Highlights EUGMS 2017 Jean-Baptiste Beuscart (France) Dhayana Dallmeier (Germany) Miguel Toscano Rico (Portugal) - on behalf of EAMA -
Conflict of Interest Disclosure: - we like to listen to our friends presentations - we like the food sponsors offered 81 hours of presentations - we enjoy visiting Nice 717 abstracts
Breaking news: - E uropean U nion G eriatric M edicine S ociety is dead - God save the EU ropean G eriatric M edicine S ociety
Developing preventive actions in geriatrics: have we been able to change the picture of geriatrics? Cognitive decline ADR Malnutrition Prevent Hospital Delirium readmission CV disease Primary Secondary Tertiary
Cardiovascular disease • For those ≥ 80 y.o. and frail SBP target of 150 mmHg (robust older people 130 mmHg – 150 mmHg) • A special subgroup - patients with history of cancer • Anti-inflammatory therapy with 150 mg Canakinumab for Cannabis atherosclerotic disease showed a reduction of recurrent CVE
Thrombotic disease Status post arterial thrombosis risk VTE/PE • • Secondary Prevention for VTE: 2016 guidelines aspirin Cardiac decompensation • HF with Preserved EF is the most common form seen in >70 y.o. • Please consider HF by any new atypical symptom such as weakness, exhaustion, somnolence, delirium, decline in oral intake or general condition • Frailty and Malnutrition are associated with poor outcomes
Delirium Non-pharmacological prevention Effective but difficult to achieve Requires a team work with nurses and Public Health administration Pharmacological prevention Complex pathophysiology 17 RCTs in the past 2 years – most in surgical patients Alpha2-receptor agonist: Dexmedetomidine !? In the clinical settings In the emergency room In nursing homes • Validation of Geriatric-friendly ER instruments to identify high risk Track changes / fluctuations in alertness patients needed
Cognitive Decline Normal cognitive stage • Hypertension treatment and physical activity may prevent cognitive decline • Other modifiable risk factors: Education, obesity, Smoking, Depression • A consensus with respect to the definition of cognitive decline is urgently needed Mild cognitive impairment (MCI) • Promote cognitive training and physical activity • Multimodal interventions could be benefitial • Insufficient evidence to prescribe antidementia drugs Dementia stage • Cholinesterase inhibitors have modest effect on cognition If not tolerated Memantine in those with moderate to severe dementia • Cognitive stimulation therapy improves cognitive function in mild to moderate dementia • Physical activity shows a trend towards cognitive benefit
Frailty Functional decline relates to of physical fitness due to physiological • changes and concomitant diseases Fitness… Frailty … Disability • Depending on the definition used frailty may involve the disability threshold or not • 67 screening instruments for Frailty • Prevention Physical activity / Nutrition / Preventing diseases • Sarcopenia has a low Positive Predictive Value to predict frailty, but it does modify the effect of frailty on different outcomes such as mortality
Iatrogenic risk • High risk of ADR in older patients • Benefit – Risk ratio evaluation – Based on best evidence: real-life studies, not only RCTs – Assess functionality and frailty (CGA) – Close follow-up • Lack of discussion with patients
Malnutrition • If you focus on nutrition, you have to pay attention to physical activity – High protein intake may not be effective on nutritional status without physical exercise – Bad appetite may be related to physical activity – Relationship between protein-energy malnutrition and diet quality is not so straightforward • Not only how much people eat but what people eat
Malnutrition • If you focus on nutrition, you have to pay attention to physical activity – High protein intake may not be effective on nutritional status without physical exercise – Bad appetite may be related to physical activity – Relationship between protein-energy malnutrition and diet quality is not so straightforward • Not only how much people eat but what people eat
Unplanned hospital readmissions • It is possible to reduce early and unplanned hospital readmission – Acute care, post-acute care, nursing homes • Similar strategies – New model and new (non-linear) organization – Assess functional status during whole hospitalization – Increase internal and external communication – Reinforce partnership
Unplanned hospital readmissions • It is possible to reduce early and unplanned hospital readmission – Acute care, post-acute care, nursing homes • Similar strategies – New model and new (non-linear) organization – Assess functional status during whole hospitalization – Increase internal and external communication – Reinforce partnership
Developing preventive actions in geriatrics: have we been able to change the picture of geriatrics? Physical Cognitive activity decline ADR Malnutrition Nutrition Screening Improve Prevent Hospital Delirium readmission Research Healthcare organization Assessment CV disease Primary Secondary Tertiary
Screening for Frailty: - Multidimentional Prognostic Index (MPI) accurately predicts mortality and other important parameters in daily practice - MPI-Age study is expected to improve cost-effectiveness of interventions in frail older persons (free access on EUGMS website) - Future trends: targeting biological and phenotypical markers of aging, before function decline emerges
Screening for sarcopenia - SARC-F is a valid tool for screening sarcopenia - Muscle-US remains controverse, but might evolve as a useful tool for bedside muscle mass evaluation (after standardized protocols)
Nutrition: - Malnutrition screening is a must (high prevalence, worse outcomes) - Mediterranean Diet ≠ Mediterranean Food - Muscle loss and functional decline starts soon after hospital admission: nutritional and physiotherapy support should start asap - Adequate nutritional status is crucial for the success of rehabilitation programs
Physical activity: - Geriatricians must achieve expertise in exercise prescription - Optimal exercise recommendations confers the best outcomes. Nevertheless, sub-optimal exercise goals also reduces mortality (to lesser extent) - To gain muscle mass: resistance exercise (+adequate protein intake 1.2g/Kg/d) She got a plastic surgery, nevertheless …
Cancer screening • Screening is a choice, not a public health imperative • Screening for cancer should be personalized – Screening can be harmful • Life expectancy should be more than 10 years: – Recommendation in most guidelines for most cancers in older patients • In the older patients with cancer – Screening tools exist to better identify those who need CGA, at risk of chemotoxicity, or death
Assessment of preventive strategies • Ideal study design is Holy grail Quest – Selection bias in RCTs / Imbalance in Real life studies • It is not possible to translate directly results from fit to frail older people • Life course approach: – Focus on function in complex clinical context: may be more appropriate for preventive strategies
Assessment of preventive strategies • Ideal study design is Holy grail Quest The geriatrician & clinical research – Selection bias in RCTs / Imbalance in Real life studies • It is not possible to translate directly results from fit to frail older people • Life course approach: – What happened during whole life? (before birth!) – Important messages for early prevention
Integrated Care for Older People WHO Clinical consortium on healthy ageing – with collaboration of EUGMS The goal is „ Function “ The Ambition is to collect function measurements globally Functional ability – Combination of intrinsic capacity and the environmental settings Intrinsic Capacity Common care and treatment • Vitality goals across different providers • Locomotion • Cognitive • Sensory • Psychosocial
Developing preventive actions in geriatrics: have we been able to change the picture of geriatrics? Physical Cognitive activity Keywords decline Functionality Physical activity ADR Malnutrition Nutrition Screening Communication Nutrition Improve Prevent Organization Social integration Evidence Hospital Delirium readmission Research Healthcare organization Assessment CV disease Primary Secondary Tertiary
Thanks To EAMA and EUGMS for giving us this opportunity to go from Learning Sharing Acting We just say Au revoir Nice…. See you in Berlin
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