an article of Doctors Juan José Arechederra Calderón and Danny Febres Panez,
geriatricians of the residence and the Hospital of Guadalajara
The term geriatric syndrome refers to a set of multi-etiological clinical pictures, characterized by their high prevalence in the elderly population, which reflect the loss of capacity of the individual’s functional and physiological reservewith a high impact on the autonomy and quality of life of the elderly person, potentially preventable but frequently underdiagnosed, and whose approach is multidimensional and multiprofessional.
Currently, the National Commission of the specialty of Geriatrics defines them as complex and real situations in clinical practice, scarcely commented on in the traditional medical literature, and includes them among the main objectives of Geriatrics training.
Bell et al., in a descriptive study published in 2016 on the data of 272 patients discharged to a residence after hospitalization (with a mean age of 75 years), detected in 55% of the cases the presence of three or more syndromes.
The accumulation of predisposing factors (advanced age, functional and cognitive impairment, gait disturbances) and the presence of chronic diseases characterize individual vulnerability and trigger the appearance of different geriatric syndromes. In this article we will discuss the main syndromes due to their clinical, social and economic relevance.
Functional deterioration, one of the main Geriatric Syndromes
The falls they are not a physiological consequence and represent one of the most serious and challenging problems of the elderly. The fall is the expression of multiple pathologies, both chronic and acute. They are clearly associated with mortality, morbidity, functional deterioration, and institutionalization. The risk of falling increases with age. The main problem with falls is not their high incidence, but the probability of suffering any of their consequences: fractures, head injuries, fear of falling, functional impairment. Treatment is complex and the approach must be multidisciplinary.
He functional impairment It is the most relevant manifestation of the repercussion of multiple diseases in the elderly, reflects their degree of vulnerability and is the best prognostic factor for morbidity and mortality in this population group. Untreated functional impairment can lead to immobility, which is defined as the decreased ability to perform basic activities of daily living due to impaired motor functions. It is usually involuntary and secondary to different causes. The sequelae can be gradual or immediate and will be more serious the greater the degree and duration of immobilization. At the skin level it can cause pressure ulcers and at the level of the digestive system it usually causes constipation.
It is called pressure ulcer (UPP) to that lesion in the skin or in the underlying tissue of ischemic origin produced by tissue damage due to pressure, rubbing or prolonged friction of the skin between a bony prominence and a hard plane. It constitutes a problem of a higher order. It is currently an indicator of the quality of patient care in all clinical care settings. It is essential to include an adequate evaluation of the skin in the comprehensive geriatric assessment.
He constipation It is not a disease, but a symptom that implies alteration in fecal elimination in terms of its objective components of frequency, consistency and size of stools, as well as subjective ones referring to excessive effort in defecation or sensation of incomplete evacuation. Age influences an increase in its prevalence that is even higher than 54% among those over 85 years of age. Regarding its etiology, it has a multifactorial origin, where immobility and polypharmacy stand out, with their side effects.
The urinary incontinence It forms part of the major geriatric syndromes given its high prevalence and clinical, psychological, social, family, and economic repercussions. The International Continence Society (ICS) defined it as “any urine leakage that causes discomfort to the patient” and coined a new term, overactive bladder syndrome, defined as the association of urinary urgency, with or without urge incontinence, Often associated with increased micturition frequency and/or nocturia. The approach must be individualized, with general measures (hygienic-dietary, drug reduction, environmental intervention, behavior modification techniques, pelvic floor exercises, bladder retraining, urination anticipation, urination programs) as well as specific pharmacological treatments.
The fecal incontinence It is not part of normal aging, being also a geriatric syndrome that affects the quality of life of the elderly and that further burdens the caregiver, with great impact not only physical (pressure ulcers, urinary infections) but also economic and psychosocial. The causes are varied, such as anatomical alterations, intestinal inflammatory processes or involvement of the CNS (dementia, ICTUS, brain tumors, etc.). Treatment and reversibility will depend on the etiology. In the elderly they have the disadvantage of finding multiple components that sometimes condition the irreversibility of the process, so we must focus management on preventing local complications in the perineum.
The term polypharmacy involves the simultaneous use of several drugs in a single person. It is more and more frequent. The elderly have a higher prevalence of chronic diseases that need to be treated with different medications. In addition, the intervention of several prescribers can duplicate treatments, hence the greater need to carry out coordinated global therapy in frail patients to prevent each drug from being the result of isolated medical acts.
The fragility it meets the criteria for “geriatric syndrome”, since it is intrinsically associated with the phenomenon of aging, it does not correspond to a specific disease, it is highly prevalent. It is characterized by a decrease in strength and resistance, with an increase in vulnerability to low-intensity stressors, produced by an alteration in multiple interrelated systems, which decreases the homeostatic reserve and the adaptability of the organism, predisposing it to to adverse health events, greater chances of dependency and even death. To prevent or reduce frailty, we have different intervention strategies depending on its risk factors, such as physical activity and healthy eating. Treatment must be individualized, long enough, and maintained over time.
The sarcopenia It is a syndrome characterized by a progressive and generalized loss of skeletal muscle mass and strength with the risk of adverse consequences such as physical disability, poor quality of life, and death. Many factors are involved in its pathophysiology: genetics, immobility, neurodegenerative processes, decreased protein synthesis, endocrine factors and other mechanisms such as apoptosis, mitochondrial dysfunction, hormonal alterations, inflammation of adipose tissue, etc. Its diagnosis will be based on the identification of the affected parameters (strength, mass and muscle function). There are widely used scales such as the SARC-F recommended by the EWGSOPP2 (European Working Group on Sarcopenia in Older People). As in frailty, physical exercise and nutritional intervention, combined, constitute its two great therapeutic pillars.
The malnutrition It is especially worrisome due to its high prevalence in the elderly population. In institutionalized people it can reach 14-29%, so one of the most important objectives of geriatric care is to optimize the nutritional status of the elderly. A global consensus document on basic diagnostic criteria has recently been produced, the Global Leadership Initiative on Malnutrition (GLIM). Firstly, a malnutrition risk screening should be established using validated detection tools, followed by a diagnostic evaluation with the GLIM criteria, phenotypic (involuntary weight loss, low BMI, reduced muscle mass) and etiological (decreased intakes of food, burden of disease/inflammatory state) and thus carry out the corresponding interventions.
The recognition of cognitive decline It is very important, because in some cases there is a treatable cause and it will allow the inclusion of preventive and therapeutic measures and care planning. Among the syndromic entities that correspond to this alteration that is not expected merely due to aging, we would include mild cognitive impairment, subjective cognitive impairment, or cognitive frailty. AD is the main cause of dementia, particularly in the geriatric population, and its early detection is key, both from a research perspective and for early intervention using both pharmacological and non-pharmacological strategies.
The depression It is one of the most frequent and disabling situations of illness among the elderly population and constitutes an important health problem due to its impact in all spheres. They have a high prevalence. Diagnosis is a complex issue that leads to many errors, since the symptoms of depression are often taken as something “normal” in the elderly, not paying enough attention to it. Antidepressant treatment in patients with major depression in the elderly is effective, although the existence of differences in efficacy between different groups of antidepressants cannot be demonstrated. It is necessary to individualize the therapy to achieve an acceptable risk vs. benefit ratio.
As a global conclusion, we know that major geriatric syndromes represent a Pandora’s box of pre-disability situations and, therefore, constitute an ideal focus on which to focus prevention measures. On many occasions these circumstances can go unnoticed by health professionals. The search for these syndromes in the elderly population must be proactive and systematized in any comprehensive assessment protocol. and the intervention must be multidimensional and multidisciplinary.
Bibliography:
Abizanda Soler P, Rodríguez Mañas L. Treatise on geriatric medicine. Fundamentals of health care for the elderly.
Guide to Good Geriatric Practice. Fragility and Nutrition in the elderly. SEEG.
Cognitive Impairment in the Elderly. Consensus document. SEGG. Enrique Arriola Manchola. Cristóbal Carnero Pardo. Alberto Freire Pérez. Rosa López Mongil. Jose Antonio Lopez Wheat. Manzano Palomo Tabernacle. Javier Olazaran Rodriguez.
Guide to Good Geriatric Practice. Approach and management of depression in the elderly. SEEG.
Therapeutic Updates. Therapeutic approach and management…