Publication: Desarrollo de una escala pronóstica del riesgo de mortalidad en ancianos tras un ingreso hospitalario en la unidad de agudos en geriatría
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2017-09-11
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Universidad Complutense de Madrid
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Abstract
La estimación de la mortalidad es esencial para la individualización de los cuidados del paciente mayor; sin embargo, dicha estimación habitualmente no es sencilla. El ingreso hospitalario supone con frecuencia para el anciano una transición relevante en su estado de salud; el ingreso brinda entonces una extraordinaria oportunidad al clínico para la estimación de la posible evolución posterior y la revisión de los objetivos de cuidados con paciente y familiares. Herramientas desarrolladas en el entorno hospitalario con este fin presentan algunas características que las convierten en poco idóneas para nuestros pacientes: todas han sido desarrolladas en entornos sociosanitarios con diferentes prestaciones a las nuestras, de forma que el perfil de paciente atendido en el hospital no es el mismo. Como ejemplo, la ausencia de programas semejantes al sistema Hospice norteamericano hace que en nuestro entorno ingresen en los hospitales ancianos cada vez más mayores y más deteriorados. Muchas de estas escalas pronósticas son complicadas, y algunas veces no tienen en cuenta factores muy relevantes en este grupo de pacientes cuya importancia ha sido puesta de manifiesto sobre todo a lo largo de los últimos años (p.e., la fragilidad). Existe por tanto la necesidad de un sistema que contemple las características específicas de la población de ancianos hospitalizados en nuestro país, y proporcione información pronóstica fiable, incorporando variables no solo demográficas y médicas, sino también funcionales y de fragilidad. Idealmente, debería tratarse de un sistema sencillo, reproducible y preciso, que permitiera su incorporación a la práctica diaria. Demostrada su utilidad en dicho entorno, probablemente pudiera emplearse también en áreas de gestión para la optimización de los modelos sanitarios de asistencia al anciano...
The percentage of elderly people, especially the oldest old (over 85 years), is rising [Christensen K, 2009]. Consequently, the prevalence of chronic diseases is also increasing. The elderly are major users of healthcare resources, mainly due to their well-known sensitivity to disability and illness [Agency for Healthcare Research and Quality (AHRQ), 2008; O'Neill , 2003]: In fact, in developed countries, elderly persons account for almost 30-40% of inpatients. Moreover, hospitalization of elderly patients leads to functional impairment, higher mortality risk after discharge, and prominent health care–related costs, regardless of the reason for admission [Creditor MC, 1993, Vidán Astiz MT, 2008; Gill TM & Allore HG, 2010]. All these circumstances make caring for elderly patients of critical importance, not only in terms of individual issues, but also in terms of the knowledge and concerns of policy makers. Elderly and young patients do not receive the same medical care, mainly because decisions are often based on arbitrary age cut-off points and are not evidence-guided [Lee SJ, 2013]. For example, the frequency of cancer screening is not appropriate for healthy older patients with a good prognosis or for very sick patients, patients with dementia, and patients with a short life expectancy, whose plans of care would not be modified based on test results. As a consequence of this lack of evidence, hospice care (patients with nonmalignant but life– threatening disease) and intensive care are poorly used in elderly patients. Given that hospitalization is a major health transition for older adults, discussions about the objectives of care and therapy provide the health care team and patients with the opportunity to establish future care directives. Prognostic information (mainly life expectancy) and patients’ preferences can provide the basis for these discussions and complement clinicians’ judgment when counseling patients and relatives about the significance of health problems and the utility of treatment options. It can also identify individuals for whom targeted interventions or palliative care are indicated [Christakis NA, 1999]...
The percentage of elderly people, especially the oldest old (over 85 years), is rising [Christensen K, 2009]. Consequently, the prevalence of chronic diseases is also increasing. The elderly are major users of healthcare resources, mainly due to their well-known sensitivity to disability and illness [Agency for Healthcare Research and Quality (AHRQ), 2008; O'Neill , 2003]: In fact, in developed countries, elderly persons account for almost 30-40% of inpatients. Moreover, hospitalization of elderly patients leads to functional impairment, higher mortality risk after discharge, and prominent health care–related costs, regardless of the reason for admission [Creditor MC, 1993, Vidán Astiz MT, 2008; Gill TM & Allore HG, 2010]. All these circumstances make caring for elderly patients of critical importance, not only in terms of individual issues, but also in terms of the knowledge and concerns of policy makers. Elderly and young patients do not receive the same medical care, mainly because decisions are often based on arbitrary age cut-off points and are not evidence-guided [Lee SJ, 2013]. For example, the frequency of cancer screening is not appropriate for healthy older patients with a good prognosis or for very sick patients, patients with dementia, and patients with a short life expectancy, whose plans of care would not be modified based on test results. As a consequence of this lack of evidence, hospice care (patients with nonmalignant but life– threatening disease) and intensive care are poorly used in elderly patients. Given that hospitalization is a major health transition for older adults, discussions about the objectives of care and therapy provide the health care team and patients with the opportunity to establish future care directives. Prognostic information (mainly life expectancy) and patients’ preferences can provide the basis for these discussions and complement clinicians’ judgment when counseling patients and relatives about the significance of health problems and the utility of treatment options. It can also identify individuals for whom targeted interventions or palliative care are indicated [Christakis NA, 1999]...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 01- 02-2016