’attenzione, alla comprensione o altre funzioni cognitive-comportamentali (ad esempio ossessioni e/o allucinazioni) con esordio nelle ultime 2 settimane e ancora presenti nelle ultime 24 ore. Bellelli G et al, Age Ageing 2014
RISULTATI PS Udine• 201 PAZIENTI• ETÀ MEDIA 85,3 ± 5,59, MEDIANA 85• 122 Donne, 79 Maschi• 172 DA DOMICILIO, 29 DA STRUTTURA RESIDENZIALE• SCORE ≥ 4: 83 PAZIENTI (41,3%) SCORE 1-2-3: 49 PAZIENTI (24,4%) SCORE 0: 69 PAZIENTI (34,3%)• 37% DELIRIUM IPOCINETICO 22% DELIRIUM IPERCINETICO 23% MISTO
At the first signs or symptoms of delirium, it is necessary tosearch for possible causes (infection, hypoglycaemia, stroke,dehydration, adverse effects of medications, use of psychotropicsubstances, withdrawal syndromes, pain inadequately treated, acuteretention of urine, and constipation). The diagnosis of delirium mayhighlight sepsis that would otherwise be missed. Linee di Indirizzo Intersocietarie 2017 AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
Il trattamento Drug treatment of delirium should be used only when the patient is a danger to himself or when symptoms are particularly important and/or threaten the ability to undertake essential therapies Linee di Indirizzo Intersocietarie 2017AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
Use the term ‘‘delirium’’ in a systematic way. The use ofgeneric and non-specific terms should be avoided to favourdissemination and to prevent argument trivialization. The definitionof delirium and the diagnostic criteria are to become a widespreadheritage of health professionals Linee di Indirizzo Intersocietarie 2017 AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
Il trattamentoNon-pharmacological aspects of care are paramount andinclude an active search for acute diseases and clinicalconditions that underlie the onset of delirium. Linee di Indirizzo Intersocietarie 2017 AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
Agitation? Is the delirium the cause of agitation?n? Check for causes of delirium Is pain well controlled? A Are non-pharmacological preventive strategies in place? AJ LF Salluh Int Care Med 2018
Una buona comunicazioneIneffective communications among health care professionals,as well as a poor communication of health care professionalswith patients and their families, have a negative impact on thequality of care provided to patients with delirium within thehospital. Linee di Indirizzo Intersocietarie 2017 AIP, AcEMC, AGE, EDA, EUGMS, FADOI, SIAARTI, SIGG, SIGOT, SIMEU, SIMI, SITOX, CNI-SPDC, WSES,
TIME to think about delirium Triggers Investigate Manage EngageY Bauernfreund, BMJ Open Quality 2018
