INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Integrated Care of Older People Integrated Care of Older People Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (University Hospital of Getafe, Spain), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez-Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v Integrated Care of Older People The World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being )unctional ability is defined as the Ȋhealth-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age Ȃ a focus on optimi]ing people’s intrinsic capacity and functional ability as they age. Ζn 2ctober , the :orld +ealth 2rgani]ation (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimi]ing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimi]ing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE) Introduction 1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? 2lder people make up a larger part of the world’s population than ever before Ζn , there were an estimated million people aged years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By , one person in every five will be years of age or older This trend began some years ago Ζt reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recogni]e and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people :+2’s Ζ&23( approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose speciali]ed knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice Ζt offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personali]ed care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organi]ing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organi]ations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on :+2’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personali]ed care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve 6'*, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimi]ing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as deYeloping and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Vision impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) 2 How to carry out a person-centred, integrated approach at the primary health-care level OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Vision capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characteri]ed by dependence on care 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective There is a wide range of intrinsic capacity around the average pattern These differences are evident both within and between countries They are reflected in persistent differences in life expectancies, which range from years or more in such countries as Australia, Japan and 6wit]erland, to less than years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY :+2 defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 2 How to carry out a person-centred, integrated approach at the primary health-care level FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity 6ignificant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late life Remove barriers to participants coPpensate for loss of capacity ICOPE APPROACH Many of the characteristics that determine intrinsic capacity can be modified These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimi]e intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline 1utrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: :orld +ealth 2rgani]ation, (1). 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences 3erson-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personali]ed care plan • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimi]e functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY STEP 1 STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 3 Generic care pathway Person-centered assessment and pathways in primary care Priority conditions associated with declines in intrinsic capacity Tests Assess fully if any answer in each domain triggers this COGNITIVE DECLINE (Chapter 4) 5emember three words flower, door, rice (for example) 2rientation in time and space :hat is the full date today" :here are you now (home, clinic, etc)" 5ecalls the three words" LIMITED MOBILITY (Chapter 5) &hair rise test 5ise from chair five times without using arms 'id the person complete five chair rises within seconds" MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months" $ppetite loss +ave you experienced loss of appetite" VISUAL IMPAIRMENT (Chapter 7) 'o you have any problems with your eyes difficulties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)" HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by Ȃ feeling down, depressed or hopeless" Ȃ little interest or pleasure in doing things" Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1) The Ζ&23( screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases Those who show signs of, or report losses in capacity at this first step should go on to a full assessment )ull assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the Ζ&23( screening tool always triggers further in-depth assessment. Findings should inform the development of the personali]ed care plan adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as $l]heimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of speciali]ed geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. 6ocial care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE $ person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimi]ing intrinsic capacity 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organi]ed generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personali]ed care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN $ 'efine with the oOdeU peUson the JoaO oI caUe The unifying goal of optimi]ing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions Ζt is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioriti]ed according to the person’s priorities, needs and preferences 3B. Design a care plan The person-centred assessment informs the development of a personali]ed care plan This personali]ed care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Comprehensive assessment and care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximi]e their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them Ζnstead, it recogni]es their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls 1utrition enhances the effects of exercise and at the same time increases muscle mass and strength Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personali]ed care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. $ link to speciali]ed geriatric care is also critical +ealth systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when speciali]ed care is needed 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personali]ed care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with speciali]ed and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personali]ed care plan The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. in collaboration with UniversalDoctor is a leading digital health & innovation social e ter ris that has worked with the WHO and other UN Agencies over the years t design and deploy various digital health solutions to tackle glob l health issu s such as Infectious Diseases, Ageing, Mental Health, Disabilities and more. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitali]ed recently are at greater risk of polypharmacy An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or $l]heimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment Ȃ that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS 'eclines in cognitive capacity can be minimi]ed and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES See malnutrition pathway Ζdentify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events 6 PASS 0ultimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONS ASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers Ζf cognitive decline aects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE 6impOe memoU\ and oUientation test 5ememEeUinJ thUee woUds Ask the person to remember three words that you will say. Use simple, concrete words such as Ȋȵowerȋ, Ȋdoorȋ, Ȋriceȋ 2Uientation in time and space Then, ask, ȊWhat is the full date today?ȋ and ȊWhere are you now?ȋ (home, clinic, etc.)? 5ecaOOinJ thUee woUds Now ask the person to repeat the three words that you mentioned 3ass oU IaiO" If a person cannot answer one of the two questions about orientation OR cannot remember all three words, coJnitive decOine is OiNeO\ and further assessment is called for 'o you have Sroblems with memory or orientation such as not knowing where one is or what day it is ? ASK ? YES 4.1 4.2 5.1 9itamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. 5isk reduction of cognitive decline and dementia W+2 Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education Ζf a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. 6uch a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. ΖI coJnitive decOines aect an oOdeU peUsonȇs aEiOit\ to Iunction eectiveO\ within theiU enviUonment a speciaOi]ed assessment ma\ Ee needed to diaJnose dementia oU $O]heimeUȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mhGAP intervention guide (https://apps.who.int/iris/handle/10665/250239) WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf Brief; minimal language, educational and racial bias 8se of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME 0ontUeaO coJnitive assessment 0o&$ https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min 0ini mentaO state e[amination 006( https://www.parinc.com/products/pkey/237 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min *eneUaO pUactitioneU assessment oI coJnition *3&2* http://gpcog.com.au/index/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS :hat is dementia" Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and tUeat these fiUst 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in &hapter , p ) Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recogni]ed risk for cognitive decline 3ractitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several different Sotential e[Slanations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 4 Cognitive capacity Care pathways to manage cognitive decline • 3eople with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition To reach the best outcomes, these may need to be addressed. Ζndividuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. &oJnitive stimuOation ma\ Ee oeUed to an individuaO oU in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personali]ed intervention for a person with significant declines may reTuire more detailed assessment and planning Ȃ tasks that reTuire speciali]ed skills Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 Care pathways to manage cognitive decline Cognitive capacity 4 Ζf cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximi]es independent activity, enhances function, helps to adapt and develop skills, and minimi]es the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside Ȃ to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities) ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care $ person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not Ζndeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. $dapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking Final SPPB score = sum of scores from the three tests above SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities The 633B measures timed performance on three tasks, each scored out of four, to derive a score from ]ero (worst performance) to (best performance) First, describe each test and ask if the person feels able to do it Ζf not, score accordingly and move to the next step 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions 8se the sum of the scores from the three positions 2. Gait speed test: Time to walk four metres (Ζf they use a cane or walking aid and feel they need it to walk a short distance, they may use it) Time for four-metre walk: seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points ! seconds 1 point 8nable to complete 0 points 3. Chair rise test: Time to rise from a chair five times seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points Ȃ seconds 1 point ! seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory Yitality and psychological capacities Ζf significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests C. Tandem stand Held for 10 seconds 2 points +eld for to seconds 1 point +eld for seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms"ȋ ('emonstrate to the person) If YES, ask them to: Ȃ sit in the middle of the chair Ȃ cross and keep their arms over their chest Ȃ rise to a full standing position and then sit down again Ȃ repeat five times as Tuickly as possible without stopping Time the person taking the test Ȃ further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity Locomotor capacity 5 Care pathways to improve mobility ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in Moint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • ȵe[iEiOit\ tUaininJ, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines xercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? 7he 9iviIUaiO pUoMect oeUs a pUacticaO Juide to deveOopinJ a tailored exercise programme. http://www.vivifrail.com/resources 6 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme 3eople whose 633B scores are in the range of Ȃ can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY $ll older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions This box summari]es :+2’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • )or additional benefit, do minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • ben]odia]epines • nonben]odia]epine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. (liminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets pdfBfile %riefB3ainBΖnventoryB)inalpdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain $ specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep :here pain is a significant barrier to movement and activity, a health professional with speciali]ed knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and Moint mobili]ation • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities The first step is to assess social care needs (see &hapter ) 6pecific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible ha]ards and offer suggestions (xamples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps $ person’s specific mobility limitations will guide what environmental adaptations are most important. :ith specific training, a community- or facility-based primary care provider can assess a person’s home Ζf a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. $ full assessment and management of a person’s risk of falls reTuires speciali]ed knowledge 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and Moint function and flexibility • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as 3arkinson’s disease 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health $ full assessment of nutritional status reTuires speciali]ed knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins ' and B are common Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet $ll older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • +elp people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire (https wwwȵintbo[compublicproMect) Short nutritional assessment questionnaire 65+ (SNAQ65+) (http wwwfightmalnutritioneutoolkits summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding Tuestion) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can sTuee]e the tool with one hand Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION )or a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with speciali]ed knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals 6peciali]ed knowledge is needed to develop a plan for 261 that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an 01$ score of Ȃ) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume sufficient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through speciali]ed commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test $ blood test informs the personali]ed nutritional plan $ blood test can identify specific vitamin and mineral deficiencies 6pecific oral nutrient supplements or inMections can treat these deficiencies )or example, tablets or inMections are needed to treat deficiencies in vitamins ' and B, which are common KEY POINTS ABOUT OSN • )ood comes first 8nless the need for 261 is urgent, improvements in diet, if possible, and more frequent meals should be tried first • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of 261 $ variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health )or example, community organi]ations might organi]e social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. 9isual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks 6uch difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. $ssistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment 5eview and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES 'o offtheshelf simSle reading glasses solve the Sroblem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK 'o you have any Sroblems with your eyes diɝculties in seeing far, reading, eye diseases or currently under medical treatment e.g. diabetes, high blood Sressure ? +ave not seen a doctor in the Srevious year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test distance and near vision to find the smallest ( each person can see 1. Test with the four small Es at 3 m. Vision is normal (6/18 or better) if the direction of at least three out of four small Es can be seen. If not able to see at least three of the large Es, … 2. … test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es, … 3. … test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as he/she wants. Test from the largest to the smallest Es. At least three out of four must be correct in each line before testing the next. If only the largest size (N48) can be seen, check if off-the-shelf simple reading glasses will help Ζf not, refer for a comprehensive eye and vision examination and specialized eye care. The medium size (N20) is similar to the print in large-print books The smallest size (N8) is similar to print in books and magazines. 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED Ζf a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • $ primary health-care provider can perform the screening It does not require formal training in eye care assessment (13). • Ζf off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment 5eview and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES 'o offtheshelf simSle reading glasses solve the Sroblem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK 'o you have any Sroblems with your eyes diɝculties in seeing far, reading, eye diseases or currently under medical treatment e.g. diabetes, high blood Sressure ? +ave not seen a doctor in the Srevious year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 43 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • /arge (s are cm x cm, at cm from each other • Full black E on plain white paper. 45 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for speciali]ed eye care • $ primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, speciali]ed eye care is recommended ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently )or these people, assistive vision devices – desk or mobile magnifiers Ȃ provide greater magnification than glasses They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning Ȃ skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES 0any people aged years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called Ȋreadersȋ) Simple reading glasses are available at low cost. They are often available in various magnification strengths Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid (xamples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. +a]ards such as furniture and other hard obMects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitali]ations and early death Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them reTuires speciali]ed knowledge and eTuipment 51 Normal locomotor capacity (SPPB score 10–12 points) Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: ≥ 81 dB) Normal hearing capacity (Audiometry: ≤ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) Normal locomotor capacity (SPPB score 10–12 points) Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness ($udiometry Ȳ dB) Normal hearing capacity ($udiometry ȱ dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1 Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing :ith brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST $n automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING ASSE HEARING CAPACITY (Diagnostic audiometry) GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. $sk the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the patient can hear you clearly, then the patient is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear 8se different words 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ fire – number Ȃ fish – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. 2lder adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs speciali]ed training Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at freTuencies from +] (very low) to +] (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity $ny cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroTuine 2ther medications also can affect hearing Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need speciali]ed hearing care such as the fitting of a hearing device Providing hearing devices needs specialized skills for testing, prescription and fittinJ MANAGE HEARING LOSS 2theU Ued ȵaJs IoU speciaOi]ed hearing care Conditions that may underlie hearing loss need speciali]ed diagnosis and management These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • di]]iness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. &ochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use $ cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. $udio induction Ooops and peUsonaO sound ampOifieUs $udio induction loops and personal sound amplifiers are also effective $n audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries oer Pore guidance http appswhointirishandle 56 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS 0inimi]ing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organi]e activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • *et the person’s attention before you speak • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf ), which is one tool for assessment of depressive symptoms, or see the depression section of WHO mhGAP intervention guide 2.0. WHEN SPECIALIZED CARE IS NEEDED • Management of depression requires a more comprehensive and usually specialist approach to develop an individualized care plan. • To manage depressive symptoms , health-care providers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may require specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down • Trouble concentrating on things such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed • Being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS PSYCHOLOGICAL CAPACITY Psychological capacity Care pathways to manage depressive symptoms If a person reports both core symptoms - feeling down, depressed or hopeless and having little interest or pleasure in doing things - make a further assessment of mood. FIRST ASSESS FOR: • physical causes of depression • normal reactions to major loss in the last six months • history of a manic or hypomanic episode. The presence of any of these would suggest a different approach from treatment for depression. DEPRESSIVE SYMPTOMS If a person has both core symptoms and two or fewer additional symptoms, she or he may have depressive symp- toms. It is important to distinguish depressive symptoms from depression because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health-care provider with complaints of mood or behavioural problems, such as apathy, loss of emotional control or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or locomotor capacity, may reduce functional ability and social participation and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the comprehensive care plan. THEN, ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour 3eople with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include () identifying problems in one’s life, () becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). 3roblem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without speciali]ed knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 9 Psychological capacity Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder +istory of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or reTuiring hospitali]ation or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ bipolarBȵowcharthtml). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of $l]heimer’s disease The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 9 Psychological capacity Care pathways to manage depressive symptoms of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with speciali]ed knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. (liminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of vitamins such as folate, vitamin B and vitamin B 'epressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 General social care support 10 Care pathways for social care and support Social care and support )or people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, Tuestions about $'/s and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Ζnterventions tailored to an older person’s priorities can improve functional ability. (ffective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. Do you have difficulty getting around indoors? 2. Do you have difficulty using the toilet (or commode)? 3. Do you have difficulty dressing yourself? 4. Do you have difficulty using the bath or shower? 5. Do you have difficulty keeping up your personal appearance? 6. Do you have difficulty feeding yourself? 7. Do you have problems with the place where you live (accommodation)? 8. Do you have problems with your finances? 9. Do you feel lonely? SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS 1. In general, how do your finances work out at the end of the month? 2. Are you able to manage your money and financial affairs? 3. Would you like advice about financial allowances or benefits? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: 1. cost, 2. distance, 3. transport, 4. lack of opportunities, 5. others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 1 10. Are you able to pursue leisure interests, hobbies, work, volunteering, supporting your family, educational or spiritual activities that are important to you? 11. Assess risk of elder abuse Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • )inances social worker, benefit advisory services WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • 0ultiple inMuries at different stages of healing • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. 2lder people who have difficulties with $'/s and or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimi]e functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s si]e, access, condition, safety and security. Supplementary questions can help to identify specific areas to address 70 Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living )inancial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances )urther Tuestions can help to identify specific areas that need addressing Financial problems can be mitigated though independent advice about financial planning and financial management Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse 71 Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is uniTue and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personali]ed care plan Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access &harges for some of these services may be subsidi]ed to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as at a day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) (xplore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). The financial costs of caregiving, potentially leading to sources of local financial support and organi]ed social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. $ssessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page ) 6upport should reflect the caregiver’s choices and emphasi]e optimi]ing the caregiver’s well-being 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills Ȃ for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability Tualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person" This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. 2eU ps\choOoJicaO suppoUt Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 Introduction 1 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioriti]ed needs and goals • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN 3ersonali]ed care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences 2nce expressed, a personali]ed care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 5eview findinJs and discuss oppoUtunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioriti]e goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 2 78 5. Monitoring and follow-up 0onitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summari]ing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 Introduction 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some specific goals that you have in your life? • QUESTION 3 :hat are some specific goals that you have for your health? • QUESTION 4 %ased on the list of both life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What about in the ne[t si[ to months? SET GOALS: *oals can be adapted to the older people’s needs and their own definition of problems • QUESTION 5 :hat specifically about goal one, two or three would you like to work on over the next three months? :hat about over the ne[t si[ to months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: $greement on prioriti]ed goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat about over the ne[t si[ to months? HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • (ffective implementation of the Ζ&23( approach requires an integrated approach linking health and social care services. • 2ptimi]ing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • 3ersonali]ed care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management The WHO World report on ageing and health set a new direction for health and long-term care systems (1). Ζt called on these systems to focus on optimi]ing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in , translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 Introduction 1 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION $s a first step, both the :+2 recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Ζncentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimi]es intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 3 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility Ȃ financial and organi]ational • sustainability Ȃ efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which :+2 defined in as Ȋthe synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s healthȋ :+2’s knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). :+2’s framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The :+2 Ζ&23( implementation framework emphasi]es the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioriti]e primary and community-based care This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recogni]ing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimi]e community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 Introduction 1 :hen speciali]ed care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective )ollow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 3 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. 'eliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organi]ing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. 2lder people’s clubs and associations are natural allies in this effort At the same time, the health-care system owes a responsibility to its partners in supporting healthy ageing – communities, community organi]ations and the family members and other unpaid caregivers of older people. This responsibility includes attention to the health and well-being of caregivers, as discussed in Chapter 11, and mutual support, collaboration and coordination with communities and community organi]ations to create a healthy environment for healthy ageing. 85 REFERENCES 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa. edu.au/pain-management, accessed 1 May 2019). 10. 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INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/publishing/copyright Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presenta- tion of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Integrated Care of Older People Integrated Care of Older People Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (University Hospital of Getafe, Spain), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez-Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v Integrated Care of Older People The World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being )unctional ability is defined as the Ȋhealth-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age Ȃ a focus on optimi]ing people’s intrinsic capacity and functional ability as they age. Ζn 2ctober , the :orld +ealth 2rgani]ation (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimi]ing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimi]ing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE) Introduction 1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? 2lder people make up a larger part of the world’s population than ever before Ζn , there were an estimated million people aged years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By , one person in every five will be years of age or older This trend began some years ago Ζt reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recogni]e and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people :+2’s Ζ&23( approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose speciali]ed knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice Ζt offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personali]ed care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organi]ing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organi]ations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on :+2’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personali]ed care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve 6'*, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimi]ing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as deYeloping and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Vision impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) 2 How to carry out a person-centred, integrated approach at the primary health-care level OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Vision capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characteri]ed by dependence on care 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective There is a wide range of intrinsic capacity around the average pattern These differences are evident both within and between countries They are reflected in persistent differences in life expectancies, which range from years or more in such countries as Australia, Japan and 6wit]erland, to less than years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY :+2 defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 2 How to carry out a person-centred, integrated approach at the primary health-care level FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity 6ignificant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late life Remove barriers to participants coPpensate for loss of capacity ICOPE APPROACH Many of the characteristics that determine intrinsic capacity can be modified These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimi]e intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline 1utrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: :orld +ealth 2rgani]ation, (1). 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences 3erson-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personali]ed care plan • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimi]e functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY STEP 1 STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 3 Generic care pathway Person-centered assessment and pathways in primary care Priority conditions associated with declines in intrinsic capacity Tests Assess fully if any answer in each domain triggers this COGNITIVE DECLINE (Chapter 4) 5emember three words flower, door, rice (for example) 2rientation in time and space :hat is the full date today" :here are you now (home, clinic, etc)" 5ecalls the three words" LIMITED MOBILITY (Chapter 5) &hair rise test 5ise from chair five times without using arms 'id the person complete five chair rises within seconds" MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months" $ppetite loss +ave you experienced loss of appetite" VISUAL IMPAIRMENT (Chapter 7) 'o you have any problems with your eyes difficulties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)" HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by Ȃ feeling down, depressed or hopeless" Ȃ little interest or pleasure in doing things" Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1) The Ζ&23( screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases Those who show signs of, or report losses in capacity at this first step should go on to a full assessment )ull assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the Ζ&23( screening tool always triggers further in-depth assessment. Findings should inform the development of the personali]ed care plan adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as $l]heimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of speciali]ed geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. 6ocial care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE $ person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimi]ing intrinsic capacity 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organi]ed generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personali]ed care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN $ 'efine with the oOdeU peUson the JoaO oI caUe The unifying goal of optimi]ing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions Ζt is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioriti]ed according to the person’s priorities, needs and preferences 3B. Design a care plan The person-centred assessment informs the development of a personali]ed care plan This personali]ed care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Comprehensive assessment and care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximi]e their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them Ζnstead, it recogni]es their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls 1utrition enhances the effects of exercise and at the same time increases muscle mass and strength Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personali]ed care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. $ link to speciali]ed geriatric care is also critical +ealth systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when speciali]ed care is needed 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personalized care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with specialized and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personalized care plan. The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitali]ed recently are at greater risk of polypharmacy An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or $l]heimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment Ȃ that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS 'eclines in cognitive capacity can be minimi]ed and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES See malnutrition pathway Ζdentify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events 6 PASS 0ultimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONS ASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers Ζf cognitive decline aects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE 6impOe memoU\ and oUientation test 5ememEeUinJ thUee woUds Ask the person to remember three words that you will say. Use simple, concrete words such as Ȋȵowerȋ, Ȋdoorȋ, Ȋriceȋ 2Uientation in time and space Then, ask, ȊWhat is the full date today?ȋ and ȊWhere are you now?ȋ (home, clinic, etc.)? 5ecaOOinJ thUee woUds Now ask the person to repeat the three words that you mentioned 3ass oU IaiO" If a person cannot answer one of the two questions about orientation OR cannot remember all three words, coJnitive decOine is OiNeO\ and further assessment is called for 'o you have Sroblems with memory or orientation such as not knowing where one is or what day it is ? ASK ? YES 4.1 4.2 5.1 9itamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. 5isk reduction of cognitive decline and dementia W+2 Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education Ζf a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. 6uch a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. ΖI coJnitive decOines aect an oOdeU peUsonȇs aEiOit\ to Iunction eectiveO\ within theiU enviUonment a speciaOi]ed assessment ma\ Ee needed to diaJnose dementia oU $O]heimeUȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mhGAP intervention guide (https://apps.who.int/iris/handle/10665/250239) WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf Brief; minimal language, educational and racial bias 8se of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME 0ontUeaO coJnitive assessment 0o&$ https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min 0ini mentaO state e[amination 006( https://www.parinc.com/products/pkey/237 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min *eneUaO pUactitioneU assessment oI coJnition *3&2* http://gpcog.com.au/index/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS :hat is dementia" Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and tUeat these fiUst 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in &hapter , p ) Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recogni]ed risk for cognitive decline 3ractitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several different Sotential e[Slanations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 4 Cognitive capacity Care pathways to manage cognitive decline • 3eople with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition To reach the best outcomes, these may need to be addressed. Ζndividuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. &oJnitive stimuOation ma\ Ee oeUed to an individuaO oU in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personali]ed intervention for a person with significant declines may reTuire more detailed assessment and planning Ȃ tasks that reTuire speciali]ed skills Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 Care pathways to manage cognitive decline Cognitive capacity 4 Ζf cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximi]es independent activity, enhances function, helps to adapt and develop skills, and minimi]es the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside Ȃ to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities) ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care $ person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not Ζndeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. $dapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking Final SPPB score = sum of scores from the three tests above SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities The 633B measures timed performance on three tasks, each scored out of four, to derive a score from ]ero (worst performance) to (best performance) First, describe each test and ask if the person feels able to do it Ζf not, score accordingly and move to the next step 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions 8se the sum of the scores from the three positions 2. Gait speed test: Time to walk four metres (Ζf they use a cane or walking aid and feel they need it to walk a short distance, they may use it) Time for four-metre walk: seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points ! seconds 1 point 8nable to complete 0 points 3. Chair rise test: Time to rise from a chair five times seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points Ȃ seconds 1 point ! seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory Yitality and psychological capacities Ζf significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests C. Tandem stand Held for 10 seconds 2 points +eld for to seconds 1 point +eld for seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms"ȋ ('emonstrate to the person) If YES, ask them to: Ȃ sit in the middle of the chair Ȃ cross and keep their arms over their chest Ȃ rise to a full standing position and then sit down again Ȃ repeat five times as Tuickly as possible without stopping Time the person taking the test Ȃ further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity Locomotor capacity 5 Care pathways to improve mobility ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in Moint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • ȵe[iEiOit\ tUaininJ, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines xercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? 7he 9iviIUaiO pUoMect oeUs a pUacticaO Juide to deveOopinJ a tailored exercise programme. http://www.vivifrail.com/resources 6 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme 3eople whose 633B scores are in the range of Ȃ can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY $ll older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions This box summari]es :+2’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • )or additional benefit, do minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • ben]odia]epines • nonben]odia]epine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. (liminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets pdfBfile %riefB3ainBΖnventoryB)inalpdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain $ specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep :here pain is a significant barrier to movement and activity, a health professional with speciali]ed knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and Moint mobili]ation • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities The first step is to assess social care needs (see &hapter ) 6pecific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible ha]ards and offer suggestions (xamples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps $ person’s specific mobility limitations will guide what environmental adaptations are most important. :ith specific training, a community- or facility-based primary care provider can assess a person’s home Ζf a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. $ full assessment and management of a person’s risk of falls reTuires speciali]ed knowledge 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and Moint function and flexibility • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as 3arkinson’s disease 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health $ full assessment of nutritional status reTuires speciali]ed knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins ' and B are common Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet $ll older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • +elp people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire (https wwwȵintbo[compublicproMect) Short nutritional assessment questionnaire 65+ (SNAQ65+) (http wwwfightmalnutritioneutoolkits summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding Tuestion) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can sTuee]e the tool with one hand Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION )or a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with speciali]ed knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals 6peciali]ed knowledge is needed to develop a plan for 261 that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an 01$ score of Ȃ) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume sufficient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through speciali]ed commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test $ blood test informs the personali]ed nutritional plan $ blood test can identify specific vitamin and mineral deficiencies 6pecific oral nutrient supplements or inMections can treat these deficiencies )or example, tablets or inMections are needed to treat deficiencies in vitamins ' and B, which are common KEY POINTS ABOUT OSN • )ood comes first 8nless the need for 261 is urgent, improvements in diet, if possible, and more frequent meals should be tried first • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of 261 $ variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health )or example, community organi]ations might organi]e social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. 9isual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks 6uch difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. $ssistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment 5eview and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES 'o offtheshelf simSle reading glasses solve the Sroblem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK 'o you have any Sroblems with your eyes diɝculties in seeing far, reading, eye diseases or currently under medical treatment e.g. diabetes, high blood Sressure ? +ave not seen a doctor in the Srevious year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test distance and near vision to find the smallest ( each person can see 1. Test with the four small Es at 3 m. Vision is normal (6/18 or better) if the direction of at least three out of four small Es can be seen. If not able to see at least three of the large Es, … 2. … test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es, … 3. … test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as he/she wants. Test from the largest to the smallest Es. At least three out of four must be correct in each line before testing the next. If only the largest size (N48) can be seen, check if off-the-shelf simple reading glasses will help Ζf not, refer for a comprehensive eye and vision examination and specialized eye care. The medium size (N20) is similar to the print in large-print books The smallest size (N8) is similar to print in books and magazines. 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED Ζf a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • $ primary health-care provider can perform the screening It does not require formal training in eye care assessment (13). • Ζf off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment 5eview and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES 'o offtheshelf simSle reading glasses solve the Sroblem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK 'o you have any Sroblems with your eyes diɝculties in seeing far, reading, eye diseases or currently under medical treatment e.g. diabetes, high blood Sressure ? +ave not seen a doctor in the Srevious year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 43 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • /arge (s are cm x cm, at cm from each other • Full black E on plain white paper. 45 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for speciali]ed eye care • $ primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, speciali]ed eye care is recommended ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently )or these people, assistive vision devices – desk or mobile magnifiers Ȃ provide greater magnification than glasses They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning Ȃ skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES 0any people aged years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called Ȋreadersȋ) Simple reading glasses are available at low cost. They are often available in various magnification strengths Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid (xamples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. +a]ards such as furniture and other hard obMects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitali]ations and early death Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them reTuires speciali]ed knowledge and eTuipment 51 Normal locomotor capacity (SPPB score 10–12 points) Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: ≥ 81 dB) Normal hearing capacity (Audiometry: ≤ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) Normal locomotor capacity (SPPB score 10–12 points) Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness ($udiometry Ȳ dB) Normal hearing capacity ($udiometry ȱ dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1 Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing :ith brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST $n automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING ASSE HEARING CAPACITY (Diagnostic audiometry) GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. $sk the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the patient can hear you clearly, then the patient is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear 8se different words 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ fire – number Ȃ fish – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. 2lder adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs speciali]ed training Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at freTuencies from +] (very low) to +] (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity $ny cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroTuine 2ther medications also can affect hearing Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need speciali]ed hearing care such as the fitting of a hearing device Providing hearing devices needs specialized skills for testing, prescription and fittinJ MANAGE HEARING LOSS 2theU Ued ȵaJs IoU speciaOi]ed hearing care Conditions that may underlie hearing loss need speciali]ed diagnosis and management These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • di]]iness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. &ochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use $ cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. $udio induction Ooops and peUsonaO sound ampOifieUs $udio induction loops and personal sound amplifiers are also effective $n audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries oer Pore guidance http appswhointirishandle 56 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS 0inimi]ing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organi]e activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • *et the person’s attention before you speak • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf ), which is one tool for assessment of depressive symptoms, or see the depression section of WHO mhGAP intervention guide 2.0. WHEN SPECIALIZED CARE IS NEEDED • Management of depression requires a more comprehensive and usually specialist approach to develop an individualized care plan. • To manage depressive symptoms , health-care providers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may require specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down • Trouble concentrating on things such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed • Being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS PSYCHOLOGICAL CAPACITY Psychological capacity Care pathways to manage depressive symptoms If a person reports both core symptoms - feeling down, depressed or hopeless and having little interest or pleasure in doing things - make a further assessment of mood. FIRST ASSESS FOR: • physical causes of depression • normal reactions to major loss in the last six months • history of a manic or hypomanic episode. The presence of any of these would suggest a different approach from treatment for depression. DEPRESSIVE SYMPTOMS If a person has both core symptoms and two or fewer additional symptoms, she or he may have depressive symp- toms. It is important to distinguish depressive symptoms from depression because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health-care provider with complaints of mood or behavioural problems, such as apathy, loss of emotional control or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or locomotor capacity, may reduce functional ability and social participation and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the comprehensive care plan. THEN, ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour 3eople with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include () identifying problems in one’s life, () becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). 3roblem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without speciali]ed knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 9 Psychological capacity Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder +istory of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or reTuiring hospitali]ation or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ bipolarBȵowcharthtml). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of $l]heimer’s disease The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 9 Psychological capacity Care pathways to manage depressive symptoms of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with speciali]ed knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. (liminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of vitamins such as folate, vitamin B and vitamin B 'epressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 General social care support 10 Care pathways for social care and support Social care and support )or people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, Tuestions about $'/s and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Ζnterventions tailored to an older person’s priorities can improve functional ability. (ffective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. Do you have difficulty getting around indoors? 2. Do you have difficulty using the toilet (or commode)? 3. Do you have difficulty dressing yourself? 4. Do you have difficulty using the bath or shower? 5. Do you have difficulty keeping up your personal appearance? 6. Do you have difficulty feeding yourself? 7. Do you have problems with the place where you live (accommodation)? 8. Do you have problems with your finances? 9. Do you feel lonely? SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS 1. In general, how do your finances work out at the end of the month? 2. Are you able to manage your money and financial affairs? 3. Would you like advice about financial allowances or benefits? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: 1. cost, 2. distance, 3. transport, 4. lack of opportunities, 5. others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 1 10. Are you able to pursue leisure interests, hobbies, work, volunteering, supporting your family, educational or spiritual activities that are important to you? 11. Assess risk of elder abuse Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • )inances social worker, benefit advisory services WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • 0ultiple inMuries at different stages of healing • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. 2lder people who have difficulties with $'/s and or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimi]e functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s si]e, access, condition, safety and security. Supplementary questions can help to identify specific areas to address 70 Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living )inancial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances )urther Tuestions can help to identify specific areas that need addressing Financial problems can be mitigated though independent advice about financial planning and financial management Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse 71 Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is uniTue and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personali]ed care plan Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access &harges for some of these services may be subsidi]ed to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as at a day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) (xplore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). The financial costs of caregiving, potentially leading to sources of local financial support and organi]ed social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. $ssessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page ) 6upport should reflect the caregiver’s choices and emphasi]e optimi]ing the caregiver’s well-being 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills Ȃ for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability Tualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person" This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. 2eU ps\choOoJicaO suppoUt Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 Introduction 1 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioriti]ed needs and goals • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN 3ersonali]ed care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences 2nce expressed, a personali]ed care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 5eview findinJs and discuss oppoUtunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioriti]e goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 2 78 5. Monitoring and follow-up 0onitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summari]ing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 Introduction 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some specific goals that you have in your life? • QUESTION 3 :hat are some specific goals that you have for your health? • QUESTION 4 %ased on the list of both life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What about in the ne[t si[ to months? SET GOALS: *oals can be adapted to the older people’s needs and their own definition of problems • QUESTION 5 :hat specifically about goal one, two or three would you like to work on over the next three months? :hat about over the ne[t si[ to months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: $greement on prioriti]ed goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat about over the ne[t si[ to months? HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • (ffective implementation of the Ζ&23( approach requires an integrated approach linking health and social care services. • 2ptimi]ing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • 3ersonali]ed care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management The WHO World report on ageing and health set a new direction for health and long-term care systems (1). Ζt called on these systems to focus on optimi]ing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in , translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 Introduction 1 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION $s a first step, both the :+2 recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Ζncentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimi]es intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 3 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility Ȃ financial and organi]ational • sustainability Ȃ efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which :+2 defined in as Ȋthe synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s healthȋ :+2’s knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). :+2’s framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The :+2 Ζ&23( implementation framework emphasi]es the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioriti]e primary and community-based care This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recogni]ing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimi]e community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 Introduction 1 :hen speciali]ed care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective )ollow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 3 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. 'eliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organi]ing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. 2lder people’s clubs and associations are natural allies in this effort At the same time, the health-care system owes a responsibility to its partners in supporting healthy ageing – communities, community organi]ations and the family members and other unpaid caregivers of older people. This responsibility includes attention to the health and well-being of caregivers, as discussed in Chapter 11, and mutual support, collaboration and coordination with communities and community organi]ations to create a healthy environment for healthy ageing. 85 REFERENCES 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa. edu.au/pain-management, accessed 1 May 2019). 10. 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INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/publishing/copyright Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presenta- tion of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Integrated Care of Older People Integrated Care of Older People Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (University Hospital of Getafe, Spain), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez-Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v Integrated Care of Older People The World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being )unctional ability is defined as the Ȋhealth-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age Ȃ a focus on optimi]ing people’s intrinsic capacity and functional ability as they age. Ζn 2ctober , the :orld +ealth 2rgani]ation (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimi]ing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimi]ing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE) Introduction 1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? 2lder people make up a larger part of the world’s population than ever before Ζn , there were an estimated million people aged years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By , one person in every five will be years of age or older This trend began some years ago Ζt reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recogni]e and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people :+2’s Ζ&23( approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose speciali]ed knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice Ζt offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personali]ed care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organi]ing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organi]ations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on :+2’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personali]ed care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve 6'*, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimi]ing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as deYeloping and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Vision impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) 2 How to carry out a person-centred, integrated approach at the primary health-care level OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Vision capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characteri]ed by dependence on care 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective There is a wide range of intrinsic capacity around the average pattern These differences are evident both within and between countries They are reflected in persistent differences in life expectancies, which range from years or more in such countries as Australia, Japan and 6wit]erland, to less than years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY :+2 defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 2 How to carry out a person-centred, integrated approach at the primary health-care level FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity 6ignificant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late life Remove barriers to participants coPpensate for loss of capacity ICOPE APPROACH Many of the characteristics that determine intrinsic capacity can be modified These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimi]e intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline 1utrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: :orld +ealth 2rgani]ation, (1). 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences 3erson-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personali]ed care plan • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimi]e functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY STEP 1 STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 3 Generic care pathway Person-centered assessment and pathways in primary care Priority conditions associated with declines in intrinsic capacity Tests Assess fully if any answer in each domain triggers this COGNITIVE DECLINE (Chapter 4) 5emember three words flower, door, rice (for example) 2rientation in time and space :hat is the full date today" :here are you now (home, clinic, etc)" 5ecalls the three words" LIMITED MOBILITY (Chapter 5) &hair rise test 5ise from chair five times without using arms 'id the person complete five chair rises within seconds" MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months" $ppetite loss +ave you experienced loss of appetite" VISUAL IMPAIRMENT (Chapter 7) 'o you have any problems with your eyes difficulties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)" HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by Ȃ feeling down, depressed or hopeless" Ȃ little interest or pleasure in doing things" Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1) The Ζ&23( screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases Those who show signs of, or report losses in capacity at this first step should go on to a full assessment )ull assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the Ζ&23( screening tool always triggers further in-depth assessment. Findings should inform the development of the personali]ed care plan adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as $l]heimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of speciali]ed geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. 6ocial care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE $ person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimi]ing intrinsic capacity 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organi]ed generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personali]ed care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN 3A. Define with the older person the goal of care The unifying goal of optimizing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions. It is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioritized according to the person’s priorities, needs and preferences. 3B. Design a care plan The person-centred assessment informs the development of a personalized care plan. This personalized care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Generic care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximize their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them. Instead, it recognizes their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls 1utrition enhances the effects of exercise and at the same time increases muscle mass and strength Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personali]ed care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. $ link to speciali]ed geriatric care is also critical +ealth systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when speciali]ed care is needed 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personalized care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with specialized and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personalized care plan. The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitali]ed recently are at greater risk of polypharmacy An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or $l]heimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment Ȃ that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS 'eclines in cognitive capacity can be minimi]ed and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES See malnutrition pathway Ζdentify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events 6 PASS 0ultimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONS ASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers Ζf cognitive decline aects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE 6impOe memoU\ and oUientation test 5ememEeUinJ thUee woUds Ask the person to remember three words that you will say. Use simple, concrete words such as Ȋȵowerȋ, Ȋdoorȋ, Ȋriceȋ 2Uientation in time and space Then, ask, ȊWhat is the full date today?ȋ and ȊWhere are you now?ȋ (home, clinic, etc.)? 5ecaOOinJ thUee woUds Now ask the person to repeat the three words that you mentioned 3ass oU IaiO" If a person cannot answer one of the two questions about orientation OR cannot remember all three words, coJnitive decOine is OiNeO\ and further assessment is called for 'o you have Sroblems with memory or orientation such as not knowing where one is or what day it is ? ASK ? YES 4.1 4.2 5.1 9itamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. 5isk reduction of cognitive decline and dementia W+2 Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education Ζf a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. 6uch a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. ΖI coJnitive decOines aect an oOdeU peUsonȇs aEiOit\ to Iunction eectiveO\ within theiU enviUonment a speciaOi]ed assessment ma\ Ee needed to diaJnose dementia oU $O]heimeUȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mhGAP intervention guide (https://apps.who.int/iris/handle/10665/250239) WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf Brief; minimal language, educational and racial bias 8se of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME 0ontUeaO coJnitive assessment 0o&$ https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min 0ini mentaO state e[amination 006( https://www.parinc.com/products/pkey/237 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min *eneUaO pUactitioneU assessment oI coJnition *3&2* http://gpcog.com.au/index/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS :hat is dementia" Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and tUeat these fiUst 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in &hapter , p ) Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recogni]ed risk for cognitive decline 3ractitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several different Sotential e[Slanations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 4 Cognitive capacity Care pathways to manage cognitive decline • 3eople with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition To reach the best outcomes, these may need to be addressed. Ζndividuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. &oJnitive stimuOation ma\ Ee oeUed to an individuaO oU in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personali]ed intervention for a person with significant declines may reTuire more detailed assessment and planning Ȃ tasks that reTuire speciali]ed skills Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 Care pathways to manage cognitive decline Cognitive capacity 4 Ζf cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximi]es independent activity, enhances function, helps to adapt and develop skills, and minimi]es the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside Ȃ to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities) ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care $ person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not Ζndeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. $dapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Ζntegrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES 3rovide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility 5ecommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise $ multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body $ multimodal exercise programme should be tailored to suit individual capacities and needs The 9iviIUaiO pUoMect offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (633B score Ȃ points) Limited mobility (633B score Ȃ points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Ζnclude falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking Final SPPB score = sum of scores from the three tests above SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities The 633B measures timed performance on three tasks, each scored out of four, to derive a score from ]ero (worst performance) to (best performance) First, describe each test and ask if the person feels able to do it Ζf not, score accordingly and move to the next step 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions 8se the sum of the scores from the three positions 2. Gait speed test: Time to walk four metres (Ζf they use a cane or walking aid and feel they need it to walk a short distance, they may use it) Time for four-metre walk: seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points ! seconds 1 point 8nable to complete 0 points 3. Chair rise test: Time to rise from a chair five times seconds 4 points Ȃ seconds 3 points Ȃ seconds 2 points Ȃ seconds 1 point ! seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory Yitality and psychological capacities Ζf significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests C. Tandem stand Held for 10 seconds 2 points +eld for to seconds 1 point +eld for seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms"ȋ ('emonstrate to the person) If YES, ask them to: Ȃ sit in the middle of the chair Ȃ cross and keep their arms over their chest Ȃ rise to a full standing position and then sit down again Ȃ repeat five times as Tuickly as possible without stopping Time the person taking the test Ȃ further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity Locomotor capacity 5 Care pathways to improve mobility ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in Moint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking ASSESS MOBILITY SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • ȵe[iEiOit\ tUaininJ, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY ASSESS LOCOMOTOR CAPACITY Locomotor capacity 5 Reinforce generic health and life style advice or usual care (SPPB or other physical performance test) Able to complete five chair rises without arms in 14 seconds? TEST LOCOMOTOR CAPACITY CHAIR RISE TEST NO Review medication and aim to reduce Integrated management of diseases (see Chapter 11) Consider rehabilitation, pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN* NO to all Use Brief Pain Inventory (Short form) https://www.aci.health.nsw.gov.au/__data/assets/ pdfBfile %riefB3ainBΖnYentoryB)inalpdf * Care pathways to improve locomotor capacity and mobility YES Recommend multimodal exercise (check 9ivifrail protocol http wwwvivifrailcomresources) Provide dietary advice Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Recommend multimodal exercise at home (check 9ivifrail http wwwvivifrailcomresources) Self-management support to increase adherence Multimodal exercise A multimodal exercise programme for people with mobility impairments combines xercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body. A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities; http://www.vivifrail.com/resources For WHO recommendations about multimodal exercise, see 5.1 5.3 5.2.1 5.2 5.4 3 Normal locomotor capacity (SPPB score 10–12 points) 0ild loss of locomotor capacity (SPPB score 7–9 points) 0oderate to severe loss of locomotor capacity (SPPB score 0–6 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SPECIFIC SOCIAL CARE NEEDS ASSESS & MANAGE Assess physical environment to reduce risk of falls Include fall prevention interventions such as home adapations Consider and provide use of assistive device to aid mobility Provide safe spaces for walking Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? 7he 9iviIUaiO pUoMect oeUs a pUacticaO Juide to deveOopinJ a tailored exercise programme. http://www.vivifrail.com/resources 6 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme 3eople whose 633B scores are in the range of Ȃ can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY $ll older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions This box summari]es :+2’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • )or additional benefit, do minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 SELF-MANAGEMENT SUPPORT Support for self-management increases adherence to and the benefits of a multimodal exercise programme The WHO Mobile Health for Ageing (mAgeing) handbook can complement health-care professionals’ routine care by supporting self-care and self-management For more information: http://www.who.int/ageing/ health-systems/mAgeing/en/ Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • ben]odia]epines • nonben]odia]epine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. (liminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets pdfBfile %riefB3ainBΖnventoryB)inalpdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain $ specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep :here pain is a significant barrier to movement and activity, a health professional with speciali]ed knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and Moint mobili]ation • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities The first step is to assess social care needs (see &hapter ) 6pecific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible ha]ards and offer suggestions (xamples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps $ person’s specific mobility limitations will guide what environmental adaptations are most important. :ith specific training, a community- or facility-based primary care provider can assess a person’s home Ζf a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. $ full assessment and management of a person’s risk of falls reTuires speciali]ed knowledge 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and Moint function and flexibility • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as 3arkinson’s disease 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health $ full assessment of nutritional status reTuires speciali]ed knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins ' and B are common Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES 2ffer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) 2ffer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet $ll older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • +elp people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire (https wwwȵintbo[compublicproMect) Short nutritional assessment questionnaire 65+ (SNAQ65+) (http wwwfightmalnutritioneutoolkits summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding question) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m2) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can squeeze the tool with one hand. Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION )or a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with speciali]ed knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals 6peciali]ed knowledge is needed to develop a plan for 261 that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an 01$ score of Ȃ) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume sufficient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through speciali]ed commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test $ blood test informs the personali]ed nutritional plan $ blood test can identify specific vitamin and mineral deficiencies 6pecific oral nutrient supplements or inMections can treat these deficiencies )or example, tablets or inMections are needed to treat deficiencies in vitamins ' and B, which are common KEY POINTS ABOUT OSN • )ood comes first 8nless the need for 261 is urgent, improvements in diet, if possible, and more frequent meals should be tried first • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of 261 $ variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health )or example, community organi]ations might organi]e social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. 9isual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks 6uch difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. $ssistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment Review and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES Do off-the-shelf simple reading glasses solve the problem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK Do you have any problems with your eyes: difficulties in seeing far, reading, eye diseases or currently under medical treatment (e.g. diabetes, high blood pressure)? Have not seen a doctor in the previous year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test distance and near vision to find the smallest ( each person can see 1. Test with the four small Es at 3 m. Vision is normal (6/18 or better) if the direction of at least three out of four small Es can be seen. If not able to see at least three of the large Es, … 2. … test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es, … 3. … test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as he/she wants. Test from the largest to the smallest Es. At least three out of four must be correct in each line before testing the next. If only the largest size (N48) can be seen, check if off-the-shelf simple reading glasses will help Ζf not, refer for a comprehensive eye and vision examination and specialized eye care. The medium size (N20) is similar to the print in large-print books The smallest size (N8) is similar to print in books and magazines. 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED Ζf a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • $ primary health-care provider can perform the screening It does not require formal training in eye care assessment (13). • Ζf off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment 5eview and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES 'o offtheshelf simSle reading glasses solve the Sroblem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK 'o you have any Sroblems with your eyes diɝculties in seeing far, reading, eye diseases or currently under medical treatment e.g. diabetes, high blood Sressure ? +ave not seen a doctor in the Srevious year FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT (14) Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 43 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • /arge (s are cm x cm, at cm from each other • Full black E on plain white paper. 45 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for specialized eye care. • A primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, specialized eye care is recommended. ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently. For these people, assistive vision devices – desk or mobile magnifiers – provide greater magnification than glasses. They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning – skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES Many people aged 50 years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called “readers”). Simple reading glasses are available at low cost. They are often available in various magnification strengths. Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid. Examples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. Hazards such as furniture and other hard objects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 Fail in distance vision always requires referral for comprehensive care 7 Care pathways to manage visual impairment Visual capacity 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitali]ations and early death Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them reTuires speciali]ed knowledge and eTuipment 51 Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: ≥ 81 dB) Normal hearing capacity (Audiometry: ≤ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) Normal locomotor capacity (SPPB score 10–12 points) Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness ($udiometry Ȳ dB) Normal hearing capacity ($udiometry ȱ dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1 Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing :ith brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST $n automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING ASSE HEARING CAPACITY (Diagnostic audiometry) GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. $sk the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the patient can hear you clearly, then the patient is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear 8se different words 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ fire – number Ȃ fish – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. Older adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted. Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs specialized training. Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at frequencies from 125 Hz (very low) to 8000 Hz (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity $ny cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroTuine 2ther medications also can affect hearing Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need speciali]ed hearing care such as the fitting of a hearing device Providing hearing devices needs specialized skills for testing, prescription and fittinJ MANAGE HEARING LOSS 2theU Ued ȵaJs IoU speciaOi]ed hearing care Conditions that may underlie hearing loss need speciali]ed diagnosis and management These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • di]]iness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. &ochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use $ cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. $udio induction Ooops and peUsonaO sound ampOifieUs $udio induction loops and personal sound amplifiers are also effective $n audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries oer Pore guidance http appswhointirishandle 56 8 Care pathways to manage hearing loss Hearing capacity 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS 0inimi]ing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organi]e activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • *et the person’s attention before you speak • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf ), which is one tool for assessment of depressive symptoms, or see the depression section of WHO mhGAP intervention guide 2.0. WHEN SPECIALIZED CARE IS NEEDED • Management of depression requires a more comprehensive and usually specialist approach to develop an individualized care plan. • To manage depressive symptoms , health-care providers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may require specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down • Trouble concentrating on things such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed • Being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS PSYCHOLOGICAL CAPACITY Psychological capacity Care pathways to manage depressive symptoms If a person reports both core symptoms - feeling down, depressed or hopeless and having little interest or pleasure in doing things - make a further assessment of mood. FIRST ASSESS FOR: • physical causes of depression • normal reactions to major loss in the last six months • history of a manic or hypomanic episode. The presence of any of these would suggest a different approach from treatment for depression. DEPRESSIVE SYMPTOMS If a person has both core symptoms and two or fewer additional symptoms, she or he may have depressive symp- toms. It is important to distinguish depressive symptoms from depression because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health-care provider with complaints of mood or behavioural problems, such as apathy, loss of emotional control or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or locomotor capacity, may reduce functional ability and social participation and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the comprehensive care plan. THEN, ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in brief structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* 9 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION (Ȳ additional symptoms) DEPRESSIVE SYMPTOMS (Ȃ additional symptoms) Psychological capacity 9 NO NO (to either of the above) (to all) YESCare pathways to manage depressive symptoms https appswhointirishandle Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Vision impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE 2ffer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour 3eople with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include () identifying problems in one’s life, () becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). 3roblem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without speciali]ed knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 9 Psychological capacity Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder +istory of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or reTuiring hospitali]ation or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ bipolarBȵowcharthtml). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of $l]heimer’s disease The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 9 Psychological capacity Care pathways to manage depressive symptoms of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with speciali]ed knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. (liminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of vitamins such as folate, vitamin B and vitamin B 'epressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 General social care support 10 Care pathways for social care and support Social care and support )or people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, Tuestions about $'/s and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Ζnterventions tailored to an older person’s priorities can improve functional ability. (ffective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. Do you have difficulty getting around indoors? 2. Do you have difficulty using the toilet (or commode)? 3. Do you have difficulty dressing yourself? 4. Do you have difficulty using the bath or shower? 5. Do you have difficulty keeping up your personal appearance? 6. Do you have difficulty feeding yourself? 7. Do you have problems with the place where you live (accommodation)? 8. Do you have problems with your finances? 9. Do you feel lonely? SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS 1. In general, how do your finances work out at the end of the month? 2. Are you able to manage your money and financial affairs? 3. Would you like advice about financial allowances or benefits? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: 1. cost, 2. distance, 3. transport, 4. lack of opportunities, 5. others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 1 10. Are you able to pursue leisure interests, hobbies, work, volunteering, supporting your family, educational or spiritual activities that are important to you? 11. Assess risk of elder abuse Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • )inances social worker, benefit advisory services WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • 0ultiple inMuries at different stages of healing • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. 2lder people who have difficulties with $'/s and or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimi]e functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s si]e, access, condition, safety and security. Supplementary questions can help to identify specific areas to address 70 Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living )inancial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances )urther Tuestions can help to identify specific areas that need addressing Financial problems can be mitigated though independent advice about financial planning and financial management Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse 71 Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is uniTue and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personali]ed care plan Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access &harges for some of these services may be subsidi]ed to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as at a day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) (xplore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). The financial costs of caregiving, potentially leading to sources of local financial support and organi]ed social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. $ssessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page ) 6upport should reflect the caregiver’s choices and emphasi]e optimi]ing the caregiver’s well-being 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills Ȃ for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability Tualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person" This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. 2eU ps\choOoJicaO suppoUt Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 Introduction 1 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioriti]ed needs and goals • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN 3ersonali]ed care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences 2nce expressed, a personali]ed care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 5eview findinJs and discuss oppoUtunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioriti]e goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 2 78 5. Monitoring and follow-up 0onitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summari]ing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 Introduction 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some specific goals that you have in your life? • QUESTION 3 :hat are some specific goals that you have for your health? • QUESTION 4 %ased on the list of both life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What about in the ne[t si[ to months? SET GOALS: *oals can be adapted to the older people’s needs and their own definition of problems • QUESTION 5 :hat specifically about goal one, two or three would you like to work on over the next three months? :hat about over the ne[t si[ to months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: $greement on prioriti]ed goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat about over the ne[t si[ to months? HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • (ffective implementation of the Ζ&23( approach requires an integrated approach linking health and social care services. • 2ptimi]ing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • 3ersonali]ed care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management The WHO World report on ageing and health set a new direction for health and long-term care systems (1). Ζt called on these systems to focus on optimi]ing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in , translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 Introduction 1 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION $s a first step, both the :+2 recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Ζncentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimi]es intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 3 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility Ȃ financial and organi]ational • sustainability Ȃ efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which :+2 defined in as Ȋthe synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s healthȋ :+2’s knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). :+2’s framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The :+2 Ζ&23( implementation framework emphasi]es the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioriti]e primary and community-based care This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recogni]ing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimi]e community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 Introduction 1 :hen speciali]ed care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective )ollow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 3 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. 'eliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organi]ing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. 2lder people’s clubs and associations are natural allies in this effort At the same time, the health-care system owes a responsibility to its partners in supporting healthy ageing – communities, community organi]ations and the family members and other unpaid caregivers of older people. This responsibility includes attention to the health and well-being of caregivers, as discussed in Chapter 11, and mutual support, collaboration and coordination with communities and community organi]ations to create a healthy environment for healthy ageing. 85 REFERENCES 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa. edu.au/pain-management, accessed 1 May 2019). 10. 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INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook 1
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/publishing/copyright Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presenta- tion of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (Institutos Nacionales de Salud de México, Mexico), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez- Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège, Belgium). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v
The 2015 World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being. Functional ability is defined as the “health-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age – a focus on optimizing people’s intrinsic capacity and functional ability as they age. In October 2017, the World Health Organization (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimizing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimizing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? Older people make up a larger part of the world’s population than ever before. In 2017, there were an estimated 962 million people aged 60 years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By 2050, one person in every five will be 60 years of age or older. This trend began some 50 years ago. It reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing. The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recognize and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people. WHO’s ICOPE approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose specialized knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice. It offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personalized care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. 2 GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organizing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organizations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on WHO’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personalized care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve SDG3, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimizing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as developing and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Visual impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Visual capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characterized by dependence on care. 2 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective. There is a wide range of intrinsic capacity around the average pattern. These differences are evident both within and between countries. They are reflected in persistent differences in life expectancies, which range from 82 years or more in such countries as Australia, Japan and Switzerland, to less than 55 years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of 10 years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY WHO defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE Many of the characteristics that determine intrinsic capacity can be modified. These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimize intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline. Nutrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: World Health Organization, 2015 (1). High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity Significant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late liIe Remove barriers to participants compensate Ior loss oI capacity ICOPE APPROACH 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences. Person-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personalized care plan. • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimize functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 Priority conditions associated with declines in intrinsic capacity Tests Assess fully any domain with a checked circle COGNITIVE DECLINE (Chapter 4) 1. Remember three words: flower, door, rice (for example) 2. Orientation in time and space: What is the full date today? Where are you now (home, clinic, etc)? 3. Recalls the three words? LIMITED MOBILITY (Chapter 5) Chair rise test: Rise from chair five times without using arms. Did the person complete five chair rises within 14 seconds? MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months? 2. Appetite loss: Have you experienced loss of appetite? VISUAL IMPAIRMENT (Chapter 7) Do you have any problems with your eyes: difficulties in seeing far, reading, eye diseases or currently under medical treatment (e.g. diabetes, high blood pressure)? HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by – feeling down, depressed or hopeless? – little interest or pleasure in doing things? Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 12 STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1). The ICOPE screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases. Those who show signs of, or report losses in capacity at this first step should go on to a full assessment. Full assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the ICOPE screening tool always triggers further in-depth assessment. Findings should inform the development of the personalized care plan. adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as Alzheimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of specialized geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. Social care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions. STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE A person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimizing intrinsic capacity. 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organized generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personalized care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN 3A. Define with the older person the goal of care The unifying goal of optimizing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions. It is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioritized according to the person’s priorities, needs and preferences. 3B. Design a care plan The person-centred assessment informs the development of a personalized care plan. This personalized care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Generic care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximize their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them. Instead, it recognizes their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains. For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls. Nutrition enhances the effects of exercise and at the same time increases muscle mass and strength. Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personalized care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. A link to specialized geriatric care is also critical. Health systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when specialized care is needed. 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personalized care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with specialized and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personalized care plan. The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitalized recently are at greater risk of polypharmacy. An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect. How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity; • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or Alzheimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment – that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS Declines in cognitive capacity can be minimized and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES – DEPRESSIVE SYMPTOMS See malnutrition pathway Identify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events See depressive symptoms pathway 6 9 PASS Multimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONSASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers If cognitive decline affects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete words such as “flower”, “door”, “rice” 2. Orientation in time and space: Then, ask, “What is the full date today?” and “Where are you now?” (home, clinic, etc.)? 3. Recalling three words: Now ask the person to repeat the three words that you mentioned Pass or fail? If a person cannot answer one of the two questions about orientation OR cannot remember all three words, cognitive decline is likely and further assessment is called for Do you have problems with memory or orientation (such as not knowing where one is or what day it is)? ASK ? YES 4.1 4.2 5.1 Vitamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. Risk reduction of cognitive decline and dementia: WHO Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education. If a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities. Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. Such a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. Ζf cognitive declines affect an older personȇs ability to function effectively within their environment a specialized assessment may be needed to diagnose dementia or Alzheimerȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mh*$3 intervention guide https://apps.who.int/iris/handle/10665/250239 WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://minicog.com/wpcontent/uploads/2015/ 12/8niversal0ini&og)orm011916.pdf Brief; minimal language, educational and racial bias Use of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME Montreal cognitive assessment (MoCA) https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min Mini mental state examination (MMSE) https://www.parinc.com/products/pNey/23 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min General practitioner assessment of cognition (GPCOG) http://gpcog.com.au/inde[/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS What is dementia? Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. 21 Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and treat these first. 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in Chapter 3, p. 18). Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recognized risk for cognitive decline. Practitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several dierent potential e[planations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 22 4 Cognitive capacity Care pathways to manage cognitive decline • People with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition. To reach the best outcomes, these may need to be addressed. Individuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. Cognitive stimulation may be offered to an individual or in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personalized intervention for a person with significant declines may require more detailed assessment and planning – tasks that require specialized skills. Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 23 Care pathways to manage cognitive decline Cognitive capacity 4 If cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximizes independent activity, enhances function, helps to adapt and develop skills, and minimizes the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside – to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities). ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 24 Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care. A person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not. Indeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. Adapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. 25 ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) $Ele to complete ȴve chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Integrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility Recommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise A multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 30 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (SPPB score 10–12 points) Limited mobility (SPPB score 0–9 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Include falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities. The SPPB measures timed performance on three tasks, each scored out of four, to derive a score from zero (worst performance) to 12 (best performance). First, describe each test and ask if the person feels able to do it. If not, score accordingly and move to the next step. 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions. Use the sum of the scores from the three positions. 2. Gait speed test: Time to walk four metres. Time for four-metre walk: < 4.82 seconds 4 points 4.82 – 6.20 seconds 3 points 6.21 – 8.70 seconds 2 points > 8.70 seconds 1 point Unable to complete 0 points 3. Chair rise test: Time to rise from a chair five times < 11.19 seconds 4 points 11.2 – 13.69 seconds 3 points 13.7 – 16.69 seconds 2 points 16.7 – 59.9 seconds 1 point > 60 seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory vitality and psychological capacities ΖI significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. C. Tandem stand Held for 10 seconds 2 points Held for 3 to 9.99 seconds 1 point Held for < 3 seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility. Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms?” (Demonstrate to the person.) If YES, ask them to: – sit in the middle of the chair – cross and keep their arms over their chest – rise to a full standing position and then sit down again – repeat five times as quickly as possible without stopping. Time the person taking the test – further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST Final SPPB score = sum of scores from the three tests above. More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity 27 Locomotor capacity 5 Care pathways to improve mobility The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in joint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS MOBILITY 28 Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut; examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • flexibility training, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? The Vivifrail project offers a practical guide to developing a tailored exercise programme. http://www.vivifrail.com/resources 6 29 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme. People whose SPPB scores are in the range of 10–12 can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY All older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions. This box summarizes WHO’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • For additional benefit, do 300 minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • benzodiazepines • nonbenzodiazepine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. Eliminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets/ pdfBȴle/0015/212910/%riefB3ainBInventoryB)inal.pdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain. A specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep. Where pain is a significant barrier to movement and activity, a health professional with specialized knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and joint mobilization • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities. The first step is to assess social care needs (see Chapter 10). Specific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible hazards and offer suggestions. Examples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps. A person’s specific mobility limitations will guide what environmental adaptations are most important. With specific training, a community- or facility-based primary care provider can assess a person’s home. If a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. A full assessment and management of a person’s risk of falls requires specialized knowledge. 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and joint function and flexibility; • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as Parkinson’s disease. 32 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health. A full assessment of nutritional status requires specialized knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins D and B12 are common. Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES Offer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) Offer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet. All older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • Help people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire https://www.ȵintEo[.com/puElic/proMect/250/ Short nutritional assessment questionnaire 65+ (SNAQ65+) http://www.ȴghtmalnutrition.eu/toolNits/ summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding question) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m2) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can squeeze the tool with one hand. Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION For a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with specialized knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals. Specialized knowledge is needed to develop a plan for OSN that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an MNA score of 17–23.5) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume suɝcient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through specialized commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test A blood test informs the personalized nutritional plan. A blood test can identify specific vitamin and mineral deficiencies. Specific oral nutrient supplements or injections can treat these deficiencies. For example, tablets or injections are needed to treat deficiencies in vitamins D and B12, which are common. KEY POINTS ABOUT OSN • Food comes first. Unless the need for OSN is urgent, improvements in diet, if possible, and more frequent meals should be tried first. • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of OSN. A variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health. For example, community organizations might organize social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. Visual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks. Such difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss. Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. Assistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment Review and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES Do otheshelf simple reading glasses solve the problem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK Do you have any problems with your eyes: diɝculties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)? FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT () Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test from the small Es to large Es. 1. Test with the four small Es at 3 metres. Vision is 6/18 or better if the direction of at least three out of four small Es can be seen (PASS the distance vision screening test). If not able to see at least three of the small Es (FAIL the distance vision screening test) require assessment of visual impairment and eye diseases. The additional tests below might help estimate visual acuity. 2. Test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es at 3 metres 3. Test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as s/he wants. Test from the largest to the smallest Es. If the person identifies the directions of at least three out of four largest Es, s/he PASS the near vision screening test. If not, check if off-the-shelf reading glasses will help. With the reading glasses, if not able to see at least three of the largest Es (FAIL the near vision screening test), require assessment of visual impairment and eye diseases. The medium size is similar to the print in books. The smallest size is similar to the smallest print in books and magazines (not required to be seen). 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED If a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • A primary health-care provider can perform the screening. It does not require formal training in eye care assessment (13). • If off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… 43 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • Large Es are 4.2cm x 4.2cm, at 4.5cm from each other • Full black E on plain white paper. 45 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for specialized eye care. • A primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, specialized eye care is recommended. ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently. For these people, assistive vision devices – desk or mobile magnifiers – provide greater magnification than glasses. They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning – skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES Many people aged 50 years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called “readers”). Simple reading glasses are available at low cost. They are often available in various magnification strengths. Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid. Examples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. Hazards such as furniture and other hard objects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitalizations and early death. Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs. KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them requires specialized knowledge and equipment. 51 Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: Ȳ 81 dB) Normal hearing capacity (Audiometry: ȱ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing. With brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST An automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. Ask the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the s/he can hear you clearly, then the person is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear. Use different words. 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ ȴre – number Ȃ ȴsh – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. Older adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted. Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs specialized training. Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at frequencies from 125 Hz (very low) to 8000 Hz (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity. Any cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroquine. Other medications also can affect hearing. Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need specialized hearing care such as the fitting of a hearing device. Providing hearing devices needs specialized skills for testing, prescription and fitting. MANAGE HEARING LOSS Other red flags for specialized hearing care Conditions that may underlie hearing loss need specialized diagnosis and management. These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • dizziness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder. They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. Cochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use. A cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. Audio induction loops and personal sound amplifiers. Audio induction loops and personal sound amplifiers are also effective. An audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries offer more guidance: http://apps.who.int/iris/handle/10665/3066 56 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Minimizing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organize activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • Get the person’s attention before you speak. • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing. This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle/10665/250239 KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. Psychological capacity Care pathways to manage depressive symptoms 9 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION Ȳ 3 additional symptoms DEPRESSIVE SYMPTOMS 0Ȃ2 additional symptoms Psychological capacity 9 NO NO to either of the aEove to all YESCare pathways to manage depressive symptoms https://apps.who.int/iris/handle/10665/250239 Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Visiual impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Offer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in ErieI structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ. • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: Ȋ2ver the last two weeNs have you Eeen Eothered Ey any of the following proElems"ȋ 9 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour. People with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include (1) identifying problems in one’s life, (2) becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). Problem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems. MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without specialized knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 62 9 Psychological capacity Care pathways to manage depressive symptoms Psychological capacity 9 Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder. History of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or requiring hospitalization or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ EipolarBȵowchart.html). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of Alzheimer’s disease. The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 Psychological capacity 9 Care pathways to manage depressive symptoms 9 Psychological capacity Care pathways to manage depressive symptoms 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with specialized knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. Eliminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of iron, vitamins such as folate, vitamin B6 and vitamin B12. Depressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 10 Care pathways for social care and support Social care and support For people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, questions about ADLs and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Interventions tailored to an older person’s priorities can improve functional ability. Effective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • Finances: social worker, benefit advisory services. WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • Multiple injuries at different stages of healing. • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. Older people who have difficulties with ADLs and/ or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimize functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s size, access, condition, safety and security. Supplementary questions can help to identify specific areas to address. 70 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living. Financial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances. Further questions can help to identify specific areas that need addressing. Financial problems can be mitigated though independent advice about financial planning and financial management. Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse. 71 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is unique and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personalized care plan. Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access. Charges for some of these services may be subsidized to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 72 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk. A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) Explore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. 2. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). 3. The financial costs of caregiving, potentially leading to sources of local financial support and organized social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. Assessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page 77). Support should reflect the caregiver’s choices and emphasize optimizing the caregiver’s well-being. 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills – for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability qualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person? This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. Offer psychological support. Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioritized needs and goals. • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN Personalized care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences. Once expressed, a personalized care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 1. Review findings and discuss opportunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioritize goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to 12 months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 12 78 5. Monitoring and follow-up Monitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summarizing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions. 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some speciȴc goals that you have in your life? • QUESTION 3 :hat are some speciȴc goals that you have for your health? • QUESTION 4 %ased on the list of Eoth life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What aEout in the ne[t si[ to 12 months" SET GOALS: Goals can be adapted to the older people’s needs and their own definition of problems. • QUESTION 5 :hat speciȴcally aEout goal one two or three would you like to work on over the next three months" :hat aEout over the ne[t si[ to 12 months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: Agreement on prioritized goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat aEout over the ne[t si[ to 12 months" HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • Effective implementation of the ICOPE approach requires an integrated approach linking health and social care services. • Optimizing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • Personalized care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management. The WHO World report on ageing and health set a new direction for health and long-term care systems (1). It called on these systems to focus on optimizing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in 2017, translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION As a first step, both the WHO recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations. Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Incentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimizes intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 13 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility – financial and organizational • sustainability – efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 82 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which WHO defined in 2005 as “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health”. WHO’s 2012 knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). WHO’s 2016 framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The WHO ICOPE implementation framework emphasizes the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care. The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioritize primary and community-based care. This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recognizing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimize community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 When specialized care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective. Follow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 13 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. Deliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organizing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. Older people’s clubs and associations are natural allies in this effort. At the same time, the health-care system owes a responsibility to its partners in supporting healthy ageing – communities, community organizations and the family members and other unpaid caregivers of older people. This responsibility includes attention to the health and well-being of caregivers, as discussed in Chapter 11, and mutual support, collaboration and coordination with communities and community organizations to create a healthy environment for healthy ageing. 85 REFERENCES 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa. edu.au/pain-management, accessed 1 May 2019). 10. Assistive devices and technologies. Geneva: WHO; no date (https://www.who.int/disabilities/technology, accessed 1 May 2019). 11. Texas Department of Aging and Disability Services. 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Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/S2214-109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128(6):3925–36. doi: 10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with dementia living in the community. J Am Med Dir Assoc. 2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. 86 24. Knowledge translation. Geneva: WHO; no date (https://www.who. int/ageing/projects/knowledge_translation, accessed 2 April 2019). 25. Integrated care for older people: Guidance for systems and services. Geneva: WHO; 2019 (https://apps.who.int/iris/ handle/10665/325669, accessed June 2019). 26. Community-based health workers (CHWs). Geneva: WHO; no date (https://www.who.int/hrh/community, accessed 2 April 2019). 87 www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook 1
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/publishing/copyright Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presenta- tion of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (Institutos Nacionales de Salud de México, Mexico), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez- Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège, Belgium). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v
The 2015 World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being. Functional ability is defined as the “health-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age – a focus on optimizing people’s intrinsic capacity and functional ability as they age. In October 2017, the World Health Organization (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimizing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimizing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? Older people make up a larger part of the world’s population than ever before. In 2017, there were an estimated 962 million people aged 60 years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By 2050, one person in every five will be 60 years of age or older. This trend began some 50 years ago. It reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing. The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recognize and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people. WHO’s ICOPE approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose specialized knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice. It offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personalized care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. 2 GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organizing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organizations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on WHO’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personalized care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve SDG3, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimizing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as developing and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Visual impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Visual capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characterized by dependence on care. 2 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective. There is a wide range of intrinsic capacity around the average pattern. These differences are evident both within and between countries. They are reflected in persistent differences in life expectancies, which range from 82 years or more in such countries as Australia, Japan and Switzerland, to less than 55 years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of 10 years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY WHO defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE Many of the characteristics that determine intrinsic capacity can be modified. These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimize intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline. Nutrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: World Health Organization, 2015 (1). High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity Significant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late liIe Remove barriers to participants compensate Ior loss oI capacity ICOPE APPROACH 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences. Person-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personalized care plan. • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimize functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 Priority conditions associated with declines in intrinsic capacity Tests Assess fully any domain with a checked circle COGNITIVE DECLINE (Chapter 4) 1. Remember three words: flower, door, rice (for example) 2. Orientation in time and space: What is the full date today? Where are you now (home, clinic, etc)? 3. Recalls the three words? LIMITED MOBILITY (Chapter 5) Chair rise test: Rise from chair five times without using arms. Did the person complete five chair rises within 14 seconds? MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months? 2. Appetite loss: Have you experienced loss of appetite? VISUAL IMPAIRMENT (Chapter 7) Do you have any problems with your eyes: difficulties in seeing far, reading, eye diseases or currently under medical treatment (e.g. diabetes, high blood pressure)? HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by – feeling down, depressed or hopeless? – little interest or pleasure in doing things? Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 12 STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1). The ICOPE screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases. Those who show signs of, or report losses in capacity at this first step should go on to a full assessment. Full assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the ICOPE screening tool always triggers further in-depth assessment. Findings should inform the development of the personalized care plan. adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as Alzheimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of specialized geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. Social care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions. STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE A person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimizing intrinsic capacity. 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organized generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personalized care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN 3A. Define with the older person the goal of care The unifying goal of optimizing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions. It is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioritized according to the person’s priorities, needs and preferences. 3B. Design a care plan The person-centred assessment informs the development of a personalized care plan. This personalized care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Generic care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximize their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them. Instead, it recognizes their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains. For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls. Nutrition enhances the effects of exercise and at the same time increases muscle mass and strength. Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personalized care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. A link to specialized geriatric care is also critical. Health systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when specialized care is needed. 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personalized care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with specialized and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personalized care plan. The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitalized recently are at greater risk of polypharmacy. An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect. How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity; • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or Alzheimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment – that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS Declines in cognitive capacity can be minimized and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES – DEPRESSIVE SYMPTOMS See malnutrition pathway Identify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events See depressive symptoms pathway 6 9 PASS Multimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONSASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers If cognitive decline affects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete words such as “flower”, “door”, “rice” 2. Orientation in time and space: Then, ask, “What is the full date today?” and “Where are you now?” (home, clinic, etc.)? 3. Recalling three words: Now ask the person to repeat the three words that you mentioned Pass or fail? If a person cannot answer one of the two questions about orientation OR cannot remember all three words, cognitive decline is likely and further assessment is called for Do you have problems with memory or orientation (such as not knowing where one is or what day it is)? ASK ? YES 4.1 4.2 5.1 Vitamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. Risk reduction of cognitive decline and dementia: WHO Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education. If a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities. Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. Such a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. Ζf cognitive declines affect an older personȇs ability to function effectively within their environment a specialized assessment may be needed to diagnose dementia or Alzheimerȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mh*$3 intervention guide https://apps.who.int/iris/handle/10665/250239 WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://minicog.com/wpcontent/uploads/2015/ 12/8niversal0ini&og)orm011916.pdf Brief; minimal language, educational and racial bias Use of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME Montreal cognitive assessment (MoCA) https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min Mini mental state examination (MMSE) https://www.parinc.com/products/pNey/23 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min General practitioner assessment of cognition (GPCOG) http://gpcog.com.au/inde[/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS What is dementia? Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. 21 Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and treat these first. 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in Chapter 3, p. 18). Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recognized risk for cognitive decline. Practitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several dierent potential e[planations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 22 4 Cognitive capacity Care pathways to manage cognitive decline • People with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition. To reach the best outcomes, these may need to be addressed. Individuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. Cognitive stimulation may be offered to an individual or in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personalized intervention for a person with significant declines may require more detailed assessment and planning – tasks that require specialized skills. Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 23 Care pathways to manage cognitive decline Cognitive capacity 4 If cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximizes independent activity, enhances function, helps to adapt and develop skills, and minimizes the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside – to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities). ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 24 Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care. A person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not. Indeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. Adapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. 25 ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) $Ele to complete ȴve chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Integrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility Recommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise A multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 30 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (SPPB score 10–12 points) Limited mobility (SPPB score 0–9 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Include falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities. The SPPB measures timed performance on three tasks, each scored out of four, to derive a score from zero (worst performance) to 12 (best performance). First, describe each test and ask if the person feels able to do it. If not, score accordingly and move to the next step. 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions. Use the sum of the scores from the three positions. 2. Gait speed test: Time to walk four metres. Time for four-metre walk: < 4.82 seconds 4 points 4.82 – 6.20 seconds 3 points 6.21 – 8.70 seconds 2 points > 8.70 seconds 1 point Unable to complete 0 points 3. Chair rise test: Time to rise from a chair five times < 11.19 seconds 4 points 11.2 – 13.69 seconds 3 points 13.7 – 16.69 seconds 2 points 16.7 – 59.9 seconds 1 point > 60 seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory vitality and psychological capacities ΖI significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. C. Tandem stand Held for 10 seconds 2 points Held for 3 to 9.99 seconds 1 point Held for < 3 seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility. Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms?” (Demonstrate to the person.) If YES, ask them to: – sit in the middle of the chair – cross and keep their arms over their chest – rise to a full standing position and then sit down again – repeat five times as quickly as possible without stopping. Time the person taking the test – further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST Final SPPB score = sum of scores from the three tests above. More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity 27 Locomotor capacity 5 Care pathways to improve mobility The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in joint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS MOBILITY 28 Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut; examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • flexibility training, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? The Vivifrail project offers a practical guide to developing a tailored exercise programme. http://www.vivifrail.com/resources 6 29 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme. People whose SPPB scores are in the range of 10–12 can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY All older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions. This box summarizes WHO’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • For additional benefit, do 300 minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • benzodiazepines • nonbenzodiazepine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. Eliminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets/ pdfBȴle/0015/212910/%riefB3ainBInventoryB)inal.pdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain. A specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep. Where pain is a significant barrier to movement and activity, a health professional with specialized knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and joint mobilization • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities. The first step is to assess social care needs (see Chapter 10). Specific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible hazards and offer suggestions. Examples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps. A person’s specific mobility limitations will guide what environmental adaptations are most important. With specific training, a community- or facility-based primary care provider can assess a person’s home. If a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. A full assessment and management of a person’s risk of falls requires specialized knowledge. 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and joint function and flexibility; • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as Parkinson’s disease. 32 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health. A full assessment of nutritional status requires specialized knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins D and B12 are common. Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES Offer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) Offer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet. All older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • Help people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire https://www.ȵintEo[.com/puElic/proMect/250/ Short nutritional assessment questionnaire 65+ (SNAQ65+) http://www.ȴghtmalnutrition.eu/toolNits/ summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding question) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m2) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can squeeze the tool with one hand. Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION For a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with specialized knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals. Specialized knowledge is needed to develop a plan for OSN that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an MNA score of 17–23.5) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume suɝcient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through specialized commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test A blood test informs the personalized nutritional plan. A blood test can identify specific vitamin and mineral deficiencies. Specific oral nutrient supplements or injections can treat these deficiencies. For example, tablets or injections are needed to treat deficiencies in vitamins D and B12, which are common. KEY POINTS ABOUT OSN • Food comes first. Unless the need for OSN is urgent, improvements in diet, if possible, and more frequent meals should be tried first. • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of OSN. A variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health. For example, community organizations might organize social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. Visual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks. Such difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss. Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. Assistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment Review and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES Do otheshelf simple reading glasses solve the problem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK Do you have any problems with your eyes: diɝculties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)? FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT () Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test from the small Es to large Es. 1. Test with the four small Es at 3 metres. Vision is 6/18 or better if the direction of at least three out of four small Es can be seen (PASS the distance vision screening test). If not able to see at least three of the small Es (FAIL the distance vision screening test) require assessment of visual impairment and eye diseases. The additional tests below might help estimate visual acuity. 2. Test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es at 3 metres 3. Test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as s/he wants. Test from the largest to the smallest Es. If the person identifies the directions of at least three out of four largest Es, s/he PASS the near vision screening test. If not, check if off-the-shelf reading glasses will help. With the reading glasses, if not able to see at least three of the largest Es (FAIL the near vision screening test), require assessment of visual impairment and eye diseases. The medium size is similar to the print in books. The smallest size is similar to the smallest print in books and magazines (not required to be seen). 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED If a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • A primary health-care provider can perform the screening. It does not require formal training in eye care assessment (13). • If off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… 43 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • Large Es are 4.2cm x 4.2cm, at 4.5cm from each other • Full black E on plain white paper. 45 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for specialized eye care. • A primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, specialized eye care is recommended. ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently. For these people, assistive vision devices – desk or mobile magnifiers – provide greater magnification than glasses. They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning – skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES Many people aged 50 years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called “readers”). Simple reading glasses are available at low cost. They are often available in various magnification strengths. Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid. Examples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. Hazards such as furniture and other hard objects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitalizations and early death. Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs. KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them requires specialized knowledge and equipment. 51 Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: Ȳ 81 dB) Normal hearing capacity (Audiometry: ȱ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing. With brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST An automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. Ask the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the s/he can hear you clearly, then the person is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear. Use different words. 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ ȴre – number Ȃ ȴsh – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. Older adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted. Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs specialized training. Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at frequencies from 125 Hz (very low) to 8000 Hz (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity. Any cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroquine. Other medications also can affect hearing. Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need specialized hearing care such as the fitting of a hearing device. Providing hearing devices needs specialized skills for testing, prescription and fitting. MANAGE HEARING LOSS Other red flags for specialized hearing care Conditions that may underlie hearing loss need specialized diagnosis and management. These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • dizziness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder. They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. Cochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use. A cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. Audio induction loops and personal sound amplifiers. Audio induction loops and personal sound amplifiers are also effective. An audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries offer more guidance: http://apps.who.int/iris/handle/10665/3066 56 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Minimizing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organize activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • Get the person’s attention before you speak. • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing. This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle/10665/250239 KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. Psychological capacity Care pathways to manage depressive symptoms 9 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION Ȳ 3 additional symptoms DEPRESSIVE SYMPTOMS 0Ȃ2 additional symptoms Psychological capacity 9 NO NO to either of the aEove to all YESCare pathways to manage depressive symptoms https://apps.who.int/iris/handle/10665/250239 Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Visiual impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Offer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in ErieI structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ. • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: Ȋ2ver the last two weeNs have you Eeen Eothered Ey any of the following proElems"ȋ 9 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour. People with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include (1) identifying problems in one’s life, (2) becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). Problem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems. MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without specialized knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 62 9 Psychological capacity Care pathways to manage depressive symptoms Psychological capacity 9 Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder. History of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or requiring hospitalization or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ EipolarBȵowchart.html). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of Alzheimer’s disease. The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 Psychological capacity 9 Care pathways to manage depressive symptoms 9 Psychological capacity Care pathways to manage depressive symptoms 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with specialized knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. Eliminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of iron, vitamins such as folate, vitamin B6 and vitamin B12. Depressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 10 Care pathways for social care and support Social care and support For people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, questions about ADLs and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Interventions tailored to an older person’s priorities can improve functional ability. Effective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • Finances: social worker, benefit advisory services. WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • Multiple injuries at different stages of healing. • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. Older people who have difficulties with ADLs and/ or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimize functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s size, access, condition, safety and security. Supplementary questions can help to identify specific areas to address. 70 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living. Financial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances. Further questions can help to identify specific areas that need addressing. Financial problems can be mitigated though independent advice about financial planning and financial management. Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse. 71 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is unique and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personalized care plan. Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access. Charges for some of these services may be subsidized to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 72 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk. A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) Explore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. 2. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). 3. The financial costs of caregiving, potentially leading to sources of local financial support and organized social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. Assessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page 77). Support should reflect the caregiver’s choices and emphasize optimizing the caregiver’s well-being. 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills – for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability qualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person? This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. Offer psychological support. Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioritized needs and goals. • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN Personalized care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences. Once expressed, a personalized care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 1. Review findings and discuss opportunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioritize goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to 12 months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 12 78 5. Monitoring and follow-up Monitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summarizing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions. 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some speciȴc goals that you have in your life? • QUESTION 3 :hat are some speciȴc goals that you have for your health? • QUESTION 4 %ased on the list of Eoth life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What aEout in the ne[t si[ to 12 months" SET GOALS: Goals can be adapted to the older people’s needs and their own definition of problems. • QUESTION 5 :hat speciȴcally aEout goal one two or three would you like to work on over the next three months" :hat aEout over the ne[t si[ to 12 months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: Agreement on prioritized goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat aEout over the ne[t si[ to 12 months" HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • Effective implementation of the ICOPE approach requires an integrated approach linking health and social care services. • Optimizing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • Personalized care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management. The WHO World report on ageing and health set a new direction for health and long-term care systems (1). It called on these systems to focus on optimizing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in 2017, translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION As a first step, both the WHO recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations. Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Incentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimizes intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 13 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility – financial and organizational • sustainability – efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 82 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which WHO defined in 2005 as “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health”. WHO’s 2012 knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). WHO’s 2016 framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The WHO ICOPE implementation framework emphasizes the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care. The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioritize primary and community-based care. This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recognizing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimize community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 When specialized care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective. Follow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 13 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. Deliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organizing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. 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Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/S2214-109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128(6):3925–36. doi: 10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with dementia living in the community. J Am Med Dir Assoc. 2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. 86 24. Knowledge translation. Geneva: WHO; no date (https://www.who. int/ageing/projects/knowledge_translation, accessed 2 April 2019). 25. Integrated care for older people: Guidance for systems and services. Geneva: WHO; 2019 (https://apps.who.int/iris/ handle/10665/325669, accessed June 2019). 26. Community-based health workers (CHWs). Geneva: WHO; no date (https://www.who.int/hrh/community, accessed 2 April 2019). 87 www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook 1
INTEGRATED CARE FOR OLDER PEOPLE Guidance on person-centred assessment and pathways in primary care Handbook Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care WHO/FWC/ALC/19.1 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/publishing/copyright Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party- owned component in the work rests solely with the user. General disclaimers. The designations employed and the presenta- tion of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either ex- pressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Erica Lefstad. Printed in Switzerland. Acknowledgements iv Abbreviations v 1. Integrated care for older people (ICOPE) 1 2. Optimizing capacities and abilities: towards healthy ageing for all 5 3. Assessing older people’s needs and developing a personalized care plan 9 4. Care pathways to manage COGNITIVE DECLINE 19 5. Care pathways to improve MOBILITY 25 6. Care pathways to manage MALNUTRITION 33 7. Care pathways to manage VISUAL IMPAIRMENT 41 8. Care pathways to manage HEARING LOSS 51 9. Care pathways to manage DEPRESSIVE SYMPTOMS 59 10. Care pathways for SOCIAL CARE AND SUPPORT 67 11. Care pathways to SUPPORT THE CAREGIVER 75 12. Develop a personalized care plan 78 13. How health and long-term care systems can support implementation of the WHO ICOPE approach 81 References 86 CONTENTS iii ACKNOWLEDGEMENTS This handbook draws on the work of the many people around the world dedicated to the care and support of older people. Islene Araujo de Carvalho and Yuka Sumi in the World Health Organization (WHO) Department of Ageing and Life Course led the preparation of this handbook. A core group responsible for writing the handbook and developing the pathways included Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) and Finbarr Martin (King’s College London, United Kingdom). Sarah Johnson and Ward Rinehart of Jura Editorial Services were responsible for writing the final text. Many other WHO staff from the regional offices and a range of departments contributed both to specific sections relevant to their areas of work and to the development of the care pathways: Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO). The handbook benefited from the rich inputs of a number of experts and academics who also contributed to the writing of specific chapters: Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd-Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (Institutos Nacionales de Salud de México, Mexico), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Payette (Université de Sherbrooke, Canada), Ian Philp (University of Stirling, United Kingdom), Leocadio Rodriguez- Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frailty, Clinical Research and Geriatric Training, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gérontopôle, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liège, Belgium). Australian National Health and Medical Research Council, Global Alliance for Musculoskeletal Health and Chulalongkorn University, Thailand, supported the development of this guidance by providing staff to develop its contents and by organizing the experts’ meetings. We also benefited from the inputs of participants at the annual meeting of WHO Clinical Consortium on Healthy Ageing, December 2018. The WHO Department Ageing and Life Course acknowledges the financial support of the Government of Japan, the Government of Germany and the Kanagawa Prefectural Government in Japan. Editing by Green Ink. iv ABBREVIATIONS ADLs activities of daily living BMI body mass index CBT cognitive behavioural therapy ICOPE integrated care for older people MNA mini nutritional assessment OSN oral supplemental nutrition PTA pure tone audiometry SPPB short physical performance battery WHO World Health Organization Denotes that specialized knowledge and skills are needed to provide the care v
The 2015 World report on ageing and health defines the goal of healthy ageing as helping people to develop and maintain the functional ability that enables well- being. Functional ability is defined as the “health-related attributes that enable people to be and to do what they have reason to value”. Functional ability consists of the intrinsic capacity of the individual, the environment of the individual and the interactions between them. Intrinsic capacity is “the composite of all the physical and mental capacities that an individual can draw on” (1). This concept of healthy ageing inspires a new focus for health care in older age – a focus on optimizing people’s intrinsic capacity and functional ability as they age. In October 2017, the World Health Organization (WHO) published Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity (2). These guidelines set out 13 evidence-based recommendations for health and care workers to help develop and carry out person-centred integrated care for older people (ICOPE) at the community level. The ICOPE approach embodies the focus on optimizing intrinsic capacity and functional ability as the key to healthy ageing. These recommendations can serve as the basis for national guidelines. They can be used to support the inclusion, in primary care programmes and essential care packages for universal health coverage, of services to prevent care-dependency. KEY POINTS • For the health-care system, the key to supporting healthy ageing for all is optimizing people’s intrinsic capacity and functional ability, even as ageing gradually reduces capacity. • Care-dependency can be prevented if priority conditions associated with declines in intrinsic capacity are promptly diagnosed and managed. • Health and social care workers in the community at the primary care level can identify older people with losses in capacities and provide appropriate care to reverse or slow these losses by following this guidance. This approach is a simple and low-cost one. • Conditions associated with declines in intrinsic capacity are interrelated and so require an integrated and person-centred approach to assessment and management. INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)1 1 WHY DO WE NEED INTEGRATED CARE FOR OLDER PEOPLE (ICOPE)? Older people make up a larger part of the world’s population than ever before. In 2017, there were an estimated 962 million people aged 60 years or over in the world, comprising 13% of the global population (3). This percentage will rise rapidly in the coming decades, particularly in low- and middle-income countries. By 2050, one person in every five will be 60 years of age or older. This trend began some 50 years ago. It reflects the combined impact of rapidly falling fertility rates and rapidly increasing life expectancy in much of the world, often accompanying socioeconomic development. Maintaining the health of older people is an investment in human and social capital and supports the United Nations Sustainable Development Goals (SDGs) (4). At the same time, caring for the growing older population creates challenges for health systems. Health-care resources will need to be rebalanced across age groups. A fundamental change in public health approaches to ageing is needed. Conventional approaches to health care for older people have focused on medical conditions, putting the diagnosis and management of these at the centre. Addressing these diseases remains important, but focusing too much on them tends to overlook difficulties with hearing, seeing, remembering, moving and the other common losses in intrinsic capacity that come with ageing. The well-being of every person will benefit at some time in their life from the identification and management of these problems. Attention throughout the health-care system to the intrinsic capacities of older people will contribute broadly to the welfare of a large and growing part of the population. Most health-care professionals lack the guidance and training to recognize and effectively manage declines in intrinsic capacity. As populations age, there is a pressing need to develop comprehensive community- based approaches that include interventions to prevent declines in intrinsic capacity, foster healthy ageing and support caregivers of older people. WHO’s ICOPE approach addresses this need. WHO IS THIS GUIDANCE FOR? The primary intended audience for this handbook is health and social care workers in the community and in primary care settings. The guidance should also inform health-care workers whose specialized knowledge will be called on, as needed, to assess and to plan care for people with losses in intrinsic capacity and functional ability. The guidance in this handbook will help community health and care workers to put the ICOPE recommendations into practice. It offers care pathways to manage priority health conditions associated with declines in intrinsic capacity – loss of mobility, malnutrition, visual impairment, hearing loss, cognitive decline, depressive symptoms. These pathways start with a screening test to identify those older people who are most likely to be experiencing some losses in intrinsic capacity already. Health and social care workers can easily carry out this screening in the community. This is the doorway to a more in-depth assessment of the health and social care needs of older people. This assessment leads, in turn, to a personalized care plan that integrates strategies to reverse, slow or prevent further declines in capacity, treat diseases and meet social care needs. The person-centred assessment and the development of the care plan usually require trained health professionals in a primary health-care setting, such as primary care physicians and nurses. However, declines in intrinsic capacity often can be managed in the community where the older person and caregivers live, with the support of a multidisciplinary team. 2 GUIDING PRINCIPLES The following principles underpin this guidance: • Older people have the right to the best possible health. • Older people should have equal opportunity to access the determinants of healthy ageing, regardless of social or economic status, place of birth or residence or other social factors. • Care should be provided equally to all, without discrimination, particularly without discrimination based on gender or age. Additionally, professionals responsible for developing training in medicine, nursing and allied health and public health fields may draw on both the concepts and the practical approaches described here. Other audiences include health-care managers and policy-makers, such as national, regional and district programme managers in charge of planning and organizing health-care services, as well as agencies that fund and/or carry out public health programmes, and non-governmental organizations and charities that serve older people in community settings. WHAT DOES THIS GUIDANCE OFFER? This guidance seeks to support health and social care workers in community settings to detect and manage declines in intrinsic capacity, based on WHO’s Guidelines on community-level interventions to manage declines in intrinsic capacity (2), and to address the health and social care needs of older adults comprehensively. This guidance describes how to: • set person-centred goals (Chapter 2); • support self-management (Chapter 2); • develop a care plan that includes multiple interventions to manage conditions associated with losses in intrinsic capacity (Chapter 3); • screen for loss in intrinsic capacity and assess health and social care needs (Chapters 4–10); • support caregivers (Chapter 11); and • develop a personalized care plan (Chapter 12). THE ICOPE APPROACH IN CONTEXT Universal health coverage is the foundation for achieving the health objective of the SDGs (4). To achieve SDG3, older people’s health and social care needs must be addressed in an integrated manner and with continuity of care over the long term. The WHO Strategy and action plan on ageing and health (5) outlines the role of health systems in promoting healthy ageing by optimizing intrinsic capacity. The ICOPE recommendations (2) and this guidance contribute to achieving the goals of that strategy. This guidance is also a tool for implementing the WHO framework on integrated, people- centred health services (6). The framework calls for shifting the way that health services are managed and delivered, towards an integrated, people-centred approach. In the context of this framework, ICOPE proposes care for older people based on: • an assessment of individual needs, preferences and goals; • the development of a personalized care plan; • coordinated services, driven towards the single goal of maintaining intrinsic capacity and functional ability and delivered as much as possible through primary and community- based care. 3 4 The WHO World report on ageing and health defines healthy ageing as developing and maintaining the functional ability that fosters well-being (1). This guidance supports healthy ageing by addressing the following priority conditions associated with declines across domains of intrinsic capacity (Figure 1), older people’s social care needs, and caregiver support. • Cognitive decline (Chapter 4) • Limited mobility (Chapter 5) • Malnutrition (Chapter 6) • Visual impairment (Chapter 7) • Hearing loss (Chapter 8) • Depressive symptoms (Chapter 9) • Social care and support (Chapter 10) • Caregiver support (Chapter 11) OPTIMIZING CAPACITIES AND ABILITIES: TOWARDS HEALTHY AGEING FOR ALL Psychological capacity Hearing capacity Visual capacity Vitality Cognitive capacity Locomotor capacity FIG. 1. KEY DOMAINS OF INTRINSIC CAPACITY HOW DOES INTRINSIC CAPACITY CHANGE OVER THE LIFE COURSE? Figure 2 shows the typical pattern of intrinsic capacity and functional ability across adult life. Intrinsic capacity and functional ability decline with increasing age as a result of the ageing process as well as underlying diseases. This typical pattern can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity and a period of significant loss of capacity, characterized by dependence on care. 2 5 INTERVENING TO OPTIMIZE INTRINSIC CAPACITY Identifying conditions associated with losses in intrinsic capacity provides an opportunity to intervene to slow, stop or reverse the declines (Figure 2). Health-care workers in clinical settings and in the community can detect tracer conditions associated with declines in intrinsic capacity. Repeated assessments over time make it possible to monitor any changes that are larger than expected so that specific interventions can be offered before functional ability is lost. In this way interventions delivered in community settings can prevent a person from becoming frail or care-dependent. Multi-component interventions appear to be more effective. There is a wide range of intrinsic capacity around the average pattern. These differences are evident both within and between countries. They are reflected in persistent differences in life expectancies, which range from 82 years or more in such countries as Australia, Japan and Switzerland, to less than 55 years in such countries as the Central African Republic, Chad and Somalia. Variation in intrinsic capacity is far greater across people in older age than across younger groups. Such diversity is one of the hallmarks of ageing. One individual may have an age difference of 10 years or more compared with another person but a similar intrinsic capacity and/or functional ability. This is why chronological age is a poor marker of health status. INTRINSIC CAPACITY AND FUNCTIONAL ABILITY WHO defines intrinsic capacity as the combination of the individual’s physical and mental, including psychological, capacities. Functional ability is the combination and interaction of intrinsic capacity with the environment a person inhabits. 6 FIGURE 2. A PUBLIC-HEALTH FRAMEWORK FOR HEALTHY AGEING: OPPORTUNITIES FOR PUBLIC HEALTH ACTION ACROSS THE LIFE COURSE Many of the characteristics that determine intrinsic capacity can be modified. These include health-related behaviours and the presence of diseases. There is thus a strong rationale for introducing effective interventions to optimize intrinsic capacity. This rationale underpins the ICOPE approach and this guidance. The different health conditions associated with losses in intrinsic capacity interact at several levels. Hearing loss, for example, is associated with cognitive decline. Nutrition enhances the effect of exercise and has a direct impact on increasing muscle mass and strength. These interactions make necessary an integrated approach to the screening, assessment and management of declines in intrinsic capacity. Source: World Health Organization, 2015 (1). High and stable capacity HEALTH SERVICES: LONG-TERM CARE: ENVIRONMENTS: Declining capacity Significant loss of capacity Functional ability Intrinsic capacity Prevent chronic conditions or ensure early detection and control Reverse or slow declines in capacity Support capacity-enhancing behaviours Promote capacity-enhancing behaviours Manage advanced chronic conditions Ensure a dignified late liIe Remove barriers to participants compensate Ior loss oI capacity ICOPE APPROACH 7 8 Person-centred care is grounded in the perspective that older people are more than the vessels of their disorders or health conditions; all people, whatever their ages, are individuals with unique experiences, needs and preferences. Person-centred care addresses individuals’ health and social care needs rather than being driven by isolated health conditions or symptoms. A person- centred, integrated approach also embraces the context of individuals’ daily lives, including the impact of their health and needs on those close to them and in their communities. There are five steps to meeting older people’s health and social care needs with an integrated care approach, as shown in the following general pathway. ASSESSING OLDER PEOPLE’S NEEDS AND DEVELOPING A PERSONALIZED CARE PLAN KEY POINTS • The identification of older people in the communi- ty with priority conditions associated with declines in intrinsic capacity can be done with the help of the integrated care for older people (ICOPE) screening tool. • Those identified with these conditions are re- ferred to a primary health-care clinic for in-depth assessment, which informs the development of a personalized care plan. • The care plan may include multiple interventions to manage declines in intrinsic capacity and to optimize functional ability, such as by physical exercises, oral supplemental nutrition, cognitive stimulation and home adaptations to prevent falls. 3 9 3 Generic care pathway Person-centered assessment and pathways in primary care Social care and support plan Remove barriers to social participation Environmental adaptation Community-level interventions to manage declines in intrinsic capacity Understand the older person's life, values, priorities and social context Integrated management of diseases Rehabilitation Palliative and end-of-life care Reinforce generic health and lifestyle advice or usual care FOR CONDITIONS ASSOCIATED WITH LOSS IN INTRINSIC CAPACITY No loss of intrinsic capacity YES YES NO NO NO YES SCREEN FOR LOSSES IN INTRINSIC CAPACITY IN THE COMMUNITY SCREEN STEP 1 PERSON-CENTRED ASSESSMENT IN PRIMARY CARE STEP 2 ASSESS IN GREATER DEPTH UNDERLYING DISEASES ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS NEEDS FOR SOCIAL CARE SERVICES (home, institution) 10 10 3 Person-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Generic care pathway 11 Priority conditions associated with declines in intrinsic capacity Tests Assess fully any domain with a checked circle COGNITIVE DECLINE (Chapter 4) 1. Remember three words: flower, door, rice (for example) 2. Orientation in time and space: What is the full date today? Where are you now (home, clinic, etc)? 3. Recalls the three words? LIMITED MOBILITY (Chapter 5) Chair rise test: Rise from chair five times without using arms. Did the person complete five chair rises within 14 seconds? MALNUTRITION (Chapter 6) 1. Weight loss: Have you unintentionally lost more than 3 kg over the last three months? 2. Appetite loss: Have you experienced loss of appetite? VISUAL IMPAIRMENT (Chapter 7) Do you have any problems with your eyes: difficulties in seeing far, reading, eye diseases or currently under medical treatment (e.g. diabetes, high blood pressure)? HEARING LOSS (Chapter 8) Hears whispers (whisper test) or Screening audiometry result is 35 dB or less or Passes automated app-based digits-in-noise test DEPRESSIVE SYMPTOMS (Chapter 9) Over the past two weeks, have you been bothered by – feeling down, depressed or hopeless? – little interest or pleasure in doing things? Wrong to either question or does not know Cannot recall all three words No Yes Yes Yes Yes Yes Fail TABLE 1. WHO ICOPE SCREENING TOOL 12 STEP 1 SCREEN FOR DECLINES IN INTRINSIC CAPACITY With the process and tools in this guidance, trained health-care workers can start the identification of people with losses in intrinsic capacity in a community or at home. To do this, they can use the ICOPE screening tool (Table 1). The ICOPE screening tool is the first step in each care pathway presented in Chapters 4 to 9 and covers six relevant conditions across the domains of intrinsic capacity (Figure 1 on page 5 ). Community outreach strategies, such as home visits by community health workers and self-assessments using mobile phone technologies, can be used to find cases. Those who show signs of, or report losses in capacity at this first step should go on to a full assessment. Full assessment is likely to require health-care professionals with the necessary training, often but not necessarily a medical doctor. Health and care workers must ensure that any limitation in capacity identified by the ICOPE screening tool always triggers further in-depth assessment. Findings should inform the development of the personalized care plan. adverse effects can cause losses in multiple domains of intrinsic capacity and so always deserves investigation (see box, Polypharmacy, page 18). The diagnosis of underlying disease, such as Alzheimer’s disease, depression, osteoarthritis, osteoporosis, cataracts, diabetes and hypertension, is critical to a person-centred assessment. Such diagnoses may require complex diagnostic tests that are not always available in the primary health-care clinic. Depending on the setting, referral to a secondary or tertiary level of specialized geriatric care may be needed. 2D. Assess social and physical environments and need for social care and support An assessment of the social and physical environments and an identification of any needs for social and support services are both required for people with losses in intrinsic capacity. This is an essential part of the person- centred assessment of older people in primary care. Social care needs can be identified by asking an older person whether they can perform various daily tasks without the help of others. The pathway in Chapter 10 presents a set of questions for assessing and determining social care needs generally. In addition, each care pathway in Chapters 4 to 9 notes possible social care needs specific to the priority conditions. STEP 2 UNDERTAKE A PERSON-CENTRED ASSESSMENT IN PRIMARY CARE A person-centred assessment of an older person’s health and social care needs in primary care is critical to then optimizing intrinsic capacity. 2A. Understand the life of the older person A person-centred assessment starts not only with a conventional history taking, but a thorough understanding of the person’s life, values, priorities and preferences for the course of their health and its management. 2B. Assess in greater depth for conditions associated with loss in intrinsic capacity The assessment also evaluates in more depth conditions associated with losses in intrinsic capacity. The care pathways for key conditions across the domains of intrinsic capacity, presented in Chapters 4 to 9, are organized generally into the three components, with screening in the community at the top, assessment in primary care in the middle, and personalized care planning at the end. 2C. Assess and manage underlying diseases Possible underlying chronic diseases should be investigated, as should any polypharmacy (the use of multiple medications). Polypharmacy and any resulting 13 STEP 3 DEFINE THE GOAL OF CARE AND DEVELOP A PERSONALIZED CARE PLAN 3A. Define with the older person the goal of care The unifying goal of optimizing intrinsic capacity and functional ability helps to ensure the integration of care and also provides the opportunity to monitor the older person’s progress and the impact of interventions. It is essential that the older person and caregiver are involved in decision-making and goal-setting from the outset – and that goals are set and prioritized according to the person’s priorities, needs and preferences. 3B. Design a care plan The person-centred assessment informs the development of a personalized care plan. This personalized care plan applies an integrated approach to implement interventions that address losses in various domains of intrinsic capacity: all interventions should be considered and applied together. 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Generic care pathway Support for self-management involves providing older people with the information, skills and tools that they need to manage their health conditions, prevent complications, maximize their intrinsic capacity and maintain their quality of life. This does not imply that older people will be expected to “go it alone” or that unreasonable or excessive demands will be placed on them. Instead, it recognizes their autonomy and abilities to direct their own care, in consultation and partnership with health-care workers, their families and other caregivers. The WHO mobile health for ageing (mAgeing) initiative can complement health-care professionals’ routine care by supporting self-care and self-management. By delivering health information, advice and reminders through mobile phones, it encourages healthy behaviours and helps older people to improve and maintain their intrinsic capacity. For information about how to set up an mAgeing programme and suggested text messages, see https://www.who.int/ageing/health-systems/ mAgeing. 14 3 Person-centered assessment and pathways in primary care Generic care pathway This integrated approach is important because most of the priority conditions associated with losses in intrinsic capacity share the same underlying physiological and behavioural determinants. As a result, interventions have benefits across domains. For example, intensive strength training is the key intervention to prevent loss of mobility. At the same time, strength training indirectly protects the brain against depression and cognitive decline and helps to prevent falls. Nutrition enhances the effects of exercise and at the same time increases muscle mass and strength. Through an integrated, unified approach, it may be possible to change the set of factors that increase the risk of care-dependency. The personalized care plan will have a number of components, which may include: • a package of multi-component interventions to manage losses in intrinsic capacity. Most care plans will include interventions to improve nutrition and encourage physical exercise; • the management and treatment of underlying diseases, multimorbidities and geriatric syndromes. WHO has developed clinical guidelines to address most of the relevant chronic diseases that may contribute to declines in intrinsic capacity (2). Every health-care provider should have access to these guidelines; • support for self-care and self-management; • the management of any advanced chronic conditions (palliative care, rehabilitation) or to ensure that older people can continue to live lives of meaning and dignity; • social care and support, including environmental adaptations, to compensate for any functional losses; and • a plan to meet social care needs with the help of family members, friends and community services. Health and social care workers can support the implementation of the care plan in the community or the primary care setting. Self-management, supported by advice, education and encouragement from a health- care provider in the community, can modify some of the factors responsible for declines in intrinsic capacity. A partnership involving the older person, primary health- care workers, family and community will sustain people’s well-being as they age. 15 3 Generic care pathway Person-centered assessment and pathways in primary care STEP 4 ENSURE A REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE Regular and sustained follow-up, with integration among different levels and types of care service, is essential for implementing the interventions recommended in this guidance. Such an approach promotes early detection of complications or changes in functional status, thus avoiding unnecessary emergencies and saving costs by acting early. Regular follow-up also provides the opportunity to monitor progress towards the care plan as well as a means for arranging additional support when needed. Follow-up and support can be especially important after major changes in health status, the treatment plan or in the person’s social role or situation (a change in residence, for example, or the death of a partner). Strong referral pathways are important to ensure rapid access to acute care in the case of unforeseen events such as falls, and to palliative and end-of-life care or after discharge from hospital. A link to specialized geriatric care is also critical. Health systems need to ensure that people have timely access to specialty and acute care when needed. There is good evidence that specialist acute-care geriatric wards deliver higher-quality care with shorter lengths of stay and lower costs than general hospital care. THE ROLE OF SPECIALIZED GERIATRIC CARE Geriatricians focus their expertise on older adults with long-term complex conditions such as geriatric syndromes (incontinence, falls, delirium, etc.), polypharmacy and diseases such as dementia and providing care for those who have limitations in activities of daily living. Multimorbidity rises with age and results in complex clinical pictures, when primary care physicians should refer to geriatricians. In the ICOPE approach, geriatricians are part of a multidisciplinary team responsible for the care of older adults, and they assist supervising primary care teams, and intervene when specialized care is needed. 16 3 Generic care pathway Person-centered assessment and pathways in primary care 3 Person-centered assessment and pathways in primary care Generic care pathway STEP 5 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS Caregiving can be demanding, and caregivers of people with loss of capacity often feel isolated and are at high risk of psychological distress and depression. A personalized care plan should include evidence-based interventions to support caregivers. Caregivers also need basic information about the older person’s health conditions, and training to develop a range of practical skills, such as how to transfer a person from a chair to a bed safely or how to help with bathing. The older person and caregiver should receive information about the community-based resources available to them. Opportunities to involve communities and neighbourhoods more directly in supporting care must be explored, particularly by encouraging volunteering and by enabling older community members to contribute. Such activities can often take place in the associations and groups that draw older people together. Chapter 11 contains a care pathway for assessing caregiver burden and addressing the needs of unpaid caregivers for care and support themselves. The ICOPE approach is based at the community or primary care level, where it can be accessible to the greatest number of people. At the same time, the approach calls for strong links with specialized and tertiary levels of care for those who need it such as with nutritionists and pharmacists. ICOPE HANDBOOK APP Mobile applications will be available to guide health and social care workers on all the steps to undertake, from screening to assessing, to designing a personalized care plan. The app will also produce a printable summary of the results of the assessment and interventions to be included in the care plan in PDF format. 17 3 Generic care pathway Person-centered assessment and pathways in primary care POLYPHARMACY Polypharmacy is commonly described as the use of five or more medicines at the same time and is often associated with adverse drug reactions. This use of multiple drugs increases the risk of negative health consequences, and it can result in unnecessary losses in intrinsic capacity and is a cause of acute hospital admissions. Older people who visit multiple health-care workers or who have been hospitalized recently are at greater risk of polypharmacy. An older person with multimorbidities is likely to be more affected by the age-related physiological changes that can alter pharmacokinetics and pharmacodynamics. Because polypharmacy can contribute to losses across multiple domains of intrinsic capacity, person-centred assessments should include a review of the medications that the older person is taking. Polypharmacy can be reduced by eliminating unnecessary, ineffective medications as well as medications with a duplicative effect. How to prescribe appropriately and reduce medication errors: • obtain a complete medication history; • consider whether the medications may affect capacity; • avoid prescribing before a diagnosis is made except in severe acute pain; • review medications regularly and before prescribing a new medication; • know the actions, adverse effects, drug interactions, monitoring requirements and toxicity of prescribed medications; • try to use one medication to treat two or more conditions; • create a pill card for the patient; and • educate the patient and caregiver about each medication. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 18 4 Cognitive capacity Care pathways to manage cognitive decline Cognitive decline presents as increasing forgetfulness, loss of attention and reduced ability to solve problems. While the exact cause is not known, cognitive decline can be related to the ageing of the brain, to diseases (for example, cardiovascular diseases, such as hypertension and stroke, or Alzheimer’s disease) or even environmental factors such as a lack of physical exercise, social isolation and a low level of education. Cognitive decline becomes of greatest concern when it starts to interfere with a person’s ability to function effectively in their environment – that is, when a person develops dementia. This pathway is intended to apply to older people with some degree of cognitive decline but who do not have dementia. Health professionals must also be able to assess the need for social care and support (see Chapter 10). KEY POINTS Declines in cognitive capacity can be minimized and sometimes reversed by a general approach to a healthier lifestyle, cognitive stimulation and social engagement. Treatment of conditions such as diabetes and hypertension may prevent declines in cognitive capacity. Declines in other domains of intrinsic capacity, such as in hearing and locomotor capacity, can impair cognition and should also be assessed and addressed. For a person with dementia, specialist care is needed to plan and carry out complex interventions. 19 Reinforce generic health and lifestyle advice or usual care SCREEN FOR COGNITIVE DECLINE cognitive decline unlikely cognitive decline unlikely – MALNUTRITION* – DELIRIUM – POLYPHARMACY – CEREBROVASCULAR DISEASES – DEPRESSIVE SYMPTOMS See malnutrition pathway Identify cause (medical conditions, intoxication from substances, use of drugs) and treat Review medications and withdraw as appropriate Assess history of vascular disease in the brain (stroke/transient ischaemic event) and prevent further events See depressive symptoms pathway 6 9 PASS Multimodal exercise Provide cognitive stimulation ASSESS COGNITIVE CAPACITY 1 FAIL FAIL cognitive decline likely PASS ASSOCIATED CONDITIONSASSESS & MANAGE i SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE PREVENT FURTHER DECLINES IN COGNITIVE CAPACITY Assess need for social care and support Give advice to maintain independent toileting skills Assess for caregiver burden or strain (see pathway for caregivers) Develop social care and support plan including support to caregivers If cognitive decline affects autonomy and independence, see dementia section of mhGAP intervention guide Provide personal care and support with activities of daily living 11 10 CARDIOVASCULAR DISEASES AND RISK FACTORS** ASSESS & MANAGE Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete words such as “flower”, “door”, “rice” 2. Orientation in time and space: Then, ask, “What is the full date today?” and “Where are you now?” (home, clinic, etc.)? 3. Recalling three words: Now ask the person to repeat the three words that you mentioned Pass or fail? If a person cannot answer one of the two questions about orientation OR cannot remember all three words, cognitive decline is likely and further assessment is called for Do you have problems with memory or orientation (such as not knowing where one is or what day it is)? ASK ? YES 4.1 4.2 5.1 Vitamin deficiency, electrolyte abnormality, severe dehydration ** Cardiovascular risk factors: hypertension, high cholesterol, diabetes, smoking, obesity, heart diseases, previous stroke or transient ischaemic attack. Risk reduction of cognitive decline and dementia: WHO Guidelines – https://apps.who.int/iris/handle/10665/312180 Provide integrated management of diseases Reduce cardiovascular risk factors: – suggest smoking cessation – treat hypertension and diabetes – provide dietary advice for weight control YES NO https://apps.who.int/iris/handle/10665/250239 Care pathways to manage cognitive decline Cognitive capacity 4 4 Cognitive capacity Care pathways to manage cognitive decline ASSESS COGNITION More in-depth assessment of cognitive capacity uses a locally validated tool if possible. Below right is a list of options for assessing cognition in older adults in primary care settings. Lack of schooling. Almost all standard cognitive assessments used for the screening or diagnosis of cognitive impairment assume a minimal amount of school education. If a person has less than five or six years of schooling or has no schooling, cognitive assessment can be limited. Instead, it must rely on interview and clinical judgement. For these individuals, enrolling in an adult literacy programme (if available) is highly recommended, as it promotes cognitive health. If a standard assessment tool is not available or not appropriate, the health worker can ask the person, and also someone who knows the person well, about problems with memory, orientation, speech and language and about any difficulties with performing key roles and daily activities. Failing in the cognitive assessment or reported problems with memory or orientation suggests cognitive impairment. Such a person should also be assessed for difficulty with activities of daily living (ADLs) or instrumental activities of daily living (IADLs). This information is important for planning social care and support as part of the personalized care plan. Ζf cognitive declines affect an older personȇs ability to function effectively within their environment a specialized assessment may be needed to diagnose dementia or Alzheimerȇs disease (the most common cause of dementia). Protocols for assessing and managing dementia can be found in the WHO mhGAP Intervention Guide, at https://apps.who.int/iris/handle/10665/250239 1 More information: WHO mh*$3 intervention guide https://apps.who.int/iris/handle/10665/250239 WHEN SPECIALIZED CARE IS NEEDED • Diagnosis and treatment of dementia. • Management of multiple associated conditions such as delirium, cerebrovascular and cardiovascular diseases. Mini-Cog http://minicog.com/wpcontent/uploads/2015/ 12/8niversal0ini&og)orm011916.pdf Brief; minimal language, educational and racial bias Use of different word lists may affect scoring 2–4 min TOOL/TEST ADVANTAGE DISADVANTAGE TIME Montreal cognitive assessment (MoCA) https://www.mocatest.org/ Can identify mild cognitive impairment; available in multiple languages Educational and cultural bias; limited published data 10–15 min Mini mental state examination (MMSE) https://www.parinc.com/products/pNey/23 Widely used and studied Subject to age and cultural bias, ceiling effects 7–10 min General practitioner assessment of cognition (GPCOG) http://gpcog.com.au/inde[/downloads Minimal cultural and educational bias; available in multiple languages May be challenging to get an informant’s report 5–6 min EXAMPLES OF COGNITION ASSESSMENT TOOLS FOR USE IN PRIMARY HEALTH-CARE SETTINGS What is dementia? Dementia is a chronic and progressive syndrome due to changes in the brain. Dementia results in decline in cognitive functioning, and interferes with activities of daily living such as washing, dressing, eating, personal hygiene and toilet activities. 21 Care pathways to manage cognitive decline Cognitive capacity 4 An important step, before any diagnostic process for cognitive decline, is to assess the presence of any associated conditions and treat these first. 4.1 CONDITIONS THAT CAUSE COGNITIVE SYMPTOMS Common reversible conditions that can cause cognitive decline include dehydration, malnutrition, infections and problems with medications. With proper treatment of these conditions, a person’s cognitive symptoms should go away. Severe dehydration. Severe dehydration and other nutritional problems can cause delirium (which resembles dementia) and, in severe cases, death. Delirium. Delirium is a sudden and drastic loss of the ability to focus attention. People also become extremely confused about where they are and what the time is. Delirium develops over a short period of time and tends to come and go during the course of a day. It may result from acute organic causes such as infection, medications, metabolic abnormalities (such as hypoglycaemia or hyponatraemia), substance intoxication or substance withdrawal. Polypharmacy. Two or more drugs may interact and cause adverse side-effects (see box in Chapter 3, p. 18). Sedatives and hypnotics are the medications most often responsible for cognitive disorders among older people. Major surgery and general anaesthesia. Major surgery and general anaesthesia are a recognized risk for cognitive decline. Practitioners should ask if the person’s cognitive decline followed major surgery. If so, that person will be at higher risk for further cognitive decline following any further major surgery. This higher risk will need to be identified and discussed with the surgical team and anaesthetist before any future surgeries or anaesthesia. Cerebrovascular disease. Vascular disease in the brain is closely associated with cognitive decline. If the patient has a history of stroke/mini-stroke/transient ischaemic event, then prevention of further events is the primary approach to stop further declines in cognition. ASSESS & MANAGE ASSOCIATED DISEASES Uncovering a reversible medical cause of cognitive decline involves a full diagnostic work-up. It may be necessary to explore several dierent potential e[planations of symptoms to arrive at an accurate approach for the care plan. 4 Cognitive capacity Care pathways to manage cognitive decline 22 4 Cognitive capacity Care pathways to manage cognitive decline • People with cognitive decline can benefit from cognitive stimulation. • Other ICOPE interventions, such as multimodal exercise (see chapter 5, limited mobility), also contribute to brain health. • Losses in other domains of intrinsic capacity, particularly hearing, vision and mood, can affect cognition. To reach the best outcomes, these may need to be addressed. Individuals with cognitive declines differ in the pattern of declines across other domains. 4.2 COGNITIVE STIMULATION Cognitive stimulation may slow declines in cognitive capacity (7). Cognitive stimulation aims to stimulate participants through cognitive activities and recollection, stimulation of multiple senses and contact with other people. Cognitive stimulation may be offered to an individual or in a group. Groups may be better for some people; social contact in the group may help. Groups may also be suitable and efficient if those in the group share a common purpose, such as improving health literacy. The standard group approach involves up to 14 themed sessions of about 45 minutes each, held twice a week. A facilitator leads these sessions. Typically, a session might start with some non-cognitive warm-up activity and then move to a variety of cognitive tasks, including reality orientation (for example, a board displaying such information as place, date and time). Sessions focus on different themes, including, for example, childhood, use of money, faces or scenes. These activities generally avoid factual recall but instead focus on questions such as, “What do these [words or objects] have in common?” Who can conduct cognitive stimulation? In high-income countries, usually it is psychologists who conduct cognitive stimulation therapy. With adaptation, it could be conducted by suitably trained and supported non-specialists. However, designing and providing a personalized intervention for a person with significant declines may require more detailed assessment and planning – tasks that require specialized skills. Therefore, local protocols should include criteria for referral to mental health specialists for cognitive stimulation therapy. Family members and caregivers can play an important role in cognitive stimulation. It is important to encourage family members and caregivers to regularly provide older people with such information as day, date, weather, time, names of people and so on. This information helps them to remain oriented in time and place. Also, providing materials such as newspapers, radio and TV programmes, family albums and household items can promote communication, orient an older person to current events, stimulate memories and enable the person to share and value their experiences. MANAGE COGNITIVE DECLINE 5 23 Care pathways to manage cognitive decline Cognitive capacity 4 If cognitive declines limit a person’s autonomy and independ- ence, that person is likely to have major social care needs. A health worker can help caregivers tailor a plan for activities of daily living that maximizes independent activity, enhances function, helps to adapt and develop skills, and minimizes the need for support. Family members and caregivers can: • provide orienting information, such as the date, current community events, identity of visitors, weather, news of family members; • encourage and arrange contacts with friends and family members at home and in the community; • make and keep the home safe to reduce the risk of falls and injury; • post signs in the home – for example, for the toilet, bedroom, door to outside – to help the person find his or her way about; and • arrange for and join in occupational activities (as appropriate to the person’s capacities). ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers for people with severe cognitive declines face heavy demands. The stress can put their health at risk. See Chapter 11 on addressing the needs of caregivers. 11 24 Care pathways to improve mobility 5 Locomotor capacity Mobility is a critical determining factor for healthy ageing. It is important for maintaining autonomy and preventing dependence on care. A person’s bodily capacity to move from one place to another is termed locomotor capacity. Many older people and their families accept losses of locomotor capacity and the associated pain as inevitable. They are not. Indeed, there are effective strategies to improve and maintain mobility in older age. KEY POINTS Limited mobility is common among older people but not inevitable. Community-level health-care workers can screen for limited mobility with simple tests. A programme of regular exercise, tailored to individual capacities and needs, is the most important approach to improve or maintain locomotor capacity. Adapting one’s environment and using assistive devices are good ways to maintain mobility despite reduced locomotor capacity. 25 ASSESS MOBILITY Reinforce generic health and lifestyle advice or usual care (SPPB or other physical performance test) $Ele to complete ȴve chair rises without using arms in 14 seconds? SCREEN FOR LOSSES IN MOBILITY Chair rise test NO Review medication and aim to reduce Integrated management of diseases Consider pain management YES – POLYPHARMACY – OSTEOARTHRITIS, OSTEOPOROSIS & OTHER BONE JOINT LIMITATIONS – FRAILTY & SARCOPENIA – PAIN NO to all YES Provide multimodal exercise with close supervision Consider referral to rehabilitation Consider increasing protein intake Consider and provide assistive device to aid mobility Recommend multimodal exercise at home Support self-management to increase adherence Multimodal exercise A multimodal exercise programme for people with limited mobility combines exercise and cross-training with emphasis on the core muscle groups of back, thigh, abdomen and lower body A multimodal exercise programme should be tailored to suit individual capacities and needs. The Vivifrail project offers a practical guide to developing an exercise programme tailored to capacities http://www.vivifrail.com/resources For WHO global recommendations on physical activity, see box, page 30 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Normal mobility (SPPB score 10–12 points) Limited mobility (SPPB score 0–9 points) ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Specialized care needed Locomotor capacity 5 Care pathways to improve mobility Assess physical environment to reduce risk of falls Include falls prevention interventions such as home adaptations Consider and provide assistive device to aid mobility Provide safe spaces for walking SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) While a wide range of physical performance tests is available, the SPPB is recommended, as it has superior measurement properties and is useful across a range of abilities. The SPPB measures timed performance on three tasks, each scored out of four, to derive a score from zero (worst performance) to 12 (best performance). First, describe each test and ask if the person feels able to do it. If not, score accordingly and move to the next step. 1. Balance tests: Stand for 10 seconds with feet in each of the following three positions. Use the sum of the scores from the three positions. 2. Gait speed test: Time to walk four metres. Time for four-metre walk: < 4.82 seconds 4 points 4.82 – 6.20 seconds 3 points 6.21 – 8.70 seconds 2 points > 8.70 seconds 1 point Unable to complete 0 points 3. Chair rise test: Time to rise from a chair five times < 11.19 seconds 4 points 11.2 – 13.69 seconds 3 points 13.7 – 16.69 seconds 2 points 16.7 – 59.9 seconds 1 point > 60 seconds or unable to complete 0 points 1 2WHEN SPECIALIZED CARE IS NEEDED Locomotor capacity should be assessed together with other aspects of intrinsic capacity, such as cognition, sensory vitality and psychological capacities ΖI significant declines in physical or mental capacity or comorbidities make exercise prescription more complex, specialist knowledge may be needed to devise a suitable exercise programme. Referral to rehabilitation may be considered. A. Side-by-side stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. B. Semi-tandem stand Held for 10 seconds 1 point Not held for 10 seconds 0 points Not attempted 0 points If not attempted, end balance tests. C. Tandem stand Held for 10 seconds 2 points Held for 3 to 9.99 seconds 1 point Held for < 3 seconds 0 points Not attempted 0 points A simple test can decide whether an older person needs further assessment for limited mobility. Instructions: Ask the person, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms?” (Demonstrate to the person.) If YES, ask them to: – sit in the middle of the chair – cross and keep their arms over their chest – rise to a full standing position and then sit down again – repeat five times as quickly as possible without stopping. Time the person taking the test – further assessment is needed if they cannot stand up five times within 14 seconds. CHAIR RISE TEST Final SPPB score = sum of scores from the three tests above. More detail on the SPPB test: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf Care pathways to improve mobility 5 Locomotor capacity 27 Locomotor capacity 5 Care pathways to improve mobility The chair rise test is one of these tests. It should be repeated after the other two tests: • the balance test – standing for 10 seconds in each of three feet positions • the walking speed test – how long it takes to walk four metres. The scores on each test are added together. Lower total scores mean limited mobility. The pathway outlines two different paths for management, depending on the total score. More information on the tests and how to score them can be found on the previous page. WHEN SPECIALIZED CARE IS NEEDED (FURTHER INFORMATION) Specialized care may also be needed for a person who has: • persistent pain that affects mood or other areas of functioning • significant impairments in joint functions • broken a bone after minimal trauma • safety risks (see box on opposite page) • a need for help choosing an appropriate assistive device for mobility. Mobility can be assessed more fully by scoring a person’s performance on three simple tests. Together, these tests are known as the Short Physical Performance Battery (SPPB). ASSESS MOBILITY 28 Care pathways to improve mobility 5 Locomotor capacity 5.1 MULTIMODAL EXERCISE PROGRAMME For those with limited mobility, a multimodal exercise programme should be tailored to suit individual capacity and needs. A multimodal exercise programme for people with limited mobility can include: • strength/resistance training, which requires muscles to work under load, using weights, resistance bands or body weight exercises such as squats, lunges and sit- to-stand exercises; • aerobic/cardiovascular training, such as fast walking or cycling that increases heart rate until the person is slightly out of breath but can maintain a conversation; • balance training, which challenges the balance system, including static and dynamic exercises; can progress to different surfaces and with eyes open and shut; examples are standing on one leg at a time and walking heel-to-toe in a straight line; and • flexibility training, which improves the extensibility of soft tissues, such as muscle, and the range of joint movement; examples are stretching and other yoga and Pilates exercises. Nutrition. Increased protein intake and other nutritional interventions can enhance the benefits of an exercise programme. See Chapter 6 on malnutrition. MANAGE LIMITED MOBILITY Safety of exercise. Before giving advice on exercise or planning an exercise programme, ask about health conditions that would affect the timing or intensity of the activity. If the person answers yes to any of the following questions, a skilled health professional should develop a tailored exercise programme. • Have you had chest pain when at rest? • Have you had a heart attack within the last six months? • Have you fainted or lost consciousness? • Have you fallen in the past 12 months? • Have you broken a bone in the last month? • Do you get out of breath doing ordinary daily activities at home, such as getting dressed? • Do you have a joint or muscle disease that limits exercise? • Has a health-care provider told you to limit exercise? The Vivifrail project offers a practical guide to developing a tailored exercise programme. http://www.vivifrail.com/resources 6 29 Locomotor capacity 5 Care pathways to improve mobility Managing limitations. Where pain limits mobility, pacing physical activity in manageable chunks of time and slowly increasing physical tasks helps to build the body’s resilience and manage pain. For people with severely reduced mobility, exercise training in bed or seated on a chair can be a starting point. For people with limitations in cognition, such as dementia, a simple and less structured exercise programme may be more suitable. 5.2 SUPPORT FOR SELF-MANAGEMENT Support for self-management increases adherence to and the benefits of a multimodal exercise programme. People whose SPPB scores are in the range of 10–12 can exercise at home and in the community. People with more severe mobility limitations may need supervision and guidance during exercise. The WHO mobile health for ageing (mAgeing) handbook explains how a mobile phone app can complement health- care professionals’ routine care by supporting self-care and self-management. More information: http://www.who.int/ageing/health-systems/mAgeing WHO’S GLOBAL RECOMMENDATIONS ON PHYSICAL ACTIVITY All older adults can benefit from advice on the physical activity recommended for their age, taking into consideration their health conditions. This box summarizes WHO’s global recommendations on physical activity for people aged 65 years and older. • Throughout each week, get at least 150 minutes of moderate-intensity aerobic physical activity or at least 75 minutes of intensive aerobic activity, or an equivalent combination. • Exercise at least 10 minutes at a time. • For additional benefit, do 300 minutes of moderate-intensity aerobic exercise per week or 150 minutes of intensive aerobic activity per week, or an equivalent combination. • Do muscle-strengthening activities two days a week or more. • If mobility is poor, perform physical activity that enhances balance on three days a week or more. • If you cannot exercise as much as recommended, be as physically active as you can. More information: http://www.who.int/dietphysicalactivity/pa/en/index.html 30 Care pathways to improve mobility 5 Locomotor capacity 5.3 POLYPHARMACY Some drugs can impair mobility or interfere with balance yet are sometimes unnecessary or ineffective for a specific person (8). These include, but are not limited to, the following: • anticonvulsants • benzodiazepines • nonbenzodiazepine hypnotics • tricyclic antidepressants • selective serotonin reuptake inhibitor (SSRI) antidepressants • antipsychotics • opioids. Eliminating unnecessary, ineffective medications as well as medications with a duplicative effect reduces polypharmacy. If in doubt about whether a medication can be safely stopped, refer to an appropriate specialist. 5.4 PAIN Assess pain. Severe pain associated with movement can limit or even prevent exercise. It is helpful to rate the severity of pain related to mobility, both to help with designing an exercise programme and for managing the pain. You can use the brief pain inventory: https://www.aci.health.nsw.gov.au/__data/ assets/ pdfBȴle/0015/212910/%riefB3ainBInventoryB)inal.pdf Manage pain (9). Musculoskeletal conditions that impair mobility often involve persistent pain. A specific biological cause of persistent pain can rarely be found, however. A best-practice approach to pain management therefore addresses multiple factors that may be associated with pain – physical factors (such as muscle strength, range of movement and endurance), psychological well-being, nutrition and sleep. Where pain is a significant barrier to movement and activity, a health professional with specialized knowledge of pain management should develop the pain management plan. Interventions for pain include: • self-management 5.2 • exercises and other physical activity • medications ranging from paracetamol and nonsteroidal anti-inflammatory drugs to gabapentin and opioids • manual therapy such as massage, joint manipulation and joint mobilization • psychological therapy and cognitive behavioural therapy (see Chapter 9 on depressive symptoms) • acupuncture • spinal injections/epidural injections • radiofrequency denervation. ASSESS & MANAGE ASSOCIATED CONDITIONS Some of these interventions can be made available in the community. Others would likely require referral to a central facility. 9 31 Locomotor capacity 5 Care pathways to improve mobility ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Someone with limited mobility may need help to cope with day-to-day activities. The first step is to assess social care needs (see Chapter 10). Specific social care needs for older people with losses in mobility may include those revealed by an assessment of their physical environment or the need for assistive devices. An exercise programme can help to prevent falls. 5.5 ASSESS THE PHYSICAL ENVIRONMENT TO REDUCE RISK OF FALLS An assessment of the physical environment involves looking around the home to find possible hazards and offer suggestions. Examples might include to reduce clutter, remove loose rugs, smooth out bumps in floors and steps, move furniture to create a wide, unblocked path, improve lighting and improve access to the toilet, especially at night (by adding handles on the wall for example). A ramp to the main doorway will make it easier for people who use wheelchairs and others with a difficulty climbing steps. A person’s specific mobility limitations will guide what environmental adaptations are most important. With specific training, a community- or facility-based primary care provider can assess a person’s home. If a visit is not possible, a primary care health worker can give general instructions instead, to the person or a caregiver on how to create a safer home environment. A full assessment and management of a person’s risk of falls requires specialized knowledge. 5.6 CONSIDER AND PROVIDE ASSISTIVE DEVICES People with limitations in mobility may need assistive devices to move around. Assistive devices are those whose primary purpose is to maintain or improve an individual’s functional ability and independence to facilitate participation and to enhance overall well-being (10). These include canes, crutches, walkers, wheelchairs and prosthetic or orthotic devices. Choices may be limited by availability and cost, but a health professional with knowledge of physical therapy, if available, can give the best advice on the choice of an appropriate device and instructions on how to use it safely. Declines in any intrinsic capacity can increase the risk of falls. The physical environment and the way the task or activity was being performed can also be factors. In addition to assessing the physical environment, a full assessment of the risk of falls includes: • taking a history of falls, including details of the activities being carried out; • assessment of gait, balance, mobility, and muscle and joint function and flexibility; • assessment of fear of falling, vision, cognition, cardiovascular and neurological status, and urinary urgency or nocturia (waking to urinate at night); and • review of medications for polypharmacy (see Chapter 3 on assessing and developing a plan). Some people will need further assessment and management for problems such as syncope (blackouts), epilepsy and neurogenerative disorders such as Parkinson’s disease. 32 6 Vitality Care pathways to manage malnutrition WHO uses the term vitality to describe the physiological factors that contribute to an individual’s intrinsic capacity. These may include energy balance and metabolism. This handbook focuses on one key reason for decreased vitality in older age – malnutrition. KEY POINTS Primary care health workers can easily make an initial assessment of nutritional status. This should be a part of any assessment of an older person’s health. A full assessment of nutritional status requires specialized knowledge and sometimes blood tests. Both inadequate nutrition and less physical activity lead to loss of muscle mass and strength. A balanced diet in adequate amounts usually provides the necessary vitamins and minerals for older people, but deficiencies of vitamins D and B12 are common. Malnutrition often leads to weight loss – but not always. Fat mass can replace muscle mass, leaving weight unchanged. Another aspect of malnutrition is obesity, which has not been addressed in this guidance. 33 Have you unintentionally lost 3 kgs over the last three months? Have you experienced loss of appetite? ? ? Normal nutritional status (MNA score: 24–30 points) At risk of malnutrition (MNA score: 17–23.5 points) Malnourished (MNA score: < 17 points) – after acute event or illness – once a year for older people living in the community – every three months for older people with social care needs ASSESS NUTRITIONAL STATUS ASK Vitality NO NO (to either question) YES Offer dietary advice Consider oral supplemental nutrition if unable to improve food intake Monitor weight closely Consider multimodal exercise Nutritional intervention necessary Give oral supplemental nutrition with increased protein intake (400–600 kcal/day) Offer dietary advice Monitor weight closely REASSESS… Example: Mini nutritional assessment (MNA) (8) Care pathways to manage malnutrition Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to an individual’s needs, tastes and physical limitations i Reinforce generic health and lifestyle advice or usual care Reinforce generic health and lifestyle advice or usual care6 SOCIAL AND PHYSICAL ENVIRONMENT ASSESS & MANAGE Overcome barriers to people's nutritional health Encourage family and social dining Arrange assistance with preparation and provision of food 6.2 6.3 6.2 ASSOCIATED CONDITIONS ASSESS & MANAGE – FRAILTY – SARCOPENIA 1 1 2 1 Integrated management of diseases Consider rehabilitation to improve muscle function SCREEN FOR MALNUTRITION IN COMMUNITY Specialized care needed 6 Vitality Care pathways to manage malnutrition ADVICE TO GIVE ON NUTRITION • Primary care health workers can give older people advice and can encourage a healthy diet. All older people can benefit from this advice, including those at risk of or affected by undernutrition, whether or not they need specialized care. Following a good diet is easier for people who record what they eat on a chart every day – both at meals and between meals. • Help people to identify specific foods that are available locally and that provide adequate energy (carbohydrates), protein and micronutrients such as vitamins and minerals. Advise on the adequate amounts of these foods. • Because protein absorption decreases with age, advise older people to eat plenty of it. Protein intake of 1.0–1.2 g per kg of body weight is recommended for healthy older adults. A person recovering from weight loss or an acute illness or injury may need up to 1.5 g per kg of body weight. Renal function needs to be monitored as high-protein intake may lead to increased intraglomerular pressure and glomerular hyperfiltration. • Advise physical activity, which enables protein to be incorporated into muscle and builds appetite. • Encourage exposure to sunlight to make the skin produce vitamin D. The vitamin D in food is not enough for older people to maintain optimal levels. A blood test is necessary to measure whether a person’s vitamin D level is adequate. • Often, older people do not eat enough. To help an older person to eat more, suggest family-style meals and social dining, particularly for older people living alone or who are socially isolated. 1 Community- and facility-based primary health-care workers can offer advice and support to help all older people maintain a healthy diet. People with malnutrition or at high risk of it need a provider with specialized knowledge to look for causes and risk factors and to prescribe a personalized nutrition plan. If indicated, make or obtain a further assessment of possible conditions that could underlie or lead to malnutrition – even if current nutritional status seems adequate. Signs of these possible conditions include wasting, rapid weight loss, oral pain, pain or difficulty swallowing, chronic vomiting or diarrhoea, and abdominal pain. WHEN SPECIALIZED KNOWLEDGE IS NEEDED Good tools are available to help assess nutritional status (11). For example: ASSESS NUTRITIONAL STATUS 2 REMEMBER! The health-care worker needs to inform family members and other caregivers as well as the older person. Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire https://www.ȵintEo[.com/puElic/proMect/250/ Short nutritional assessment questionnaire 65+ (SNAQ65+) http://www.ȴghtmalnutrition.eu/toolNits/ summary-screening-tools). The care pathway on the facing page uses the mini nutritional assessment (MNA). 35 Vitality Care pathways to manage malnutrition 6 Most nutrition assessment tools ask about: • food and fluid intake • recent weight loss (same as the case-finding question) • mobility • recent psychological stress or acute disease • psychological problems • living situation. Also, they record: • weight • height • body mass index (BMI – weight in kg/height in m2) • arm and calf circumferences. ASSESS NUTRITIONAL STATUS BODY MASS COMPOSITION AND AGEING Typically after around 70 years of age, muscle mass may decrease, with important and potentially harmful effects on vitality. Both inadequate nutrition and inadequate physical exercise lead to loss of muscle mass and strength. At the same time, fat mass may increase. Body weight may decrease, or it may remain the same, masking these possible harmful changes. An undernourished person might, therefore, have lost crucial lean body tissue and still have a BMI in the accepted or even overweight range. A trained non-specialist can reliably assess muscle function, and thus protein malnutrition, with a tool such as a hand dynamometer to measure grip strength. This tool measures how hard a person can squeeze the tool with one hand. Low hand grip strength indicates the need for exercise and a diet that includes more protein. 36 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 6.2 FOR OLDER PEOPLE WITH MALNUTRITION For a person identified with malnutrition (for example, an MNA score below 17), a nutritional intervention should start at once. The primary care health worker can immediately give standard dietary advice (see box on page 35). As soon as possible, a health worker with specialized knowledge should also offer dietary advice and, if needed, prescribe oral supplemental nutrition (see below). The intervention should be part of a comprehensive care plan addressing the underlying factors contributing to poor nutrition, along with other interventions that address other domains of intrinsic capacity, such as limited mobility. In particular, adequate energy and protein intake will make multimodal physical exercise programmes more effective (see Chapter 5 on limited mobility). Oral supplemental nutrition Oral supplemental nutrition (OSN) provides additional high- quality protein, calories and adequate amounts of vitamins and minerals. Specialized knowledge is needed to develop a plan for OSN that is tailored to an individual’s needs, tastes and physical limitations. The assessment allows for choice of the best method of supplementation – whether through nutrient-rich foods, vitamin or mineral supplement pills or Sensory impairments (a decreased sense of taste and smell), poor oral health such as chewing problems and swallowing difficulties, isolation, loneliness, low income and complex long-term chronic conditions all increase the risk of malnutrition in older age. 6.1 FOR OLDER PEOPLE AT RISK OF MALNUTRITION An older person at risk of malnutrition (for example, an MNA score of 17–23.5) can benefit from advice on nutrition (see box on page 35). A person at risk of developing malnutrition should also preferably be offered a nutritional intervention, to prevent the development of malnutrition. MANAGE MALNUTRITION IN OLDER AGE 5 37 Vitality Care pathways to manage malnutrition 6 Oral supplemental nutrition should be prescribed only when a person cannot consume suɝcient calorie and nutrient-dense regular foods or when OSN is a temporary strategy in addition to regular food strategies to increase caloric intake. through specialized commercial products or non-commercial nutritional formulations. The health worker in the community can support and monitor the person taking OSN (see box). Blood test A blood test informs the personalized nutritional plan. A blood test can identify specific vitamin and mineral deficiencies. Specific oral nutrient supplements or injections can treat these deficiencies. For example, tablets or injections are needed to treat deficiencies in vitamins D and B12, which are common. KEY POINTS ABOUT OSN • Food comes first. Unless the need for OSN is urgent, improvements in diet, if possible, and more frequent meals should be tried first. • OSN adds to food. It should not replace food. A person taking OSN should understand the need to keep eating as well as possible. • People need instruction in how to mix OSN, how much to take at a time and when to take it. • OSN should be taken between meals, not at meal times. • People often need continuing support and encouragement (from family members, caregivers and health workers) to keep taking OSN and also to keep eating as well as possible. • After a time, a person may be tired of the taste and texture of one kind of OSN. A variety of flavours and a change from time to time may help. • Weight should be monitored and recorded regularly. • Ideally, the goal should be to stop OSN once the risk of malnu- trition has passed and the diet provides adequate nutrition. 38 6 Vitality Care pathways to manage malnutrition Vitality Care pathways to manage malnutrition 6 ASSESS & MANAGE ASSOCIATED CONDITIONS 6.3 SARCOPENIA AND FRAILTY Sarcopenia and frailty are conditions that can be associated with poor nutrition. Lifestyle interventions, including better nutrition and physical exercise, can help with both. Sarcopenia. This term describes a general, increasing loss of muscle mass, strength and function. It can result from disease, poor nutrition or a lack of physical activity (lying in bed for long periods of time, for example), or it may not have any obvious cause and may be associated with the ageing process. Frailty. Frailty can involve weight loss, muscle weakness, low levels of physical activity, exhaustion and slowness (walking slowly, for example). Frailty can result from physical or psychological stress, such as trauma, disease or the loss of a loved one. A person with frailty can lose functional abilities and become care-dependent. ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Caregivers and communities can help to overcome barriers to older people’s nutritional health. For example, community organizations might organize social dining events for older people. For their part, community health workers may be able to facilitate access to groceries, access to help with managing finances or accessing sources of income support, may facilitate assistance to prepare food, or receive prepared foods such as via a community-based catering service. 39 40 7 Visual capacity Care pathways to manage visual impairment Vision is a critical component of intrinsic capacity, enabling people to be mobile and to interact safely with their peers and the environment. Some causes of visual impairment become more common with ageing: near- sightedness and far-sightedness, cataracts, glaucoma and macular degeneration. Visual impairment can cause difficulties in maintaining family and other social relationships, in accessing information, moving safely (especially in the context of balance and the risk of falls) and in performing manual tasks. Such difficulties may lead to anxiety and depression. An assessment of vision is a critical component of a person-centred assessment. KEY POINTS With a simple eye chart, primary and community health workers can test for significant vision loss. Many people with vision loss can have their conditions treated. It is important to ask about, assess or verify the presence of established eye disease. Eyeglasses often can correct loss of near or distant vision. Assistive devices (magnifiers, telescopes) can support those with vision loss that cannot be corrected with glasses. In the home and community, simple measures such as better lighting can improve the functional ability of older people with vision loss. 41 Specialized care needed 7 DISTANCE VISION NEAR VISION ASSESS VISUAL IMPAIRMENT AND EYE DISEASES Treat eye diseases Manage visual impairment Review and update glasses prescription, or offer new glasses Consider eye rehabilitation, including assistive vision devices such as desk and mobile magnifiers Reinforce eye care and lifestyle advice, provide vision hygiene advice for person and environment NO YES Do otheshelf simple reading glasses solve the problem? FAIL TEST VISUAL ACUITY using WHO simple eye chart 1 2 3 4 ASSOCIATED CONDITIONS ASSESS & MANAGE Manage cardiovascular risk factors Refer to specialized eye care for retina check every year Review medication to avoid adverse drug reactions on eyes YES – HYPERTENSION – DIABETES – STEROID USE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Provide reading glasses Give advice on daily living with poor vision Introduce home adaptation (lighting, contrasting colours) to prevent falls Remove hazards from the usual walking path ASK Do you have any problems with your eyes: diɝculties in seeing far, reading, eye diseases or currently under medical treatment (eg diabetes, high blood pressure)? FAIL YES – Always test distance before near vision – Test without glasses if normally worn – Test one eye at the time, then together Fail in distance vision always requires referral for comprehensive care VISUAL IMPAIRMENT () Distance vision impairment: • Mild – visual acuity worse than 6/12 • Moderate – acuity worse than 6/18 • Severe – acuity worse than 6/60 • Blindness – acuity worse than 3/60. Near vision impairment: • Near visual acuity worse than N6 or M.08 with existing correction. i 7.4 7.5 7.9 7.10 Care pathways to manage visual impairment Visual capacity Repeat the test yearly even in the absence of vision impairment REASSESS… 7TEST DISTANCE VISION WITH WHO SIMPLE EYE CHART Demonstrate close to the person how to do the E test by showing the direction the Es point. Test from the small Es to large Es. 1. Test with the four small Es at 3 metres. Vision is 6/18 or better if the direction of at least three out of four small Es can be seen (PASS the distance vision screening test). If not able to see at least three of the small Es (FAIL the distance vision screening test) require assessment of visual impairment and eye diseases. The additional tests below might help estimate visual acuity. 2. Test with the large Es at 3 metres. If the Es are seen, vision is 6/60. If not able to see at least three of the large Es at 3 metres 3. Test with the large Es at 1.5 metres. If at least three out of four Es are seen, vision is 3/60. 2 1 TEST NEAR VISION WITH WHO SIMPLE EYE CHART Let the person hold the near vision test card as close as s/he wants. Test from the largest to the smallest Es. If the person identifies the directions of at least three out of four largest Es, s/he PASS the near vision screening test. If not, check if off-the-shelf reading glasses will help. With the reading glasses, if not able to see at least three of the largest Es (FAIL the near vision screening test), require assessment of visual impairment and eye diseases. The medium size is similar to the print in books. The smallest size is similar to the smallest print in books and magazines (not required to be seen). 3 VISION HYGIENE Vision hygiene involves both the environment and the person. Environmental factors and behaviours can facilitate vision function (for example, lighting, contrast, use of colours) or can be detrimental (for example, lengthy electronic media watching, extensive time spent using near vision). Personal hygiene includes the whole set of eye hygiene behaviours such as washing hands frequently, not rubbing the eyes, using only mild soap for eyelids and refraining from eye cosmetics. 4 WHEN SPECIALIZED CARE IS NEEDED If a person has established eye disease or is identified as having eye disease, an eye care specialist decides the frequency and type of examination. • Simple screening for vision loss should be carried out at least once a year for people aged 50 and older. • Screening can be performed using the WHO simple eye chart to test both distance and near vision. Instructions appear at right. • A primary health-care provider can perform the screening. It does not require formal training in eye care assessment (13). • If off-the-shelf reading glasses solve a person’s vision problem, comprehensive examination may not be needed. TEST VISUAL ACUITY IN PRIMARY CARE 7.1 7.2 7.2 7.3 Visual capacity Care pathways to manage visual impairment REASSESS… 43 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO SIMPLE EYE CHART (FOUR SMALL Es FOR DISTANCE VISION) • Small Es are 1.3cm x 1.3cm, at 1.3cm from each other • Full black E on plain white paper. 44 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO SIMPLE EYE CHART (FOUR LARGE Es FOR DISTANCE VISION) • Large Es are 4.2cm x 4.2cm, at 4.5cm from each other • Full black E on plain white paper. 45 7 Care pathways to manage visual impairment Visual capacity english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO SIMPLE EYE CHART (NEAR VISION) 46 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity • Reading glasses help many older people to see near objects. For some people, however, reading glasses are not the answer. For example, people who are far-sighted or who have astigmatism need eyeglasses prescribed by an eye care professional after examination. • A standard diagnostic examination includes a trained professional using a slit lamp to examine the eye in detail. This instrument can be used, for example, to detect a cataract and can help decide the need for surgery. Examination of the retina and optic nerve requires using other instruments and sometimes taking images to detect early changes and to guide treatment that can prevent vision loss. Examination of the retina at regular intervals is particularly important for people with diabetes. 7.4 ASSESS VISUAL IMPAIRMENT AND EYE DISEASES • Sudden or rapidly progressing loss of vision in one or both eyes requires a basic eye and vision examination and a referral for specialized eye care. • A primary care professional can look at the person’s eyes. If there are changes such as red eyes, secretions, scars, ongoing pain, intolerance to sunlight or a cataract, an eye care professional (ophthalmologist, optometrist) should examine the person. • A primary care professional can examine the eyes for signs of common eye diseases. This examination is generally not comprehensive and requires examination performed by a specialist. If the eye condition listed above persists, specialized eye care is recommended. ASSESS FOR VISUAL IMPAIRMENT AND EYE DISEASES Cataracts Cataract is clouding of the lens of the eye, which prevents clear vision, often related to the ageing process. Cataract remains the leading cause of blindness. Reduction of smoking and ultraviolet light exposure may prevent or delay the development of cataract. Diabetes and obesity are additional risk factors. Visual impairment and blindness from cataracts are avoidable because cataract surgery is safe and can restore sight. 47 7 Care pathways to manage visual impairment Visual capacity 7.6 IRREVERSIBLE LOW VISION Many people have low vision for which prescription glasses cannot correct their vision sufficiently. For these people, assistive vision devices – desk or mobile magnifiers – provide greater magnification than glasses. They can make tasks involving near vision possible, such as reading a book or newspaper, identifying money, reading labels and inspecting small objects or parts of large objects. Community-level health or rehabilitation workers can help people obtain these devices. Vision rehabilitation. A person with irreversible low vision will benefit from comprehensive vision rehabilitation services that include psychological support as well as orientation, mobility and training in activities of daily living. Eye care and rehabilitation specialists can train people with low vision in skills that enhance visual functioning – skills such as awareness, fixation, scanning and tracking. These skills are usually needed for the effective use of magnifiers, but they can be useful in other circumstances as well. 7.5 READING GLASSES Many people aged 50 years and older have difficulty seeing or reading at short distances. They can often benefit from using reading glasses (also called “readers”). Simple reading glasses are available at low cost. They are often available in various magnification strengths. Reading glasses simply make close-up objects appear larger. When simple reading glasses do not resolve the problem, comprehensive eye and vision examination is advisable. If possible, all people aged 50 or older should be examined by an eye care professional at regular intervals. Simple vision and reading tests are not a substitute for a comprehensive examination done by an eye care professional. MANAGE VISUAL IMPAIRMENT 48 7 Visual capacity Care pathways to manage visual impairment 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE ASSOCIATED DISEASES 7.9 STEROID USE In some people, long-term therapy with steroids can increase pressure in the eyeball (intraocular pressure) or lead to cataract. This increased pressure can lead to vision loss, which involves damage to the optic nerve, and can lead to blindness if not treated. Anyone receiving long- term steroid therapy needs regular eye examinations and eye pressure checks. 7.7 HYPERTENSION Hypertension is an important risk factor for retinal diseases and glaucoma. 7.8 DIABETES A person with diabetes should have an eye examination by an eye care specialist each year to check for diabetic retinopathy. 49 7 Care pathways to manage visual impairment Visual capacity ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Create contrast. Good contrast within and between objects makes them easier to see, find or avoid. Examples are high- contrast marking on the edges of steps (particularly for those with vision in only one eye), coloured plates so that food stands out in contrast, and using a black pen for writing. People with low vision, family members and caregivers can colour the handles of household and kitchen tools to make them more visible and safer – for example, wrapping a knife handle with brightly coloured adhesive tape or painting it. Use the most legible type. For printed materials and electronic display screens on computers and telephones, large, sans serif type (such as the type in this handbook) that stands out clearly from a uniform background colour is easiest to read. Choose household objects with larger type and good contrast. There are often products available in shops that use larger letters and numbers or good contrast. Exam- ples of products available in this way are clocks, watches and large-print books. For leisure, large game boards and pieces, and playing cards with large print and symbols, for example, can be bought or made. Use hearing as well as vision assistive tools. Many items in shops now have speech capacity, such as talking watches, thermometers and scales. Many mobile telephones and computer programs now have a text-to-speech functions. There are many ways to help people with low vision enjoy better function. Family members and caregivers can help. Local adaptation of this guidance to specify where to get assistive vision devices and how to get services is required depending on the settings. 7.10 ADAPTATIONS TO LOW VISION Beyond provision of assistive vision devices, simple changes can enable people with low vision to maintain their activities and, thus, maintain their quality of life. Changes can be made to the home and in a person’s usual areas of movement to make usual tasks and leisure activities safer and easier. The following are examples. Improve lighting. Good lighting is particularly important for near vision. Light is best coming from the side of the person (without creating shadow). Reduce glare. Brighter light is usually better. But glare from the sun or bright lights can bother some people. Move obstacles. Hazards such as furniture and other hard objects can be moved out of the person’s usual walking path or, if needed there, should always be left in the same place. 50 8 Hearing capacity Care pathways to manage hearing loss Age-related hearing loss may be the most common sensory impairment in older people. Untreated hearing loss interferes with communication and can lead to social isolation. Limitations of other capacities, such as cognitive decline, can make these social consequences worse. Hearing loss is linked to many other health issues, including cognitive decline and risk of dementia, depression and anxiety, poor balance, falls, hospitalizations and early death. Assessing hearing is therefore a critical part of monitoring older people’s intrinsic capacity at the community level. Assessing hearing in greater depth is also a critical part of a full assessment of an older person’s health and social care needs. KEY POINTS Community- and facility-based primary care workers can screen for hearing loss with simple portable equipment or a whisper voice test. Simple actions in the household and community can reduce the impact of hearing loss. Communication strategies to make hearing easier include speaking clearly, facing the person with hearing loss when speaking, and reducing background noise. Improving the hearing itself involves hearing devices such as hearing aids and cochlear implants. Providing them requires specialized knowledge and equipment. 51 Specialized care needed Moderate to severe hearing loss (Audiometry: 36–80 dB) Deafness (Audiometry: Ȳ 81 dB) Normal hearing capacity (Audiometry: ȱ 35 dB) 8 ASK ABOUT: – RISK FACTORS (such as noise exposure and ototoxic medications) – PAIN IN THE EAR – HISTORY of active drainage of fluid from the ear(s), sudden or rapidly progressive hearing loss – DIZZINESS – CHRONIC OTITIS MEDIA – UNILATERAL HEARING LOSS Provide hearing aids If no hearing aids available, inform about lip reading and signing as well as other communication strategies NO PASS Reinforce generic advice on caring for ears or usual care Reinforce generic advice on caring for ears or usual care REASSESS once every year FAIL TEST HEARING – Whisper voice test: Able to hear whispers OR – Screening audiometry: 35 dB or less to pass OR – Automated app-based digits-in-noise test Care pathways to manage hearing loss Hearing capacity SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE ASSESS HEARING CAPACITY (Diagnostic audiometry) 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) Provide the person with hearing loss, their family members and caregivers with strategies to stay connected and maintain relationships (to any) YES Refer to specialized hearing care Evaluate and provide hearing device (hearing aids or cochlear implants) 8.1 8.5 8.4 8.4 2 – (to all) 1Initial assessment uses one of three possible tests. WHISPER VOICE TEST The whisper voice test is a screening tool that can help determine whether a person has normal hearing or needs diagnostic audiometry. SCREENING AUDIOMETRY (15) Use screening audiometry if you have the equipment. Screening audiometry presents tones across the speech spectrum (500 to 4,000 Hz) at the upper limits of normal hearing. Results are recorded as pass or refer. A reading of 35 dB or less indicates normal hearing. With brief specific training, a non- specialist can accurately test hearing with this equipment. AUTOMATED APP-BASED DIGITS-IN-NOISE TEST An automated digits-in-noise self-test also can be used to determine whether diagnostic audiometry is needed. Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). TEST HEARING GENERIC ADVICE ON CARING FOR EARS DO NOT put dirty fingers in ears or forget to wash hands before working with food, and do not eat with dirty hands ALWAYS wash your hands after going to the toilet DO NOT swim or wash in dirty water DO NOT put anything in your ears: – hot or cold oil – herbal remedies – liquids such as kerosene. 2 WHISPER VOICE TEST Stand about an arm’s length away behind and to one side of the person. Ask the person or an assistant to close off the opposite ear by pressing on the tragus. (The tragus is the projection in front of and partly covering the opening of the ear.) Breathe out and then softly whisper four words. Use any common, unrelated words. Ask the person to repeat your words. The words should be spoken one by one, and wait for the response to each one at time. If the person repeats more than three words and you are sure that the s/he can hear you clearly, then the person is likely to have normal hearing in this ear. Move to the other side of the person and test the other ear. Use different words. 3 Whisper words that will be familiar to the person. Here are examples: – factory – sky Ȃ ȴre – number Ȃ ȴsh – bicycle – garden – yellow WHEN SPECIALIZED CARE IS NEEDED • Evaluation of a person with severe hearing loss/deafness. • Fitting of a hearing assistive device. • Management of an underlying problem that causes or contributes to hearing loss. 8 Hearing capacity Care pathways to manage hearing loss 53 8 Care pathways to manage hearing loss Hearing capacity Speech audiometry. Older adults benefit from an additional test – speech audiometry. In this test a series of pre-recorded simple words are played at increasing volumes, and the person is asked to repeat the words when they hear them. This test cross-checks the results of the PTA. It helps to determine whether speech recognition is consistent with the PTA results, if there is an asymmetry of speech perception that is not predicted by the PTA, or identifies which ear to fit with a hearing aid if only one hearing aid is being fitted. Tympanometry. Finally, tympanometry tests the compliance (or mobility) of the ear drum. This test can support the pure tone and speech audiometry results to determine the type of hearing problem. 8.1 THREE TESTS FOR COMPREHENSIVE ASSESSMENT Hearing assessment can involve three tests with specialized equipment – a diagnostic audiometer for pure tone, and speech audiometry and a tympanometer for middle ear assessment. These tests can help to identify the need for rehabilitation. Doing these tests needs specialized training. Pure tone audiometry. Pure tone audiometry (PTA) tests a person’s ability to hear sounds of different pure tone frequencies (pitches). It consists of playing pre-recorded sounds louder and louder until the person can hear them – the hearing threshold. It tests air conduction and bone conduction of sounds to assess hearing thresholds at frequencies from 125 Hz (very low) to 8000 Hz (very high). This test helps to determine the degree and type of hearing loss. ASSESS HEARING CAPACITY 54 8 Hearing capacity Care pathways to manage hearing loss Both communication strategies and hearing devices should be considered to deal with hearing loss. The best approach to managing hearing loss should be decided in light of the complete assessment of the person’s intrinsic capacity. Any cognitive decline, any loss of locomotor capacity or loss of dexterity in the arms or hands, and the support available from family and community all need to be considered. 8.2 FOR OLDER PEOPLE WITH MODERATE TO SEVERE HEARING LOSS • Explain to people with hearing loss and their families the benefit of hearing devices such as hearing aids, where to get them and how to use them. Once a person has a hearing aid, the health worker can support and encourage its use. • Audiometry alone should not determine whether a person needs a hearing aid. Most people with hearing loss complain about difficulty communicating when there is background noise. A person must be assessed for their overall need before suggesting the use of hearing aids. • Give clear guidance to people with hearing loss and to their families and caregivers on communication strategies that can improve functional ability. • Certain medications can cause damage to the inner ear, resulting in hearing loss and/or loss of balance. These include antibiotics such as streptomycin and gentamicin and antimalarials such as quinine and chloroquine. Other medications also can affect hearing. Reducing these medications, if possible, may prevent further hearing loss. 8.3 FOR OLDER PEOPLE WITH DEAFNESS An older person with a high degree of hearing loss (severe or profound) or who does not benefit from the above- mentioned interventions will need specialized hearing care such as the fitting of a hearing device. Providing hearing devices needs specialized skills for testing, prescription and fitting. MANAGE HEARING LOSS Other red flags for specialized hearing care Conditions that may underlie hearing loss need specialized diagnosis and management. These include: • pain in the ear • chronic otitis media (middle ear infection) • sudden or rapidly progressive hearing loss • dizziness with moderate to severe hearing loss • active drainage of fluid from the ear(s) • presence of risk factors such as noise exposure and taking medications that can damage hearing. 8.5 55 8 Care pathways to manage hearing loss Hearing capacity 8.4 HEARING DEVICES Hearing aids. Hearing aids are usually the best technology for older people with hearing loss. Hearing aids make sounds louder. They can be effective for most people, and they are convenient because they are worn in or on the ear. It is important to explain to people that hearing aids do not cure or treat hearing loss. Cochlear implants. Cochlear implants can benefit a person with a high degree of hearing loss who is not benefitted by hearing aid use. A cochlear implant is surgically placed in the ear. It turns sounds into electrical impulses and sends them to the nerves of the ear. A person must be evaluated carefully to see if a cochlear implant will help. If cochlear implantation is not available or feasible, the older adult and his or her family should be informed about and trained in lip-reading and sign language. Audio induction loops and personal sound amplifiers. Audio induction loops and personal sound amplifiers are also effective. An audio induction loop, or hearing loop, is a wire or wires placed around a space (for example, a meeting room or service counter). The wires send signals from a microphone and amplifier to certain types of hearing aids. The WHO Guidelines for hearing aids and services for developing countries offer more guidance: http://apps.who.int/iris/handle/10665/3066 56 8 Hearing capacity Care pathways to manage hearing loss ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS Minimizing the impact of hearing loss can help to preserve independence and reduce the need for older adults to rely on community services for everyday living needs. Family members, other caregivers and the community can all help. Hearing loss often leads to psychological distress and social isolation. For this reason, audiological rehabilitation is now placing greater emphasis on psychosocial consider- ations, tailored to the goals of the older person and their caregivers. • Regular social interaction may reduce the risk of cognitive decline, depression and other emotional and behavioural consequences of hearing loss. In times of particular distress, social support networks can help. • Partners and family members can help to prevent loneliness and isolation. They may need advice on how to do this. For example, they should keep communicat- ing with the person who has hearing loss and organize activities that keep the person involved in a social network. See the box at right for advice on speaking to a person with hearing loss. • Environmental solutions at home can include putting doorbells and telephones where they can be heard throughout the house. 8.5 COMMUNICATION STRATEGIES FOR FAMILY MEMBERS AND CAREGIVERS Health-care workers can advise family members and caregivers to follow certain simple practices when speaking to a person with hearing loss (14). • Let the person see your face when you speak. • Make sure there is good light on your face to help the listener to see your lips. • Get the person’s attention before you speak. • Try to avoid distractions, especially loud noises and background noise. • Speak clearly and more slowly. Do not shout. • Do not give up speaking to people who have difficulty hearing. This would isolate them and could lead to depression. These strategies are helpful whether or not a person has a hearing assistive device. 8.5 57 58 The term “depressive symptoms” (or low mood) applies to older adults who have two or more simultaneous symptoms of depression most of or all the time for at least two weeks, but who do not meet the criteria for a diagnosis of major depression. Depressive symptoms are more common in older people with long-term and disabling conditions, in social isolation or who are caregivers with demanding care responsibilities. These issues should be considered as part of a comprehensive approach to managing depressive symptoms. Depressive symptoms are an important aspect of psychological capacity, but only one dimension. There are other aspects such as anxiety, personality characteristics, coping and mastery that need complex measures. This chapter provides guidance on preventing and managing depressive symptoms in older people. Further guidance on interventions for depression can be found in the WHO mhGAP intervention guide, at https://apps.who.int/iris/ handle/10665/250239 KEY POINTS By asking a series of questions, the primary care worker in the community can identify those with depressive symptoms and distinguish depressive symptoms from depression. Using brief structured psychological interventions, trained and supervised non-specialist health-care professionals can help people with depressive symptoms in the community and other primary care settings. Depression requires a comprehensive and usually specialist approach to treatment. Declines in other domains of intrinsic capacity, such as in hearing or mobility, may impair functional abilities, reduce social participation and contribute to depressive symptoms. Psychological capacity Care pathways to manage depressive symptoms 9 59 * Older people use a wide variety of terms for low mood, like sadness, depressed, down, etc. Feeling down, depressed or hopeless?* Little interest or pleasure in doing things? ? ? DEPRESSION Ȳ 3 additional symptoms DEPRESSIVE SYMPTOMS 0Ȃ2 additional symptoms Psychological capacity 9 NO NO to either of the aEove to all YESCare pathways to manage depressive symptoms https://apps.who.int/iris/handle/10665/250239 Reinforce generic health and lifestyle advice or usual care Over the past two weeks, have you been bothered by – Major loss in the last six months – History of mania – Cognitive impairment – Hearing loss – Visiual impairment – Disability due to illness or injury Review medications such as antidepressants, antihistamines, antipsychotics Integrated management of conditions Assess and manage pain – POLYPHARMACY – ANAEMIA, MALNUTRITION, HYPOTHYROIDISM – PAIN NO 9.1 9.2 9.3 Reduce stress and strengthen social support Motivate older people to stay mobile and socially connected Promote functioning in daily activities Encourage participation in community-based exercise programmes and skills development Identify and tackle loneliness and social isolation (consider technology- assisted interventions ) ASSESS MOOD 12 ASSOCIATED CONDITIONS ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS ASSESS & MANAGE Offer brief structured psychological interventions: – cognitive behavioural therapy – problem-solving counselling or therapy – behavioural activation – life review therapy Multimodal exercise Mindfulness practice Treat depression Older people who have a diagnosis of major depression generally need specialized care. They should be advised and treated as recommended in the WHO mhGAP intervention guide. 9.4–9.7 SCREEN FOR DEPRESSIVE SYMPTOMS ASK 6 Specialized care needed 12 * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. WHEN SPECIALIZED CARE IS NEEDED • Management of depression needs a more comprehensive and usually specialist approach to develop a personalized care plan. • To manage depressive symptoms, health workers need specific training in ErieI structured psychological interventions. • Certain associated conditions, such as hypothyroidism, may need specialized diagnosis and management. • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD Psychological capacity Care pathways to manage depressive symptoms If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. DEPRESSIVE SYMPTOMS If a person has at least one of core symptoms and one or two additional symptoms, they may have depressive symptoms. If a person has more than two symptoms, they may qualify for a diagnosis of depressive disorder. It is important to distinguish depressive symptoms from depressive disorder because their treatments differ. • Cognitive decline and dementia may be associated with depressive symptoms and must be assessed as well. People with dementia often come to a health worker with complaints of mood or behavioural problems, such as apathy, loss of emotional control, or difficulties carrying out usual work, domestic or social activities. • At the same time, declines in other domains of intrinsic capacity, such as sensory or mobility, may reduce functional ability and social participation, and so contribute to depressive symptoms. • Interventions for declines in other components of intrinsic capacity, such as cognition or hearing, may be more effective if depressive symptoms are addressed at the same time. This should be considered when developing the personalized care plan. ASK: Ȋ2ver the last two weeNs have you Eeen Eothered Ey any of the following proElems"ȋ 9 61 Psychological capacity 9 Care pathways to manage depressive symptoms Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is based on the idea that feelings are affected by both beliefs and behaviour. People with depressive symptoms (or diagnosed mental disorders) may have unrealistic, distorted negative thoughts that, if unchecked, can lead to harmful behaviour. Thus, CBT typically has a cognitive component – helping the person to develop the ability to identify and challenge unrealistic negative thoughts – as well as a behavioural component to enhance positive behaviours and reduce negative behaviours. Steps can include (1) identifying problems in one’s life, (2) becoming aware of thoughts, emotions and beliefs about these problems, (3) identifying negative or inaccurate thinking (4) and reshaping this thinking to be more realistic. Problem-solving counselling or therapy A problem-solving approach should be considered for people with depressive symptoms who are in distress or who have some degree of impaired social functioning (in the absence of a diagnosed depressive episode or disorder). Problem-solving therapy offers the person direct and practical support. The health professional acting as the therapist and the older person work together to identify and isolate key problem areas that might be contributing to the depressive symptoms. Together, they break these down into specific, manageable tasks by problem-solving and by developing coping strategies for specific problems. MANAGE DEPRESSIVE SYMPTOMS 9.1 BRIEF STRUCTURED PSYCHOLOGICAL INTERVENTIONS Brief structured psychological interventions, such as cognitive behavioural therapy, problem-solving approaches, behavioural activation and life review therapy, may considerably reduce depressive symptoms in older adults. Multimodal exercise and mindfulness practice can also reduce depressive symptoms. Many psychological interventions can be used, with the consent and agreement of the older person and taking into account their concerns, such as difficulties with problem-solving. Physical exercise should be considered, in addition to structured psychological treatments, due to the positive effect of physical exercise in improving mood (see Chapter 5 on limited mobility). Prescriptions of antidepressants by primary care physicians without specialized knowledge in mental health is not recommended. 5 Health professionals with training in mental health would usually administer these interventions. Community health workers also could provide them if they are skilled in using them and trained in the mental health issues of older people. No harms have been associated with these interventions. 62 9 Psychological capacity Care pathways to manage depressive symptoms Psychological capacity 9 Care pathways to manage depressive symptoms 5 9.2 MULTIMODAL PHYSICAL EXERCISE A programme of exercise tailored to the physical abilities and preferences of the person can reduce depressive symptoms in the short term and perhaps in the longer term as well. See Chapter 5 on limited mobility. 9.3 MINDFULNESS PRACTICE Mindfulness consists of paying attention to what is happening in the present moment instead of being carried along by a train of thoughts about the past, future, wishes, responsibilities or regrets. Such latter thoughts can become a downward spiral for a person with depressive symptoms. There are many types of mindfulness practice. An approach widely used is sitting or lying quietly and focusing attention on the sensations of breathing. Mindfulness of physical movement – for example, during yoga or walking – is also helpful for some people. Behavioural activation Behavioural activation involves encouraging the person to participate in rewarding activities as a means to reduce depressive symptoms. This approach can be learned more quickly than most other evidence-based psychological treatments. It might be learned by non-specialists and so access to care for depressive symptoms can be increased. The intervention has been studied mainly as a multiple-session intervention conducted by specialists. It is possible, however, that the intervention could be modified into a brief intervention and delivered by trained health professionals as an adjunct treatment or as part of a first step in a comprehensive care approach in primary care. Life review therapy Life review therapy involves a therapist guiding a person to remember and evaluate their past in order to achieve a sense of peace or acceptance about their life. This type of therapy can help put life in perspective and even recover important memories about friends and loved ones. Life review therapy can help to treat depression in older adults and can help those facing end-of-life issues. Therapists centre life review therapy on life themes or by looking back on certain time periods, such as childhood, parenthood, becoming a grandparent or working years. 63 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE ASSOCIATED CONDITIONS • Hearing loss. Older people with hearing loss may be likely to report embarrassment, anxiety and loss of self-esteem, and are less likely to participate in social activities and physical activity, leading to social isolation and loneliness, and eventually depression (15). • Visual impairment and the presence of major age- related eye diseases such as age-related macular degeneration and glaucoma are associated with an increased risk of depression (16). People with poor visual functioning often report that they feel unhappy, lonely or even hopeless. • Reaction to disability due to illness or injury. Depression is a common secondary condition in people with disabilities. People who experience disability due to illness and injury undergo stress; they must also cope with life transitions. The stages of adjusting to a new form of disability include shock, denial, anger/ depression and adjustment/acceptance. Older people with new disabilities are at risk of developing anxiety and depression. The presence of the following associated conditions would suggest a different approach from treatment for depression is needed. • Major loss in the last six months. • History of mania. Mania is an episode of mood elevation and increased energy and activity. People who experience manic episodes are classified as having bipolar disorder. History of mania can be identified by checking several symptoms occurring simultaneously, lasting for at least one week, and severe enough to interfere significantly with work and social activities or requiring hospitalization or confinement (see the mhGAP intervention guide https://www.paho.org/mhgap/en/ EipolarBȵowchart.html). • Cognitive decline. The relationship between depression and cognitive decline is complex. The epidemiological studies have long linked depression to the development of Alzheimer’s disease. The cognitive functions affected in depression are attention, learning and visual memory as well as executive functions. Depression could be a psychological response to the individual’s self-awareness of mild cognitive decline that has not yet begun to interfere with daily functioning. 64 Psychological capacity 9 Care pathways to manage depressive symptoms 9 Psychological capacity Care pathways to manage depressive symptoms 9.6 HYPOTHYROIDISM Hypothyroidism is a common disorder in older people, especially women. The symptoms of hypothyroidism can be non-specific and vary from person to person, but they can include depressive symptoms. Hypothyroidism should be assessed and managed by health workers with specialized knowledge. 9.7 PAIN Individuals reporting chronic pain more often have depressive symptoms. It is important to assess and manage pain (see Chapter 5 on limited mobility). 9.4 POLYPHARMACY Polypharmacy can lead to depressive symptoms, and depressive symptoms may lead to polypharmacy. Addressing polypharmacy as well as depressive symptoms is important, to break the vicious circle. In addition to drugs that act primarily on the central nervous system, drugs with psychotropic properties, such as antihistamines and antipsychotics, muscle relaxants and other non-psychotropic drugs with anticholinergic properties can be associated with depressive symptoms. Eliminating unnecessary, ineffective medications as well as medications with duplicative effects reduces polypharmacy. 9.5 ANAEMIA, MALNUTRITION Anaemia and malnutrition can lead to depressive symptoms because of deficiencies of iron, vitamins such as folate, vitamin B6 and vitamin B12. Depressive symptoms can also play a role in the development of anaemia. Loss of appetite and lack of interest in performing daily activities (such as shopping and cooking) can reduce the quality and quantity of nutrition of older adults, facilitating the development of anaemia and malnutrition. To manage depressive symptoms, it is crucial to manage anaemia and improve nutritional status (see Chapter 6 on malnutrition). 5 6 65 Psychological capacity 9 Care pathways to manage depressive symptoms ASSESS & MANAGE SOCIAL AND PHYSICAL ENVIRONMENTS If an older person experiences loss in capacity, such as hearing loss or limitation in locomotor capacity, family members and caregivers can pay special attention to avoiding social isolation. Social isolation can lead to depressive symptoms. Consider technology-assisted interventions using the phone or the Internet to address loneliness. Loss of interest in activities that used to be interesting or pleasurable is typical in depression. Family members and caregivers can offer gentle encouragement and support for more physical activity and more social engagement such as community-based exercise programmes and skills development. 66 10 Care pathways for social care and support Social care and support For people with significant losses of intrinsic capacity, dignity is often possible only with care, support and assistance from others. The availability of social care and support is critical to ensuring a dignified and meaningful life. Social care and support includes not only help with activities of daily living (ADLs) and personal care, but also facilitating access to community facilities and public services, reducing isolation and loneliness, helping with financial security, providing a suitable place to live, freedom from harassment and abuse, and participation in activities that give life meaning. The most appropriate person to ask about social care and support needs may vary by question. If the older person has cognitive decline, questions about ADLs and finances may be best asked of someone who knows the person well, such as a family member, caregiver or friend. KEY POINTS Reduced functional ability is common among older people, especially among those with declined intrinsic capacity, but it is not inevitable. Community health workers can screen for losses in functional abilities with a simple questionnaire. Interventions tailored to an older person’s priorities can improve functional ability. Effective interventions include those to improve intrinsic capacity, functional ability and the provision of social care and support. 67 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Care pathways for social care and support A B Social care and support 10 1. 'o you have diɝculty getting around indoors" 2. 'o you have diɝculty using the toilet or commode " 3. 'o you have diɝculty dressing yourself" 4. 'o you have diɝculty using the Eath or shower" 5. 'o you have diɝculty Neeping up your personal appearance" 6. 'o you have diɝculty feeding yourself" 7. 'o you have proElems with the place where you live accommodation " 8. 'o you have proElems with your ȴnances" 9. 'o you feel lonely" SOCIAL CARE AND SUPPORT NEEDS HELP WITH SOCIAL CARE (PERSONAL ASSISTANCE) ASSESS YES YES Assess and modify physical environment to compensate for loss of intrinsic capacity, improve mobility and prevent falls Consider use of assistive technologies, aids and adaptations Assess support from spouse, family or other unpaid caregivers, and include an assessment of the caregiver’s needs Review needs for support from paid care workers Caregivers and services should be available such as home-base care, day-care, nursing home ASK SUPPLEMENTARY QUESTIONS Do you have concerns because of: 1. Your safety and security where you live? 2. The condition of your house? 3. The location of your home? 4. The costs of housing? 5. The repair and maintenance of your home? 6. Managing to live independently where you are? Consider: – home adaptations – alternative accommodation – refer to social welfare or community housing programmes or existing support networks ASK SUPPLEMENTARY QUESTIONS Ζn general, how do your ȴnances work out at the end of the month? $re you able to manage your money and ȴnancial aairs? Would you like advice about ȴnancial allowances or beneȴts? ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Review ways to enhance: – close social connections (spouse, family, friends, pets) – use of local community resources (clubs, faith groups, day centres, sports, leisure, education) – opportunities to contribute (volunteering, employment) – connectivity using communications technology Consider: – referral for specialist financial advice – advice on delegation of financial decision-making with protection against financial abuse If any immediate threat, refer for specialist assessment through social work, adult protection, or law enforcement systems ASK YES NO YES YES Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse. 10. $re you aEle to pursue leisure interests hoEEies worN volunteering supporting your family educational or spiritual activities that are important to you" 11. $ssess risN of elder aEuse 1 Health workers should know who older people should be referred to for specialist assessment. Protocols will vary depending on availability. A village head, school principal, monk or leader of a faith group are examples of people who can be appropriate instead of a social worker in some settings. Given that integrated social care and support requires the support of multiple dimensions, regular meetings to foster trust among specialists and services are important. The following are examples of the areas of expertise of different specialists involved in older people’s care. • Living condition: housing services, social worker, occupational therapist. • Finances: social worker, benefit advisory services. WHEN SPECIALIZED KNOWLEDGE IS NEEDED • Loneliness: social worker, voluntary services, primary care physician. • Participation: social worker, leisure, employment and voluntary services. • Abuse: social worker, adult protection, law enforcement services. • Activities of daily living: occupational therapist, social worker, nurse or multidisciplinary older age specialist team. • Indoor mobility: physiotherapist, occupational therapist, social worker or multidisciplinary older people’s specialist team. • Outdoor mobility: physiotherapist, social worker, voluntary transport services. BEHAVIOUR OF THE OLDER PERSON • Seems to be afraid of a relative or a professional caregiver. • Does not want to answer when asked, or looks with anxiety at the caregiver/relative before responding. • Behaviour changes when the caregiver/relative enters or exits the room. • Refers to the caregiver in terms such as “strong willed” or often “tired” or “bad tempered”, or as becoming irritable/very anxious/highly stressed/loses temper very easily. • Shows exaggerated respect or extreme deference for the caregiver. 1 BEHAVIOUR OF THE CAREGIVER/RELATIVE • Hinders or prevents the professional and the older person from talking in private, or keeps finding reasons to interrupt the flow of the assessment interview (repeatedly coming into the room, for example). • Insists on answering questions that are instead addressed to the older person. • Places obstacles in the way of providing assistance at home for the older person. • Demonstrates a high level of dissatisfaction about having to take care of the older person. • Attempts to convince practitioners that the older person is ”crazy” or demented, or that the person does not know what they are saying due to confusion, when this is not the case. • Is hostile, tired or impatient during the interview, and the older person is very restless or indifferent in their presence. OBSERVATIONAL CUES FOR POSSIBLE ELDER ABUSE PHYSICAL ABUSE • Cuts, burns, bruises and scratches. • Injuries that do not match an explanation given for them. • Injuries that are unlikely to have happened accidentally. • Injuries and wounds in concealed places. • Bruising that is shaped like fingers from rough handling (often upper arms). • Injuries in protected areas, e.g. underarms. • Untreated injuries. • Multiple injuries at different stages of healing. • Medication underuse or overuse. 10 Care pathways for social care and support Social care and support 69 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 ASSESS & MANAGE SOCIAL SUPPORT NEEDS 10.1 ASSESS AND MANAGE NEED FOR PERSONAL CARE AND ASSISTANCE WITH DAILY ACTIVITIES (SECTION A OF PATHWAY) Six questions are used to assess whether a person has reached the point of no longer being able to take care of themselves without the help of others. An older person with significant loss of intrinsic capacity would benefit from this assessment. Getting around indoors covers a number of activities, such as moving from a bed to a chair, walking, getting to the toilet and using it, and managing stairs. Limited mobility leads to increased risks and for the need for personal care. Dressing, feeding, bathing and grooming are ADLs. Being unable to do ADLs leads to a need for personal care. Many older people do not want to rely on others for help with ADLs, preferring to be able to manage for themselves. Older people who have difficulties with ADLs and/ or mobility problems benefit from a programme of rehabilitation. This may be focused on improving capacities but may also include assistive technologies and environmental adaptations to optimize functional ability despite the limitations in intrinsic capacity. Transport services can be provided to help with outdoor mobility. If difficulties remain, support from a spouse, family and other unpaid carers should be reviewed, including a consideration of their own needs. If further support is needed, voluntary, private or public home care services should be provided. 10.2 ASSESS AND MANAGE SOCIAL SUPPORT NEEDS (SECTION B OF PATHWAY) Regardless of the level of intrinsic capacity and functional ability, an assessment of social support needs will benefit an older person. Providing social support enables an older person to do the things that are important to them. This includes support for their living condition, financial security, loneliness, access to community facilities and public services, and support against elder abuse. B7 LIVING CONDITION The place where an older person lives can affect their health, independence and well-being. Problems can relate to many things, including the place’s size, access, condition, safety and security. Supplementary questions can help to identify specific areas to address. 70 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 10 Care pathways for social care and support Social care and support B9 LONELINESS Loneliness is common in older age and is associated with an increased likelihood of depression and early death. See Chapter 9 for guidance on screening for depressive symptoms. Being alone is not the same as being lonely – an older person can be lonely even when surrounded by other people, if the quality of the relationships is poor. It is helpful to ask a lonely older person if increased social contact with family and friends, or meeting others with similar interests, would help to reduce their sense of loneliness. But when asking an older person if increased contact may help, reassure them that the question is private, to help overcome any fears about revealing the nature of personal relationships. Having a pet animal reduces loneliness for many older people. Use of local community facilities such clubs, faith groups, day centres and sports, leisure or education services should be encouraged. There may be opportunities to contribute through volunteering or paid employment. Social connections can be increased through communications technology. A general review of these measures to combat loneliness should be undertaken. Assessors should be aware of the broad range of local assets. Problems with living conditions can be mitigated by introducing new security measures, having a number to call in the event of an emergency and making adaptations to maintain independent living. Financial benefits may be available to help with accommodation costs, and for repair and maintenance. If all else fails, a move to more suitable accommodation should be considered. B8 FINANCE Financial resources are strongly associated with health, independence and well-being in older age. Problems can include having too little money to meet basic needs or to fully participate in society, and older people can worry that money will run out or that they will become unable to manage their finances. Further questions can help to identify specific areas that need addressing. Financial problems can be mitigated though independent advice about financial planning and financial management. Arrangements can be put in place for devolved authority to a trusted third party for managing finances, provided legal protection is in place to prevent financial abuse. 71 ASK SUPPLEMENTARY QUESTIONS TO IDENTIFY THE BARRIERS: You are not able to pursue… because of: cost, distance, transport, lack of opportunities, others? Provide a list of local community services available to older people, such as leisure facilities and clubs, adult education providers, volunteering and employment advisory services Encourage the older person to use these services to increase their participation Care pathways for social care and support Social care and support 10 B10 SOCIAL ENGAGEMENT AND PARTICIPATION The goal of the ICOPE approach is to help older people to do the things that are important to them. It is helpful to find out what is important to the older person through an understanding of the older person’s life, priorities and preferences, as it may be possible to find ways to increase participation. Leisure activities, hobbies, work, learning and spiritual activities are examples of participation in society. Every older person is unique and will have different, often very specific, priorities for what is important to them. You should ask about and record these as a guide for the personalized care plan. Further questions should be asked to identify any barriers such as cost, accessibility and opportunity. Assessors should know about the availability of local leisure facilities and clubs, adult education providers, volunteering services and employment advisory services, and discuss whether these might be of interest to the older person. Transport may be an important issue, and services may be available to increase access. Charges for some of these services may be subsidized to allow older people and those on reduced incomes to participate. B11 ELDER ABUSE Many older people dependent on care are vulnerable to abuse, and around one in six older people experience some form of abuse, a figure higher than previously estimated (20). Abuse can take many forms, including neglect, psychological abuse, physical abuse, sexual abuse and financial abuse. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or signs of physical abuse should be used to identify potential abuse . If there is any suggestion of abuse, specialist assessment and management will be needed. You will need to let the older person know that you have concerns and will ask for specialist help. You should record your concerns and that you have let the older person know about the referral for specialist help. If you identify any immediate threat, you should refer for specialist assessment through social work, adult protection or law enforcement systems. 72 11 Caregiver support Care pathways to support the caregiver When declines in intrinsic capacity and functional ability make a person dependent on others for care, caregiving often falls on a spouse, another family member or others in the household. Depending on the older person’s needs, the burden of providing care can put the caregiver’s well-being at risk. A health or social care worker in the community can monitor the well-being of caregivers and try to see that caregivers get care for their own health and help with giving care. KEY POINTS The burden and stress of caring for older people with significant losses in intrinsic capacity and functional ability can impair the health of the family members and friends who serve as caregivers. Also, it can keep them – particularly women – out of the paid workforce. Finding caregivers who themselves need help is an important part of identifying older people with declines in capacity. A range of interventions – respite care, advice, education, financial support and psychological interventions – can support the caregiver to sustain a satisfactory and healthy caring relationship. Occasionally, the caring relationship becomes abusive. A community worker may see signs of abuse during the assessment of an older person or of a caregiver. At this point, specialist referral is needed. 73 Caregiver support 11 YES YES YES Care pathways to support the caregiver ASK ASK Over the past two weeks, have you been bothered by: – feeling down, depressed or hopeless? – little interest or pleasure in doing things? ASK Are you facing loss of income and/or additional expenses because of the needs for care? REASSESS EVERY 6 MONTHS ASSESS MOOD OF CAREGIVER Explore support for caregiver such as training, counselling, coaching, respite care, such as day-care centre, community engagement with caregiving, a support network (ideas are given by iSupport at https://www.isupportfordementia.org) Explore local financial support options Strengthen link with formal long-term care system and community support such as volunteer associations Does your role as a caregiver for (…) have a negative impact on your life? Do you feel unsupported in your role as a caregiver? ? ? (to either question) (to either question) NO NO NO YES Manage depression: See mhGAP intervention guide https://apps.who.int/iris/handle/10665/250239 NO 1 (to both questions) Specialized care needed Address the strain with support and psychoeducation Provide problem-solving counselling Provide cognitive behavioural therapy 11 Caregiver support Care pathways to support the caregiver • To treat depression. • To offer problem-solving counselling or cognitive behavioural therapy to a caregiver with depressive symptoms. • When an abusive relationship is suspected. WHEN SPECIALIZED KNOWLEDGE IS NEEDED If a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment of mood. Alternative words can be used if a person is not familiar with those in the two screening questions. ASK: “Over the last two weeks, have you been bothered by any of the following problems?”* • Trouble falling or staying asleep, or sleeping too much. • Feeling tired or having little energy. • Poor appetite or overeating. • Feeling bad about yourself or that you are a failure or that you have let yourself or your family down. • Trouble concentrating on things such as reading the newspaper or watching television. • Moving or speaking so slowly that other people could have noticed. • Being so fidgety or restless that you have been moving around a lot more than usual. • Thoughts that you would be better off dead or of hurting yourself in some way. ASSESS MOOD OF THE CAREGIVER 1 THE RISK OF ABUSE The two-way relationship between the person receiving care and the caregiver may be complex. Healthy, happy caregivers are capable of extraordinary support, but sometimes the caring relationship may be unwelcome to one or both participants. This can give rise to conflict, which may make the older person vulnerable to abuse. Abuse can take the form of neglect, of taking material advantage (financially, for example) or of physical, emotional or sexual abuse. Neglect may also occur due to ignorance, lack of skills in caregiving or lack of external support or supervision. Neither the older person nor the caregiver may mention abuse to the health worker. Observational information based on the behaviour of the older person, the behaviour of their caregivers or relatives, or from signs of physical abuse should be used to identify potential abuse (see Chapter 10 on social care and support). Factors that increase the likelihood of an abusive relationship are: • poor long-term relationship; • a history of family violence; • the caregiver’s difficulty consistently providing the level or type of care needed; and • the caregiver’s physical or mental health problems, particularly depression and, particularly in men, alcohol and substance abuse. The likelihood of abuse is not solely related to the nature of the care provided or even to factors often associated with caregiver stress, such as the challenges posed by the behaviour of a person with dementia. If an abusive relationship is suspected, more detailed specialist assessment is needed, following local referral pathways. * These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239 75 Caregiver support 11 Care pathways to support the caregiver 11.1 ASK THE CAREGIVER The pathway on page 74 guides discussion with the caregiver. In this pathway, every caregiver interviewed is asked about three areas: 1. The burden of caregiving (two questions), potentially leading to practical strategies that support caregivers. 2. The two core symptoms of depression, potentially prompting full assessment for depression (see Chapter 9 on depressive symptoms). 3. The financial costs of caregiving, potentially leading to sources of local financial support and organized social care, as available. When talking with the caregiver, the worker looks for any signs of exhaustion, anger, frustration or disrespect. Also, the health worker can ask the caregiver if they would like further assessment or support from a social care provider. Over time, the burdens of caregiving can pile up. Reassessment every six months is appropriate. Assessment of the caregiver’s role and its impact is best done away from the older person, to reduce the caregiver’s embarrassment or hesitation about speaking openly and fully. The accounts of the older person and the caregiver may differ for various reasons, including memory problems of the older person. The assessment should thus be considered in light of knowledge gained from the complete assessment of intrinsic capacity. 11.2 OFFER SUPPORT FOR THE CAREGIVER Backed and supervised through the health and social care services, appropriately trained professionals and paid caregivers should support unpaid caregivers. In the community, health and social care workers – both professionals and volunteers – can create a network to share available resources for the support of unpaid caregivers. iSupport is a WHO online training programme that can help caregivers of people living with dementia to provide good care and take care of themselves – see https://www. isupportfordementia.org. Support focuses on the primary family caregiver. To understand the caregiver’s needs, the provider can ask what tasks are performed, how and how often, looking for aspects of care that may be helped by advice, practical support or innovative assistive technologies (see Box on page 77). Support should reflect the caregiver’s choices and emphasize optimizing the caregiver’s well-being. 76 Caregiver support 11 Care pathways to support the caregiver 11 Caregiver support Care pathways to support the caregiver Health and social workers can: • provide the caregiver with training and support for specific care skills – for example, managing difficult behaviour; • consider providing or arranging practical support, such as respite from care; and • explore whether the person with loss in functional ability qualifies for any social benefits or other social or financial support from government or non-government sources. Give advice. Acknowledge that caregiving can be extremely frustrating and stressful. It also may be complicated by feelings of bereavement over loss of the previous relationship between the older person and the caregiver, particularly if the caregiver is a spouse. Encourage caregivers to respect the dignity of older people by involving them in decisions about their life and care as much as possible. Arrange respite care. When caring has become too burdensome or tiring, can another person temporarily supervise and care for the older person? This could be another member of the family or household, or a trained social care worker, whether professional or volunteer. This respite care, such as day care, can relieve the main caregiver, who can then rest or carry out other activities. Day care is one type of community support service, which provides personal care (bathing, feeding, shaving, toileting), rehabilitation, recreational and social activity programmes, meals and transportation, several hours a day for a number of days a week. Day care also provides support services for caregivers such as home visits, family activities, support groups and training for caregivers. Respite from caregiving may help to keep the caring relationship healthy and sustainable, and periods away from the usual caregiver need not be harmful to the person receiving care. Offer psychological support. Try to address the caregiver’s psychological stress with support and problem-solving counselling, particularly when the care is complex and extensive and the strain on the caregiver is great. INNOVATIVE ASSISTIVE TECHNOLOGIES Innovative assistive health technologies such as remote monitoring and assistive robots are promising means for enhancing the functional abilities of older people, for improving their quality of life as well as of their caregivers, for increasing choice, safety, independence and a sense of control, and for enabling ageing in place. The use of these technologies should be based on the needs and preferences of older people or their caregivers, and needs appropriate training for end-users. Careful attention should be given to developing a financing mechanism for research and development and to ensure equitable implementation. Examples of innovative assistive technologies: • Socially assistive robot PARO. This robotic pet seal provides companionship (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) lumbar type. This gives caregivers the robotic muscles they need to lift and move patients from bed to chair to bath. https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 KEY POINTS • Person-centred care is holistic, tailored care supported by collaborative relationships between health workers and older people, and the family and friends who support them. • Multidisciplinary teams can help older people set their goals. • Interventions supporting person-centred care should be agreed in light of the older person’s prioritized needs and goals. • Sustained, regular follow up is essential for achieving goals. DEVELOP A PERSONILIZED CARE PLAN Personalized care planning is a humanistic approach that moves away from the traditional disease-oriented methods and instead focuses on older people’s needs, values and preferences. Once expressed, a personalized care plan guides all aspects of health and social care and supports realistic person-centred goals. STEPS TO DEVELOP A PERSONALIZED CARE PLAN 1. Review findings and discuss opportunities to improve functional ability, health and well-being With older people and their family members and/ or caregivers (if appropriate), multidisciplinary teams will now review the results of the person-centred assessment and interventions proposed in the care pathways. The person-centred assessment will generate a list of proposed interventions that can be included in the care plan and discussed with the patient. The ICOPE app can assist the health worker on this process. Multidisciplinary teams may include everyone involved in the older person’s care, such as primary care physicians, specialty physicians, nurses, community care workers, social care workers, therapists (physiotherapy, occupational, speech, psychological), paid and unpaid caregivers, pharmacists and volunteers. 2. Person-centred goal setting Person-centred goal setting to identify, set and prioritize goals is a key element in developing a care plan. It is important for the multidisciplinary team to involve older people in the decision-making about their own care, and to understand and respect their needs, values, preferences and priorities. This can be a transformational shift in the way health professionals relate to their patients today. The goals of the care can go beyond reducing the direct impact of medical conditions and be more focused on things that enable older people to do what they value most, such as to age independently and safely in place, to maintain their personal development, to be included and to contribute to their communities while retaining their autonomy and health. In addition to goals for the mid- to long term (six to 12 months), it is recommended to include short-term (three months) goals to leverage more immediate improvements or benefits to keep older people motivated and engaged. 12 78 5. Monitoring and follow-up Monitoring with regular follow-up of the care plan’s implementation is essential for achieving agreed goals. This allows the opportunity to monitor progress and enables early detection of difficulties in participating in interventions, adverse effects of interventions, and changes in functional status. It also helps to maintain a successful relationship between older people and their care providers. The follow-up process includes, but is not limited to: • ensuring successful implementation, step by step, of the care plan; • repeating the person-centred assessment and documenting any changes; • summarizing outcomes, barriers and complications of the implementation of the health and social care interventions; • identifying changes and new needs; • agreeing on further addressing these changes and needs, including the adoption of new interventions when needed, and revising and improving the plan as needed; and • repeating the cycle. 3. Agree on interventions The interventions proposed for inclusion in the care plan as a result of the person-centred assessment and pathways will need: a) concurrence from the older person b) to be in line with the older person’s goals, needs, preferences and priorities c) to accommodate their physical and social environments. The health or social care worker should then have a discussion with the older person to agree on each intervention, one by one, that should remain in the final care plan. 4. Finalize and share the care plan The health professional should now document in the care plan the results of the discussions, and share the document with the older person, their family members, caregivers and any others who might be involved in their care, with consent. The ICOPE mobile app can support this process by furnishing everyone involved with a summary of the care plan, which includes the priority goals and identified conditions. 12 DOMAINS OF FUNCTIONAL ABILITY 1. To meet basic needs such as financial security, housing and personal security. 2. To learn, grow and make decisions, which include efforts to continue to learn and apply knowledge, engage in problem-solving, maintain personal development, and ability to make choices. 3. To be mobile, which is necessary for doing things around the house, accessing shops, services and facilities in the community, and participating in social, economical and cultural activities. 4. To build and maintain a broad range of relationships, including with children and other family members, informal social relationships with friends, neighbours, colleagues, as well as formal relationships with community care workers. 5. To contribute, which is closely associated with engagement in social and cultural activities, such as assisting friends and neighbours, mentoring peers and younger people, and caring for family members and the community. 79 12 IDENTIFY GOALS: Identify goals with the older person, their family members and caregivers (23): • QUESTION 1 3lease e[plain the things that matter to you most in all parts of your life. • QUESTION 2 :hat are some speciȴc goals that you have in your life? • QUESTION 3 :hat are some speciȴc goals that you have for your health? • QUESTION 4 %ased on the list of Eoth life and health goals we just discussed, can you pick three that you would like to focus on in the next three months? What aEout in the ne[t si[ to 12 months" SET GOALS: Goals can be adapted to the older people’s needs and their own definition of problems. • QUESTION 5 :hat speciȴcally aEout goal one two or three would you like to work on over the next three months" :hat aEout over the ne[t si[ to 12 months? • QUESTION 6 What are you currently doing about [goal area]? • QUESTION 7 What would be an ideal yet possible target for you in achieving this goal? PRIORITIZE GOALS: Agreement on prioritized goals of care between older people and providers will demonstrate improved outcomes. • QUESTION 8 Of these goals, which one are you most willing to work on over the next three months – either by yourself or with support from [Dr XX and their team]? :hat aEout over the ne[t si[ to 12 months" HOW TO UNDERTAKE PERSON-CENTRED GOAL SETTING Source: adapted from original by Health Tapestry (http://healthtapestry.ca) 80 KEY POINTS • Effective implementation of the ICOPE approach requires an integrated approach linking health and social care services. • Optimizing the intrinsic capacities and functional abilities of older people begins in the community and with community- level workers. Systems in the health and social sectors should support care focused at the community level. • Personalized care plans are at the heart of the ICOPE approach. To carry out and manage these plans, workers may need specific training in case management. The WHO World report on ageing and health set a new direction for health and long-term care systems (1). It called on these systems to focus on optimizing the intrinsic capacities of older adults with the goal of preserving and improving their functional abilities. The WHO Guidelines on community-level interventions to manage declines in intrinsic capacity, published in 2017, translate this new direction into a practical approach to assessment and care at the community level (2). Together, they foster person-centred, integrated health and social care and support. This approach begins with a person-centred assessment of health and social care needs that a community-level worker can conduct. This chapter highlights some key considerations for implementation of the ICOPE approach. The WHO ICOPE guidance for systems and services to implement the ICOPE approach will address implementation in detail (https://apps.who.int/iris/handle/10665/325669) HOW HEALTH AND LONG-TERM CARE SYSTEMS CAN SUPPORT IMPLEMENTATION OF THE WHO ICOPE APPROACH 13 81 13.1 NATIONAL SUPPORT FOR IMPLEMENTATION As a first step, both the WHO recommendations and this handbook will need to be adapted to the local context, culture and language as appropriate for care and health workers, caregivers and older people themselves. An inclusive process of adaptation can start to build broad support for the new approach. Implementation of the ICOPE approach will require continuing collaboration at all levels and stages among stakeholders, including policy-makers, health professionals, social care workers, researchers, communities and older adults. Local knowledge will support the translation of global guidance into feasible and acceptable service configurations. Promoting healthy ageing requires the engagement of both the health and the social care sectors. Both sectors will be better able to adopt and apply the ICOPE approach when national policies support an integrated approach to health and social care. Policy should thus specify how the link between health care and social care will function at national, regional and community levels. Incentives and rewards, financing mechanisms and performance monitoring can encourage the shift in priority to care for older people that optimizes intrinsic capacity and functional ability. Information systems should be oriented to monitoring this transformation at national and local levels. 13.2 BUDGETARY AND HUMAN RESOURCE REQUIREMENTS The implications of implementing the ICOPE approach should be analysed to identify where additional investment will be needed – for example, in the training of health workers, the use of technologies and the adaptation of health information systems. In particular, community health and social care workers and primary care teams will need support to understand and apply the new approach. National and local professional societies can play an important role in this as part of a participatory process that involves all stakeholders. 13 KEY CONSIDERATIONS FOR NATIONAL IMPLEMENTATION Planning to integrate the ICOPE approach into health and long-term care systems should ensure: • feasibility – financial and organizational • sustainability – efficiency and workforce capacity • coherence – aligned with policies supporting healthy ageing • integration – links between health and social care services. 82 13.3 INTEGR ATION OF CARE AND SUPPORT ACROSS HEALTH AND SOCIAL SERVICES All integrated care interventions should follow the principles of knowledge translation, which WHO defined in 2005 as “the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health”. WHO’s 2012 knowledge translation framework for ageing and health was developed specifically to apply these principles to care for older adults with multiple comorbidities and/or difficulties with access to health services (24). WHO’s 2016 framework on integrated people-centred health services proposes key approaches to ensure high-quality integrated care (6). An important element of integrated care is strong case management to support the design, coordination and monitoring of care plans, which are likely to span multiple domains of health and social care. Health and social care workers may need specific training in case management as well as in the clinical aspects of the ICOPE recommendations. The WHO ICOPE implementation framework emphasizes the key actions at service and system levels for implementing ICOPE (25). The guidance covers the actions (page 84) that need to be taken by service and system managers to deliver integrated care. The framework recommends specific actions depending on the extent of existing health and social services. 13.4 ALIGNING LOCAL HEALTH AND SOCIAL CARE SERVICES TO SUPPORT IMPLEMENTATION The ICOPE interventions should be implemented with a view to supporting ageing in place. That is, health and social care services should be provided so as to enable older people to live in their own home and community safely, independently and comfortably. The interventions are designed to be provided through models of care that prioritize primary and community-based care. This includes a focus on home-based interventions, community engagement and a fully integrated referral system. This focus can be achieved only by recognizing and supporting the critical role that community workers play in increasing access to primary health care and universal health coverage. WHO guidelines on health policy and system support to optimize community-based health worker programmes make evidence-based suggestions and recommendations on the selection, training, core competencies, supervision and compensation of community health workers (26). 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 When specialized care is needed, a network of health workers at secondary and tertiary levels must support the work of community health workers. Clear referral criteria and pathways must be established through agreement among all parties at the operational level and then monitored for quality assurance. Arrangements for follow-up need to be clear to ensure that care plans remain suitable and that the provision of health care and support is effective. Follow-up and support can be especially important following major changes in health status or if the older person experiences a major life event such as change of residence or the death of a spouse or caregiver. 13 SUMMARY OF ACTIONS FROM THE ICOPE IMPLEMENTATION FRAMEWORK AC TIONS FOR SERVICES • Engage and empower people and communities. Engage older people, their families and civil society in service delivery; support and train caregivers. • Support the coordination of services provided by multidisciplinary teams. Identify older people in the community who need care, undertake comprehensive assessments and develop comprehensive care plans; establish networks of health and social care workers. • Orient services toward community-based care. Deliver effective and acceptable care focused on functional ability through community-based workers and services backed by adequate infrastructure. AC TIONS FOR SYSTEMS • Strengthen governance and accountability systems. Engage stakeholders in policy and service development; develop policy and regulation to support integrated care and responses to elder abuse; undertake continuous quality assurance and quality improvement; regularly review capacity to deliver care equitably. • Enable systems strengthening. Develop workforce capacity, financing and human resources management; use technology to exchange information among service providers; collect and report data on intrinsic capacity and functional ability; use digital technologies to support self-management. 84 13.5 ENGAGEMENT OF COMMUNITIES AND SUPPORT TO CAREGIVERS Care workers need the help of additional resources in the community. More active and direct involvement of communities and neighbourhoods in care and support for older people may need both local organizing and political will, particularly to encourage volunteering and to facilitate the contributions of older community members. Older people’s clubs and associations are natural allies in this effort. At the same time, the health-care system owes a responsibility to its partners in supporting healthy ageing – communities, community organizations and the family members and other unpaid caregivers of older people. This responsibility includes attention to the health and well-being of caregivers, as discussed in Chapter 11, and mutual support, collaboration and coordination with communities and community organizations to create a healthy environment for healthy ageing. 85 REFERENCES 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa. edu.au/pain-management, accessed 1 May 2019). 10. Assistive devices and technologies. Geneva: WHO; no date (https://www.who.int/disabilities/technology, accessed 1 May 2019). 11. Texas Department of Aging and Disability Services. 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Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/S2214-109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128(6):3925–36. doi: 10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with dementia living in the community. J Am Med Dir Assoc. 2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. 86 24. Knowledge translation. Geneva: WHO; no date (https://www.who. int/ageing/projects/knowledge_translation, accessed 2 April 2019). 25. 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Рекомендации в отношении проведения оценок и составления схем организации ухода, ориентированных на потребности людей, в первичном звене медико-санитарной помощи МЕТОДИЧЕСКОЕ ПОСОБИЕ Рекомендации для систем и служб Механизм реализации концепции КОМПЛЕКСНЫЙ УХОД ЗА ПОЖИЛЫМИ ЛЮДЬМИ 1
КОМПЛЕКСНЫЙ УХОД ЗА ПОЖИЛЫМИ ЛЮДЬМИ Рекомендации в отношении проведения оценок и составления схем организации ухода, ориентированных на потребности людей, в первичном звене медико-санитарной помощи МЕТОДИЧЕСКОЕ ПОСОБИЕ Рекомендации для систем и служб Механизм реализации концепции ОКАЗАНИЕ КОМПЛЕКСНОЙ ПОМОЩИ ПОЖИЛЫМ ЛЮДЯМ (ICOPE) МЕТОДИЧЕСКОЕ ПОСОБИЕ Рекомендации в отношении проведения оценок и составления схем организации ухода, ориентированных на потребности людей, в первичном звене медико-санитарной помощи WHO/FWC/ALC/19.1 © Всемирная организация здравоохранения, 2019 Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Некоммерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводится библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за его содержание и точность. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интеллектуальной собственности. Образец библиографической ссылки: Оказание комплексной помощи пожилым людям (ICOPE), методическое пособие: рекомендации в отношении проведения оценок и составления схем организации ухода, ориентированных на потребности людей, в первичном звене медико-санитарной помощи. Женева: Всемирная организация здравоохранения; 2019 (WHO/FWC/ALC/19.1). Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке: http://apps.who.int/iris/. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/about/licensing/. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминание определенных компаний или продукции определенных производителей не означает, что они одобрены или рекомендованы ВОЗ в отличие от аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет никакой ответственности за ущерб, связанный с использованием материалов. Дизайн и макет Erica Lefstad. Отпечатано в Швейцарии. Выражение благодарности iv Сокращения v 1. Оказание комплексной помощи пожилым людям (ICOPE) 1 2. Оптимизация индивидуальной жизнеспособности и функциональной способности на пути к здоровому старению для всех 5 3. Оценка потребностей пожилых людей и разработка индивидуализированного плана ухода 9 4. Схемы организации ухода при снижении когнитивных способностей 19 5. Схемы организации ухода для улучшения двигательной активности 25 6. Схемы организации ухода для коррекции нарушений питания 33 7. Схемы организации ухода при ухудшении зрения 41 8. Схемы организации ухода при потере слуха 51 9. Схемы организации ухода для ведения депрессивных симптомов 59 10. Схемы организации ухода, направленные на оказание социальной помощи и поддержки 67 11. Схемы организации помощи лицам, осуществляющим уход 75 12. Разработка индивидуализированного плана ухода 78 13. Каким образом системы медицинской и долгосрочной помощи могут содействовать реализации концепции ICOPE 81 Библиография 86 СОДЕРЖАНИЕ iii ВЫРАЖЕНИЕ БЛАГОДАРНОСТИ В основу данного руководства легла работа многих людей во всем мире, посвятивших себя делу помощи и поддержки пожилым людям. Подготовка данного руководства проводилась силами Айлен Араужо де Карвальо и Юка Суми, сотрудников Департамента по проблемам старения и жизненного цикла Всемирной организации здравоохранения (ВОЗ). В состав рабочей группы, ведающей написанием руководства и разработкой схем организации ухода, входили Айлен Араужо де Карвальо, Джон Бирд, Юка Суми, Эндрю Бриггс (Куртинский университет, Австралия) и Финбарр Мартин (Королевский колледж Лондона, Соединенное Королевство). Написанием итоговой версии текста ведали представители компании Jura Editorial Services Сара Джонсон и Уорд Райнхарт. Многие другие сотрудники ВОЗ из региональных бюро и ряда департаментов внесли вклад как в подготовку конкретных разделов, имеющих отношение к их областям работы, так и в разработку схем организации ухода. Шелли Чадха (Департамент ВОЗ по ведению неинфекционных заболеваний и предупреждению инвалидности, насилия и травматизма), Нерха Чаудхари (Департамент психического здоровья и токсикомании ВОЗ), Тарун Дуа (Департамент психического здоровья и токсикомании ВОЗ), Мария де Лас-Ниевес Гарсия Касал (Департамент ВОЗ по вопросам питания), Зее А Хань (Департамент ВОЗ по ведению неинфекционных заболеваний и предупреждению инвалидности, насилия и травматизма), Дина Джавади (Альянс по исследованиям в области политики и систем здравоохранения), Сильвио Паоло Мариотти (Департамент ВОЗ по ведению неинфекционных заболеваний и предупреждению инвалидности, насилия и травматизма), Аларкос Чеса (Департамент ВОЗ по ведению неинфекционных заболеваний и предупреждению инвалидности, насилия и травматизма), Алана Маргарет Офисер (Департамент ВОЗ по проблемам старения и жизненного цикла), Хуан Пабло Пенья-Росас (Департамент ВОЗ по вопросам питания), Тайво Адедамола Ойеладе (Кластер по вопросам семьи и репродуктивного здоровья, Региональное бюро ВОЗ для стран Африки), Рамез Махайни (Репродуктивное и материнское здоровье, Региональное бюро ВОЗ для стран Восточного Средиземноморья), Карен Рейес Кастро (Департамент ВОЗ по ведению неинфекционных заболеваний и предупреждению инвалидности, насилия и травматизма), Энрике Вега Гарсия (Здоровая жизнь, Панамериканская Организация Здравоохранения/ВОЗ). Ряд специалистов и ученых, авторству которых принадлежат отдельные главы, внесли весомый вклад в настоящее руководство: Маттео Сезари (Фонд IRCCS Ca’Granda – Больница Ospedale Maggiore Policlinico, Италия), Джилл Киффе (Сотрудничающий центр ВОЗ по профилактике слепоты, Индия), Эльза Дент (Университет Квинсленда, Австралия), Наоки Кондо (Университет Токио, Япония), Аруни Лайтерапонг (Университет Чулалонгкорна, Таиланд), Мигель Искьердо (Государственный университет Наварры, Испания) Питер Ллойд-Шерлок (Университет Восточной Англии, Соединенное Королевство), Луис Мигель Гутьерес Робледо (Национальный институт здравоохранения, Мексика), Кэтрин МакМаон (Университет Маккуори, Австралия), Сера Ндегва (Университет Найроби, Кения), Хироши Огава (Ниигатский университет, Япония), Элен Пайетт (Университет Шербрука, Канада), Ян Филп (Университет Стирлинга, Соединенное Королевство), Леокадио Родригес-Маньяс (Университетская больница Хетафе, Испания), Джон Старр (Эдинбургский университет, Соединенное Королевство), Келли Тремблей (Университет Вашингтона, Соединенные Штаты Америки), Майкл Валенсуэла (Сиднейский университет, Австралия), Бруно Велас (Сотрудничающий центр ВОЗ по проблемам немощности, клиническим исследованиям и обучению в сфере гериатрии, больница университета Тулузы, исследовательский центр Gérontopôle, Франция), Марджолейн Виссер (Амстердамский свободный университет, Амстердам, Нидерланды), Кристина Зданис (Университет штата Коннектикут, Соединенные Штаты Америки), а также сотрудничающие центры ВОЗ по проблемам немощности, клиническим исследованиям и обучению в сфере гериатрии (больница университета Тулузы, исследовательский центр Gérontopôle, Франция), а также по общественно значимым аспектам заболеваний опорно- двигательного аппарата и старения (Льежский университет, Бельгия). Национальный совет по здоровью и медицинским исследованиям Австралии, Глобальный альянс по изучению заболеваний опорно-двигательного аппарата и университет Чулалонгкорна в Таиланде содействовали в разработке содержания этого руководства, привлекая к работе своих сотрудников, а также проводя совещания экспертов. Дополнительным вкладом в данное руководство стали выступления участников на ежегодном заседании Клинического консорциума ВОЗ по вопросам здорового старения в декабре 2018 г. Департамент ВОЗ по проблемам старения и жизненного цикла выражает признательность правительству Японии, правительству Германии и правительству префектуры Канагава в Японии за финансовую поддержку. Редактура Green Ink. iv СОКРАЩЕНИЯ ICOPE Концепция оказания комплексной помощи пожилым людям mAgeing Инициатива ВОЗ по разработке мобильного приложения для пожилых людей mhGAP Руководство ВОЗ в отношении комплекса основных мероприятий по психическому здоровью MNA Краткая оценка статуса питания SPPB Краткая батарея тестов физического функционирования ВОЗ Всемирная организация здравоохранения ИМТ Индекс массы тела СИОЗС Селективные ингибиторы обратного захвата серотонина ЦУР Цели в области устойчивого развития Организации Объединенных Наций Обозначает, что для оказания помощи требуются специальные познания и навыки v
Во Всемирном докладе о старении и здоровье, 2015 г. цель здорового старения определяется как содействие людям в развитии и поддержании функциональной способности, обеспечивающей благополучие. Функциональная способность определяется как «связанные со здоровьем характеристики, которые позволяют людям существовать и делать то, что они считают значимым для них». Функциональная способность включает в себя индивидуальную жизнеспособность человека, его окружающую среду и взаимодействие между ними. Индивидуальная жизнеспособность – это «совокупность всех физических и психических способностей человека.» (1) При таком понимании здорового старения рисуется картина новых приоритетов в сфере здравоохранения для пожилых людей: оптимизация индивидуальной жизнеспособности и функциональной способности людей по мере их старения. В октябре 2017 г. Всемирная организация здравоохранения опубликовала Рекомендации по оказанию помощи на уровне общин при снижении индивидуальной жизнеспособности (2). В этих рекомендациях содержатся научно обоснованные руководящие указания для медицинских и социальных работников, призванные помочь им в разработке и реализации мероприятий, ориентированных на потребности человека, по комплексной помощи пожилым на уровне местных сообществ (ICOPE). В основе концепции ICOPE лежит представление о том, что оптимизация индивидуальной жизнеспособности и функциональной способности – ключевой фактор здорового старения. Данные рекомендации могут служить основой для национальных руководств. Их можно применять для содействия процессу интеграции услуг, направленных на профилактику зависимости от посторонней помощи, в программы первичной помощи, а также в наборы базовых услуг в рамках всеобщего охвата услугами здравоохранения. ОСНОВНЫЕ ПОЛОЖЕНИЯ В системах здравоохранения ключевым элементом поддержки здорового старения для всех является оптимизация индивидуальной жизнеспособности и функциональной способности людей, даже по мере того как старение приводит к постепенному снижению физических возможностей человека. Возникновение зависимости от посторонней помощи можно предотвратить при условии своевременной диагностики и ведения важных расстройств здоровья, связанных со снижением индивидуальной жизнеспособности. С тем чтобы замедлить или обратить вспять такое снижение, работники первичного звена здравоохранения и работники социальной сферы на уровне местных сообществ могут вести работу по выявлению пожилых людей со снижением физических возможностей, а также по организации ухода надлежащего уровня. Данный подход является простым и малозатратным. Расстройства здоровья, связанные со снижением индивидуальной жизнеспособности, взаимосвязаны и требуют комплексного подхода, ориентированного на потребности людей. ОКАЗАНИЕ КОМПЛЕКСНОЙ ПОМОЩИ ПОЖИЛЫМ ЛЮДЯМ (ICOPE)1 1 ДЛЯ ЧЕГО НУЖНА КОМПЛЕКСНАЯ ПОМОЩЬ ПОЖИЛЫМ ЛЮДЯМ (ICOPE)? Доля пожилых людей в населении земного шара высока как никогда. В 2017 г. во всем мире проживало порядка 962 миллионов человек в возрасте 60 лет и старше, что составило 13% населения Земли (3). Этот показатель будет стремительно возрастать в ближайшие десятилетия, в особенности в странах с низким и средним уровнем дохода. К 2050 г. возраст каждого пятого жителя планеты составит 60 лет или старше. Эта тенденция сложилась около 50 лет назад. Она отражает совокупный результат быстрого снижения показателей рождаемости и быстро возрастающих показателей продолжительности жизни во многих странах мира, что часто сопутствует социально-экономическому развитию. Поддержание здоровья пожилых людей является инвестицией в человеческий и социальный капитал и способствует достижению Целей в области устойчивого развития Организации Объединенных Наций (ЦУР) (4). В то же время, забота о все возрастающем числе пожилых людей создает сложности для систем здравоохранения. В будущем потребуется изменить соотношение между объемом ресурсов здравоохранения, направляемых на нужды различных возрастных групп. Назрели фундаментальные изменения в подходах системы общественного здравоохранения к старению. В основе традиционных подходов к охране здоровья пожилых людей лежали представления о расстройствах здоровья, что выдвигало на первый план диагностику и лечение. Внимание к этим заболеваниям по-прежнему остается важным, однако чрезмерный упор на этот аспект приводит к тому, что без внимания остаются такие нарушения индивидуальной жизнеспособности, сопутствующие старению, как ухудшение слуха, зрения, памяти, снижение двигательной активности и характерная утрата других функций. Выявление и ведение этих нарушений будет содействовать благополучию каждого человека в определенный период жизни. Внимание всей системы здравоохранения к индивидуальной жизнеспособности пожилых людей будет всемерно содействовать благосостоянию большой и все более многочисленной части населения. Большинство медицинских работников нуждаются в соответствующих рекомендациях и подготовке, с тем чтобы они могли распознавать и эффективно вести случаи снижения индивидуальной жизнеспособности. По мере старения населения все более острой становится необходимость разработки всеобъемлющих подходов на базе общин, которые включают мероприятия по профилактике снижения индивидуальной жизнеспособности, содействию здоровому старению и поддержке лиц, осуществляющих уход за пожилыми людьми. Этой цели служит предлагаемая ВОЗ концепция ICOPE. КОМУ АДРЕСОВАНЫ НАСТОЯЩИЕ РЕКОМЕНДАЦИИ? В первую очередь данное руководство предназначено для медицинских и социальных работников в общинах, а также работников учреждений первичного звена здравоохранения. Кроме того, руководство адресовано медицинским работникам, чьи специализированные познания будут требоваться по мере необходимости для оценки состояния здоровья и планирования ухода за лицами с потерей индивидуальной жизнеспособности и функциональной способности. Рекомендации, содержащиеся в настоящем документе, призваны помочь общинным работникам здравоохранения и социальным работникам внедрить рекомендации ICOPE в практику. В них представлены схемы организации ухода, нацеленные на ведение важных расстройств здоровья, связанных со снижением индивидуальной жизнеспособности: утрату двигательной активности, нарушения питания, нарушения зрения, потерю слуха, снижение когнитивных функций, симптомы депрессии. Отправной точкой в этих схемах является скрининговый тест для выявления тех пожилых людей, которые с наибольшей степенью вероятности уже испытывают утрату индивидуальной жизнеспособности. Работники здравоохранения и социальные работники легко могут проводить такой скрининг в общинах. Это подготовит путь к проведению углубленной оценки состояния здоровья и потребностей пожилых людей в социальной помощи. Такая оценка, в свою очередь, приведет к созданию индивидуализированного плана ухода, который включает стратегии, направленные на обращение вспять, замедление или профилактику дальнейшего снижения физических возможностей, лечение заболеваний и удовлетворение потребностей в социальной помощи. Подобная оценка, ориентированная на потребности людей, и разработка плана лечения, как правило, требуют участия подготовленных медицинских работников в учреждении первичного звена, таких как врачи и медицинские сестры первичной помощи. Однако при снижении индивидуальной жизнеспособности уход зачастую можно осуществлять силами междисциплинарного коллектива на уровне общин, где проживают пожилые люди и лица, осуществляющие уход. 2 РУКОВОДЯЩИЕ ПРИНЦИПЫ В ОСНОВУ НАСТОЯЩЕГО РУКОВОДСТВА ПОЛОЖЕНЫ СЛЕДУЮЩИЕ ПРИНЦИПЫ: Пожилые люди имеют право на максимально возможный уровень здоровья. Пожилые люди должны иметь равные возможности доступа к детерминантам здорового старения независимо от социального или экономического статуса, места рождения или жительства, или других социальных факторов. Оказание помощи должно производиться в равном для всех объеме, без дискриминации, в особенности без дискриминации по гендерному или возрастному признаку. Помимо этого, извлечь пользу как из описанных здесь принципов, так и из практических подходов смогут специалисты, ведающие разработкой программ подготовки в области лечебного дела, сестринского дела и смежных отраслей медицины и общественного здравоохранения. Другие аудитории включают руководителей учреждений здравоохранения и разработчиков политики, таких как руководители национальных, региональных и окружных программ, ведающие планированием и организацией услуг здравоохранения, учреждения, финансирующие и(или) осуществляющие программы в области общественного здравоохранения, а также неправительственные и благотворительные организации, оказывающие помощь пожилым людям на уровне сообществ. КАКОВА ЦЕЛЬ ЭТИХ РЕКОМЕНДАЦИЙ? Данные рекомендации ставят целью поддержку медицинских и социальных работников на уровне местных сообществ в деле выявления и ведения случаев снижения индивидуальной жизнеспособности на основе Рекомендаций ВОЗ по оказанию помощи на уровне общин при снижении индивидуальной жизнеспособности (2), а также всестороннее удовлетворение потребностей пожилых людей в социальной и медицинской помощи. В данном руководстве описано, каким образом: • производят целеполагание, ориентированное на потребности человека (Глава 2); • содействуют сохранению самостоятельности (Глава 2); • разрабатывают план ухода, который включает ряд мероприятий для ведения расстройств здоровья, связанных с утратой индивидуальной жизнеспособности (Глава 3); • проводят скрининг утраты индивидуальной жизнеспособности и оценивают потребности в социальной и медицинской помощи (Главы 4–10); • оказывают поддержку лицам, осуществляющим уход (Глава 11); и • разрабатывают индивидуализированный план ухода (Глава 12). ПОДХОД ICOPE В КОНТЕКСТЕ Всеобщий охват населения услугами здравоохранения является основой для достижения ЦУР в области здравоохранения (4). Для достижения ЦУР 3 подход к медицинскому и социальному обслуживанию пожилых людей должен быть комплексным, а помощь – характеризоваться преемственностью в долгосрочной перспективе. В глобальной стратегии и плане действий ВОЗ по старению и здоровью (5) описана роль систем здравоохранения в деле пропаганды здорового старения через посредство оптимизации индивидуальной жизнеспособности. Рекомендации ICOPE (2), а также данное руководство содействуют достижению целей данной стратегии. Кроме того, настоящее руководство является инструментом реализации механизма комплексного медицинского обслуживания, ориентированного на потребности человека (6). В данном механизме содержится призыв вывести на новый уровень способы поставки и предоставления медицинских услуг, перейдя к комплексному подходу, ориентированному на потребности человека. В контексте этого механизма рекомендациями ICOPE предлагаются следующие основы оказания помощи пожилым людям: • оценка индивидуальных потребностей, предпочтений и целей; • разработка индивидуализированного плана ухода; • координация обслуживания с упором на основную цель: поддержание индивидуальной жизнеспособности и функциональной способности, а также оказание помощи в полном объеме, по возможности, на базе первичного звена и местных сообществ. 3 4 Во «Всемирном докладе ВОЗ о старении и здоровье» здоровое старение определяется как развитие и поддержание функциональной способности, обеспечивающей благополучие (1). В данном руководстве сделан акцент на здоровом старении, в связи с чем внимание уделено следующим важным расстройствам здоровья, связанным со снижением индивидуальной жизнеспособности (рисунок 1), потребностям пожилых в социальной помощи и поддержке лиц, осуществляющих уход. • Снижение когнитивных функций (Глава 4) • Снижение двигательной активности (Глава 5) • Нарушения питания (Глава 6) • Нарушение зрения (Глава 7) • Потеря слуха (Глава 8) • Симптомы депрессии (Глава 9) • Социальная помощь и поддержка (Глава 10) • Поддержка лиц, осуществляющих уход (Глава 11) ОПТИМИЗАЦИЯ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ И ФУНКЦИОНАЛЬНОЙ СПОСОБНОСТИ НА ПУТИ К ЗДОРОВОМУ СТАРЕНИЮ ДЛЯ ВСЕХ Психологические способности Способность слышать Способность видеть Бодрость Когнитивные способности Способность к движению РИС. 1. КЛЮЧЕВЫЕ СОСТАВЛЯЮЩИЕ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ КАК ИЗМЕНЯЕТСЯ ИНДИВИДУАЛЬНАЯ ЖИЗНЕСПОСОБНОСТЬ НА ПРОТЯЖЕНИИ ЖИЗНИ ЧЕЛОВЕКА? На рисунке 2 приведена типичная динамика индивидуальной жизнеспособности и функциональной способности после достижения зрелого возраста. Индивидуальная жизнеспособность и функциональная способность приходят в упадок с возрастом в результате процесса старения, а также на фоне протекающих заболеваний. График, отображающий эту типичную динамику, можно разделить на три характерных периода: период относительно высоких и стабильных физических возможностей, период снижения физических возможностей и период значительной утраты физических возможностей, который характеризуется зависимостью от посторонней помощи. 2 5 МЕРОПРИЯТИЯ ПО ОПТИМИЗАЦИИ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ Выявление расстройств здоровья, связанных со снижением индивидуальной жизнеспособности, открывает возможность для принятия мер, направленных на замедление, прекращение или обращение вспять такого снижения (рисунок 2). Медицинские работники в лечебных учреждениях и на уровне местных сообществ могут выявлять характерные расстройства здоровья, которые связаны со снижением индивидуальной жизнеспособности. Регулярная оценка в динамике позволяет отслеживать любые чрезмерные отклонения и предлагать конкретные мероприятия для профилактики утраты функциональной способности. Таким образом, мероприятия, проводимые на базе местных сообществ, могут сохранить людям здоровье и избавить их от потребности в посторонней помощи. Имеются основания полагать, что эффективность комплексных мероприятий выше. Диапазон отклонений показателя индивидуальной жизнеспособности от средних значений крайне велик. Эти различия очевидны как на уровне отдельно взятых стран, так и в международном масштабе. Они проявляются в неизменных различиях продолжительности жизни, которая составляет от 82 лет и более в таких странах, как Австралия, Япония и Швейцария, до менее 55 лет в таких странах, как Центральноафриканская Республика, Чад и Сомали. Различия в индивидуальной жизнеспособности куда выше среди людей старшего возраста, нежели в возрастных группах молодых людей. Такое разнообразие является одной из особенностей старения. Один человек может быть старше другого на 10 лет и более и при этом иметь сопоставимую индивидуальную жизнеспособность и(или) функциональную способность. По этой причине хронологический возраст человека слабо связан с состоянием его здоровья. ИНДИВИДУАЛЬНАЯ ЖИЗНЕСПОСОБНОСТЬ И ФУНКЦИОНАЛЬНАЯ СПОСОБНОСТЬ ВОЗ определяет индивидуальную жизнеспособность как сочетание физических и умственных способностей человека, включая психологические способности. Функциональная способность – это сочетание и взаимодействие индивидуальной жизнеспособности и характеристик среды проживания человека. 6 РИСУНОК 2. КОНЦЕПЦИЯ ЗДОРОВОГО СТАРЕНИЯ, ПРИНЯТАЯ В СИСТЕМЕ ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ: ВОЗМОЖНОСТИ ДЛЯ ОСУЩЕСТВЛЕНИЯ ДЕЙСТВИЙ ПО ОХРАНЕ ОБЩЕСТВЕННОГО ЗДОРОВЬЯ НА ПРОТЯЖЕНИИ ЖИЗНИ ЧЕЛОВЕКА Многие из параметров, определяющих индивидуальную жизнеспособность, поддаются коррекции. К их числу относится связанное со здоровьем поведение, а также наличие заболеваний. Таким образом, имеются веские основания для внедрения эффективных вмешательств с целью оптимизации индивидуальной жизнеспособности. На этих основах зиждется концепция ICOPE, а также рекомендации, предложенные в данном руководстве. Различные расстройства здоровья, связанные с утратой индивидуальной жизнеспособности, взаимосвязаны на различных уровнях. Например, потеря слуха сопряжена со снижением когнитивных способностей. Питание дополняет эффекты физической нагрузки и оказывает непосредственное влияние на увеличение мышечной массы и силы. Такой взаимосвязью объясняется необходимость комплексного подхода к скринингу, оценке и ведению случаев снижения индивидуальной жизнеспособности. Источник: Всемирная организация здравоохранения; 2015 г. (1) Высокая и стабильная способность УСЛУГИ ЗДРАВООХРАНЕНИЯ ДОЛГОСРОЧНАЯ ПОМОЩЬ ОКРУЖАЮЩИЕ УСЛОВИЯ Снижающаяся способность Значительная потеря способности Функциональная способность Истинная способность Предупреждение хронических состояний или обеспечение раннего выявления и контроля Обращение вспять или замедление снижения способности Поддержка видов поведение, усиливающих способность содействие поведению, укрепляющему способность Ведение хронических состояний на продвинутой стадии Обеспечение достойного конца жизни Устранение препятствий для участия, компенсация потери способности КОНЦЕПЦИЯ ICOPE 7 8 Помощь, ориентированная на интересы и нужды человека, основана на понимании того, что пожилые люди – не средоточие заболеваний и расстройств здоровья; каждый человек независимо от возраста – индивидуум с уникальным опытом, потребностями и предпочтениями. Ориентир на интересы и нужды человека означает, что во главу угла ставятся потребности индивидуума в медицинской и социальной помощи, а не отдельно взятые расстройства здоровья или симптомы. В рамках комплексного подхода, ориентированного на интересы и нужды человека, также учитывается контекст повседневной жизни индивидуумов, в том числе взаимосвязь состояния их здоровья и их потребностей с таковыми в их ближайшем окружении и общинах. Как показано в обобщенной схеме ниже, в рамках комплексного подхода выделяют пять этапов на пути к удовлетворению потребностей пожилых людей в медицинской и социальной помощи. ОЦЕНКА ПОТРЕБНОСТЕЙ ПОЖИЛЫХ ЛЮДЕЙ И РАЗРАБОТКА ИНДИВИДУАЛИЗИРОВАННОГО ПЛАНА УХОДА ОСНОВНЫЕ ПОЛОЖЕНИЯ Выявление в общинах пожилых людей со значимыми расстройствами здоровья, связанными со снижением индивидуальной жизнеспособности, может производиться при помощи скринингового инструмента комплексной помощи пожилым людям (ICOPE). Выявленные лица с такими расстройствами направляются в учреждение первичного звена здравоохранения для углубленного обследования, на основании которого разрабатывают индивидуализированный план ухода. Данный план ухода может включать комплекс мероприятий для применения в случаях снижения индивидуальной жизнеспособности и для оптимизации функциональной способности, например, физические упражнения, улучшение питания, стимуляция умственной активности и переоборудование жилья с целью профилактики падений. 3 9 3Планирование социальной помощи и поддержки Преодоление барьеров для участия в общественной жизни Переоборудование окружающей обстановки Оказание помощи на уровне общин при снижении индивидуальной жизнеспособности Понимание особенностей жизни пожилого человека, ценности, приоритеты и социальный контекст Комплексное лечение заболеваний Реабилитация Паллиативная помощь и помощь на завершающем этапе жизни Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода НА ПРЕДМЕТ РАССТРОЙСТВ, СВЯЗАННЫХ СО СНИЖЕНИЕМ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ Нет снижения индивидуальной жизнеспособности ДА ДА НЕТ НЕТ НЕТ ДА СКРИНИНГ В ОБЩИНЕ НА ПРЕДМЕТ СНИЖЕНИЯ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ СКРИНИНГ ЭТАП 1 ОЦЕНКА, ОРИЕНТИРОВАННАЯ НА ИНДИВИДУАЛЬНЫЕ НУЖДЫ ЧЕЛОВЕКА, В ПЕРВИЧНОМ ЗВЕНЕ ЗДРАВООХРАНЕНИЯ ЭТАП 2 ПРОВЕСТИ УГЛУБЛЕННУЮ ОЦЕНКУ ТЕЧЕНИЯ ОСНОВНЫХ ЗАБОЛЕВАНИЙ ОЦЕНКА И ВЕДЕНИЕ С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ ОЦЕНКА И РАБОТА ОЦЕНКА ПОТРЕБНОСТИ В СОДЕЙСТВИИ СЛУЖБ СОЦИАЛЬНОЙ ПОМОЩИ (дом, учреждение) 10 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи 10 3Целеполагание, ориентированное на потребности человека Мультидисциплинарный коллектив Разработать план ухода, включающий многокомпонентные мероприятия и ведение основных заболеваний, самообслуживание и самопомощь, а также социальную помощь и поддержку РАЗРАБОТКА ИНДИВИДУАЛИЗИРОВАННОГО ПЛАНА УХОДА ЭТАП 3 ОБЕСПЕЧЕНИЕ МАРШРУТИЗАЦИИ ПАЦИЕНТОВ ПРИ НАПРАВЛЕНИИ К СПЕЦИАЛИСТАМ И МОНИТОРИНГ ВЫПОЛНЕНИЯ ПЛАНА УХОДА В УВЯЗКЕ С СИСТЕМОЙ СПЕЦИАЛИЗИРОВАННОЙ ГЕРИАТРИЧЕСКОЙ ПОМОЩИ ЭТАП 4 ПРИВЛЕЧЕНИЕ К УЧАСТИЮ ЧЛЕНОВ ОБЩИНЫ И СОДЕЙСТВИЕ ЛИЦАМ, ОСУЩЕСТВЛЯЮЩИМ УХОД ЭТАП 5 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи Целеполагание, ориентированное на потребности человека Мультид сц пли арный коллектив Р зработать план ухода, вкл чающий многок мпонентные ме опр тия и вед ние с овных заболеваний, самообслуживание и самопомощь, а также социальную помощь и поддержку РАЗРАБОТКА ИНД ВИДУАЛ ЗИРОВАНН ГО ПЛ НА УХОДА ЭТАП 3 ОБЕСП ЧЕНИЕ МАРШРУТИЗАЦИИ ПАЦИЕНТОВ ПРИ НАПРАВЛЕНИИ К СПЕЦИАЛИСТАМ И МОНИТОРИНГ ВЫПОЛ ЕНИЯ ПЛ НА УХОДА В УВЯЗКЕ С СИСТЕМОЙ СПЕЦ АЛИЗИРОВАННОЙ ГЕРИАТРИЧЕСКОЙ ПОМОЩИ ЭТАП 4 ПРИВЛ ЧЕНИЕ К УЧАСТИЮ ЧЛЕНОВ ОБЩИНЫ И СОДЕЙСТВИЕ ЛИЦАМ, ОСУЩЕСТВЛЯЮЩИМ УХОД ЭТАП 5 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном зв не медико-санитарной п мощи 11 Важные расстройства здоровья, связанные со снижением индивидуальной жизнеспособности Проверка Провести полную оценку компонента, если кружок напротив него отмечен СНИЖЕНИЕ КОГНИТИВНЫХ СПОСОБНОСТЕЙ (Глава 4) 1. Повторение трех слов: пол, дверь, рис (примерный список) 2. Ориентированность в пространстве и времени: назовите сегодняшнюю дату; где вы сейчас находитесь (дом, клиника, и т.п.)? 3. Повторяет ли испытуемый три слова? СНИЖЕНИЕ ДВИГАТЕЛЬНОЙ АКТИВНОСТИ (Глава 5) Подъем со стула: встаньте со стула пять раз подряд без помощи рук. Выполнил ли испытуемый подъем со стула пять раз подряд в течение 14 секунд? НАРУШЕНИЯ ПИТАНИЯ (Глава 6) 1. Потеря веса: вы теряли без явной причины больше 3 килограммов веса за последние три месяца? 2. Потеря аппетита: у вас пропадал аппетит? НАРУШЕНИЕ ЗРЕНИЯ (Глава 7) Есть ли у вас проблемы со зрением: затруднения при смотрении вдаль или чтении, имеются ли у вас заболевания глаз, получаете ли вы в настоящее время лечение по какому-либо поводу (например, в связи с диабетом, повышением артериального давления)? ПОТЕРЯ СЛУХА (Глава 8) Испытуемый слышит шепотную речь или Результат скрининговой аудиометрической пробы составляет 35 Дб или менее, либо Испытуемый проходит автоматизированный тест на распознавание цифр в шуме на слух в специальном приложении. СИМПТОМЫ ДЕПРЕССИИ (Глава 9) Вы испытывали за последние две недели – эмоциональный упадок, чувство подавленности или безнадежности? – отсутствие интереса или удовольствия от своей деятельности? Испытуемый ошибается при ответе на любой из вопросов или не знает ответ Испытуемый не повторяет всех трех слов Нет Да Да Да Да Да Результат проверки неудовлетворителен ТАБЛИЦА 1. СКРИНИНГОВЫЙ ИНСТРУМЕНТ ВОЗ ICOPE 12 ЭТАП 1 ПРОВЕСТИ СКРИНИНГ НА ПРЕДМЕТ СНИЖЕНИЯ ИНДИВИДУАЛЬНОЙ ЖИЗНЕСПОСОБНОСТИ Применяя процесс и инструменты, предложенные в данном руководстве, подготовленные медицинские работники могут приступать к выявлению лиц со снижением индивидуальной жизнеспособности в общине или на дому. Для этого можно воспользоваться скрининговым инструментом ICOPE (таблица 1). Скрининг с использованием инструмента ICOPE является первым этапом каждой из схем ухода, представленных в Главах с 4 по 9, и охватывает шесть основных групп расстройств здоровья, затрагивающих компоненты индивидуальной жизнеспособности (рисунок 1 на стр. 5). Стратегии по работе с населением, например, домашние визиты общинных работников здравоохранения и самооценка с использованием мобильной телефонной связи, могут помочь при выявлении соответствующих случаев. Лицам, имеющим характерные проявления или заявляющим о снижении физических возможностей на первом этапе, следует пройти процедуру полного обследования. Процедура полного обследования, вероятнее всего, потребует участия медицинских работников с необходимым уровнем подготовки, чаще всего, хотя и не всегда, врача. Медицинские и социальные работники должны выступить гарантами того, что любой факт снижения физических возможностей, установленный с использованием скринингового инструмента ICOPE, всякий раз будет влечь за собой процедуру подробной оценки. Необходимо, чтобы выявленные результаты легли в основу разработки индивидуального плана ухода. 2C. Оценить и взять под контроль течение имеющихся заболеваний Необходимо провести обследование на предмет имеющихся хронических заболеваний, а также возможной полипрагмазии (одновременное применение целого ряда лекарственных средств). Полипрагмазия и развивающиеся в связи с ней нежелательные эффекты лекарственных средств могут приводить к утрате нескольких компонентов индивидуальной жизнеспособности, и поэтому она всякий раз требует анализа (см. врезку «Полипрагмазия», стр. 18). Диагностика имеющихся заболеваний, таких, как болезнь Альцгеймера, депрессия, остеоартрит, остеопороз, катаракта, диабет и гипертензия, играет ключевую роль в оценке, ориентированной на индивидуальные нужды. Постановка таких диагнозов может требовать выполнения сложных диагностических проб, которые не всегда доступны в учреждениях здравоохранения первичного звена. В зависимости от обстоятельств может потребоваться направление пациента в гериатрические учреждения специализированной или высокотехнологичной помощи. 2D. Провести оценку социального и физического окружения пациента, а также выявить потребности в социальной помощи и поддержке Людям со снижением индивидуальной жизнеспособности требуется как оценка социального и физического окружения, так и выявление различных потребностей в социальных услугах и поддержке. Это весомая часть процедуры оценки, ориентированной на индивидуальные нужды, в первичном звене. Потребность в социальной помощи можно выявить путем опроса пожилого человека о том, может ли он(она) вести свою повседневную деятельность без посторонней помощи. В Главе 10 наряду со схемой организации ухода представлен ряд вопросов для общей оценки и выявления потребностей в социальной помощи. Кроме того, каждая из схем оказания помощи, описанных в главах с 4 по 9, позволяет выявить возможные потребности в социальной помощи, специфичные для значимых расстройств здоровья. ЭТАП 2 СИЛАМИ СПЕЦИАЛИСТОВ ПЕРВИЧНОГО ЗВЕНА ПРОВЕСТИ ОЦЕНКУ, ОРИЕНТИРОВАННУЮ НА ИНДИВИДУАЛЬНЫЕ НУЖДЫ Оценка потребностей пожилых людей в медицинской и социальной помощи играет ведущую роль в последующей оптимизации индивидуальной жизнеспособности. 2A. Изучить контекст жизни пожилого человека При использовании подхода, ориентированного на потребности людей, не происходит сбора анамнеза стандартным способом; вместо этого стремятся тщательно изучить особенности жизни человека, ценности, приоритеты и предпочтения касательно изменений собственного здоровья и заботы о нем. 2B. Провести углубленную оценку на предмет расстройств здоровья, связанных с утратой индивидуальной жизнеспособности При выполнении подобной оценки проводится углубленный диагностический поиск расстройств здоровья, приводящих к утрате индивидуальной жизнеспособности. Представленные в Главах с 4 по 9 схемы организации ухода при расстройствах здоровья, затрагивающих компоненты индивидуальной жизнеспособности, как правило, имеют три составляющих, из которых скрининговые мероприятия на уровне сообщества занимают ведущее место, оценка на уровне первичного звена – промежуточное, а индивидуальный план ухода – последнее. 13 ЭТАП 3 ОПРЕДЕЛИТЬ ЦЕЛЬ УХОДА И РАЗРАБОТАТЬ ИНДИВИДУАЛИЗИРОВАННЫЙ ПЛАН 3A. Наметить цель осуществления ухода вместе с пожилым человеком всеобъемлющая цель оптимизации индивидуальной жизнеспособности и функциональной способности позволяет обеспечить интеграцию помощи, а также открывает возможности мониторинга прогресса, совершаемого пожилым человеком, и эффективности проводимых мероприятий. Важно, чтобы пожилой человек и лицо, осуществляющее уход, были вовлечены в процесс принятия решений и целеполагания с самого начала, и чтобы определение и приоритизация целей происходили сообразно приоритетам, нуждам и предпочтениям самого человека. 3B. Разработать план ухода Результаты оценки, ориентированной на индивидуальные нужды человека, ложатся в основу разработки индивидуализированного плана ухода. Такой индивидуализированный план применяется в рамках целостного подхода к реализации мероприятий, выполняемых в связи с утратой различных компонентов индивидуальной жизнеспособности: все мероприятия необходимо рассматривать и применять в комплексе. 3 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи 3 Поддержка способности к самообслуживанию означает предоставление пожилым людям информации, инструментов и навыков, необходимых для ведения имеющихся у них расстройств здоровья, профилактики осложнений, укрепления индивидуальной жизнеспособности и сохранения качества жизни. Это ни в коей мере не означает, что пожилые люди должны быть предоставлены самим себе или что к ним должны предъявляться нерациональные или чрезмерно высокие требования. Напротив, это означает признание их автономии и способности к самообслуживанию при консультативной поддержке и в партнерстве с медицинскими работниками, членами семей и другими лицами, осуществляющими уход. Инициатива ВОЗ по разработке мобильного приложения (mAgeing) может дополнить регулярные усилия медицинских работников, поскольку содействует самообслуживанию и самопомощи. Направляя информацию о состоянии здоровья, рекомендации и напоминания через мобильные телефоны, программа способствует практике здорового поведения и помогает пожилым людям улучшить и поддержать индивидуальную жизнеспособность. Более подробные сведения о том, как настроить программу mAgeing, а также предлагаемые варианты текстовых сообщений представлены по ссылке: https://www.who.int/ ageing/health-systems/mAgeing. 14 3 Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи Общая схема ухода Подобный интегрированный подход имеет первостепенное значение, поскольку большинство важных расстройств здоровья, связанных с утратой индивидуальной жизнеспособности, объединены общими физиологическими и поведенческими детерминантами. В результате этого проводимые мероприятия укрепляют целый ряд компонентов индивидуальной жизнеспособности. Например, интенсивная силовая тренировка является ключевым мероприятием для профилактики утраты двигательной активности. В то же самое время, силовая тренировка косвенным образом охраняет мозг от депрессии и снижения когнитивных функций, а также способствует профилактике падений. Питание дополняет эффекты физической нагрузки и в то же время оказывает непосредственное влияние на увеличение мышечной массы и силы. Через посредство комплексного, единообразного подхода становится возможным изменить влияние ряда факторов, повышающих риск возникновения зависимости от посторонней помощи. Индивидуальный план ухода будет характеризоваться рядом составляющих, в число которых могут входить: • пакет многокомпонентных мероприятий по ведению случаев утраты индивидуальной жизнеспособности. Большинство планов ухода будут включать мероприятия по улучшению питания и поощрять выполнение физических упражнений; • ведение и лечение имеющихся заболеваний, мультиморбидности и гериатрических синдромов. ВОЗ разработала клинические рекомендации в отношении большинства соответствующих хронических заболеваний, которые могут способствовать снижению индивидуальной жизнеспособности (2). У каждого поставщика услуг здравоохранения должен иметься доступ к этим рекомендациям; • содействие самообслуживанию и самопомощи; • ведение любых хронических расстройств здоровья на поздней стадии (паллиативная помощь, реабилитация) или поддержание достойного качества и приемлемого уровня жизни; • социальная помощь и поддержка, включая модификацию окружающей человека обстановки с целью компенсации возможной утраты функций; а также • план по удовлетворению потребностей в социальной поддержке при содействии членов семьи, друзей, представителей служб, оказывающих помощь по месту жительства. Медицинские и социальные работники могут поддержать реализацию плана ухода на уровне общины или в учреждении здравоохранения первичного звена. Самообслуживание вкупе с консультативной поддержкой, просветительской работой и поддержкой со стороны поставщика услуг здравоохранения на уровне общины может модифицировать ряд факторов, приводящих к снижению индивидуальной жизнеспособности. Партнерские отношения пожилого человека, медицинских работников первичного звена, членов семьи и общины будут способствовать поддержанию уровня благополучия людей по мере их старения. 15 3 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи ЭТАП 4 ОБЕСПЕЧИВАТЬ МАРШРУТИЗАЦИЮ ПАЦИЕНТОВ ПРИ НАПРАВЛЕНИИ НА КОНСУЛЬТАЦИЮ И ПРОВОДИТЬ МОНИТОРИНГ ПЛАНА УХОДА В УВЯЗКЕ С СИСТЕМОЙ СПЕЦИАЛИЗИРОВАННОЙ ГЕРИАТРИЧЕСКОЙ ПОМОЩИ Регулярное и систематическое последующее наблюдение с интеграцией различных уровней и типов оказания помощи играет важную роль в реализации мероприятий, рекомендованных в настоящем руководстве. Такой подход содействует раннему выявлению осложнений или изменений функционального состояния, тем самым предотвращая необходимость в экстренной помощи и снижая уровень затрат за счет раннего вмешательства. Регулярное последующее наблюдение открывает возможности для мониторинга прогресса при реализации плана ухода, а также для организации дополнительной помощи в случае необходимости. Последующее наблюдение и поддержка могут приобретать особое значение после серьезных изменений в состоянии здоровья, плане лечения, социальной роли или общественном положении человека (например, смена места жительства или смерть партнера). Отлаженная маршрутизация пациентов при направлении на консультацию важна для обеспечения быстрого доступа к неотложной помощи в случае непредвиденных обстоятельств, например, падений, а также к паллиативной помощи и помощи на завершающем этапе жизни или после выписки из стационара. Решающее значение имеет также увязка с системой специализированной гериатрической помощи. Задачей систем здравоохранения также является обеспечение своевременного доступа к специализированной и неотложной помощи при возникновении необходимости. Имеются убедительные фактические данные, свидетельствующие о том, что специализированные гериатрические отделения неотложной помощи оказывают более качественную помощь с более короткими сроками госпитализации при более низком уровне расходов по сравнению с помощью в больницах общего профиля. РОЛЬ СПЕЦИАЛИЗИРОВАННОЙ ГЕРИАТРИЧЕСКОЙ ПОМОЩИ Гериатры специализируются на оказании помощи пожилым людям с длительно протекающими сочетанными расстройствами здоровья, такими, как гериатрические синдромы (недержание, падения, делирий, и т.п.), полипрагмазия и такие расстройства, как деменция, а также не оказании помощи лицам с ограничениями повседневной активности. Мультиморбидность возникает с возрастом и приводит к появлению сложных клинических картин, когда врачу первичного звена следует направить пациента к гериатру. В рамках подхода ICOPE гериатры являются частью междисциплинарного коллектива, ведающего оказанием помощи пожилым людям, и они содействуют, контролируя работу специалистов первичного звена и вступая в дело при потребности в специализированной помощи. 16 3 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи 3 Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи Общая схема ухода ЭТАП 5 ПРИВЛЕЧЬ ЧЛЕНОВ СООБЩЕСТВА И ОКАЗАТЬ ПОДДЕРЖКУ ЛИЦАМ, ОСУЩЕСТВЛЯЮЩИМ УХОД Реализация ухода может требовать значительных усилий, и лица, осуществляющие уход за людьми с утратой физических возможностей, часто ощущают себя в изоляции и подвергаются риску психологического дистресса и депрессии. Индивидуализированный план ухода должен включать вмешательства на доказательной основе с целью поддержки лиц, осуществляющих уход. Кроме того, лицам, осуществляющим уход, требуется базовая информация о расстройствах здоровья, которыми страдает пожилой человек, а также подготовка, направленная на развитие ряда практических навыков, таких, как помощь пожилому человеку в безопасном перемещении между стулом и кроватью или помощь в принятии ванной. Пожилому человеку и лицу, осуществляющему уход, необходимо предоставлять информацию о доступных для них ресурсах общины. Следует рассмотреть возможности более активного привлечения членов общин и микрорайонов к помощи на уровне сообщества, в частности, за счет поощрения волонтерства и привлечения пожилых людей к участию в общественной жизни. Подобные виды деятельности зачастую могут разворачиваться на уровне ассоциаций и групп, объединяющих пожилых людей. В Главе 11 представлена схема ухода для оценки нагрузки на лицо, осуществляющее уход, и принятия мер для удовлетворения потребностей лиц, осуществляющих уход на безвозмездной основе, в поддержке и самопомощи. Концепция ICOPE действует на уровне сообщества или первичного звена здравоохранения, где она может стать доступной для как можно большего числа людей. В то же время, в данной концепции содержится призыв к активному наращиванию связей с учреждениями специализированной и высокотехнологичной помощи для тех, кто в ней нуждается, например, с привлечением нутрицевтов и фармацевтов. ПРИЛОЖЕНИЕ ICOPE HANDBOOK С целью содействия медицинским и социальным работникам при выборе конкретных шагов на всех этапах от скрининга до оценки и разработки индивидуального плана ухода будут доступны мобильные приложения. Приложение будет создавать пригодный для печати отчет в формате PDF о результатах оценки и о мероприятиях, необходимых для включения в план ухода. 17 3 Общая схема ухода Оценки и схемы организации ухода, ориентированные на потребности людей, в первичном звене медико-санитарной помощи ПОЛИПРАГМАЗИЯ Полипрагмазия часто определяется как одномоментное применение пяти и более препаратов, и ее часто связывают с возникновением неблагоприятных лекарственных реакций. Подобное применение целого ряда препаратов повышает риск негативных последствий для здоровья и может привести к преждевременной утрате индивидуальной жизнеспособности, а также является причиной неотложной госпитализации. Пожилые люди, которые получают помощь нескольких медицинских работников или были недавно госпитализированы, имеют больший риск полипрагмазии. У пожилых людей с мультиморбидной патологией существует риск более выраженного проявления возрастных физиологических изменений, которые могут влиять на фармакокинетику и фармакодинамику препаратов. Поскольку полипрагмазия может дополнительно усугублять утрату ряда компонентов индивидуальной жизнеспособности, оценка, ориентированная на индивидуальные нужды человека, должна включать изучение списка препаратов, которые принимает пожилой человек. Выраженность полипрагмазии можно снизить за счет исключения ненужных, неэффективных препаратов, а также препаратов, которые дублируют действие друг друга. Каким образом производить надлежащее назначение препаратов и минимизировать ошибки при их назначении: • собрать полный анамнез; • учесть, может ли прием препарата отрицательно сказаться на физических возможностях; • не назначать препарата до момента постановки диагноза за исключением случаев, сопровождающихся выраженной острой болью; • регулярно пересматривать список назначений, в том числе до назначения очередного препарата; • ясно представлять механизм действия, нежелательные эффекты, лекарственные взаимодействия, требования к мониторингу и токсичность назначенных препаратов; • стремиться к назначению одного препарата по поводу одного и более расстройств здоровья; • выдать пациенту карту для учета принимаемых препаратов; и • просветить пациента и лицо, осуществляющее уход, в части каждого из препаратов. В случае сомнения относительно возможности безопасной отмены какого-либо из препаратов, следует получить консультацию специалиста соответствующего профиля. 18 4 Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ Снижение когнитивных способностей проявляется прогрессирующей забывчивостью, снижением внимания и способности к решению задач. Хотя точная причина не выяснена, снижение когнитивных способностей может быть связано с процессами старения мозга, заболеваниями (например, сердечно-сосудистыми заболеваниями, такими, как гипертензия и инсульт или болезнь Альцгеймера) или факторами окружающей среды, такими, как недостаток физической нагрузки, социальная изоляция и низкий уровень образования. Снижение когнитивных способностей начинает представлять проблему тогда, когда оно влияет на способность человека эффективно функционировать в окружающей его среде, то есть тогда, когда у человека возникает деменция. Данная схема разработана для применения у пожилых людей с определенным уровнем снижения когнитивных способностей, но не страдающих деменцией. Медицинский работник, кроме того, должен уметь оценивать потребность в социальной помощи и поддержке (см. Главу 10). ОСНОВНЫЕ ПОЛОЖЕНИЯ Снижение когнитивных способностей можно свести к минимуму и иногда обратить вспять за счет мероприятий общего характера по формированию более здорового образа жизни, когнитивной стимуляции и вовлечения в общественную жизнь. Лечение таких расстройств, как диабет и гипертензия, может оказать профилактическое действие в отношении снижения когнитивных способностей. Утрата других компонентов индивидуальной жизнеспособности, например слуха или способности к движению, может отрицательно сказаться на когнитивной функции, поэтому в отношении нее также необходимо проводить оценку и принимать меры. Для планирования и реализации комплексных мероприятий у лиц с деменцией необходима специализированная помощь. 19 https://apps.who.int/iris/handle/10665/250239 Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода снижение когнитивных способностей маловероятно снижение когнитивных способностей маловероятно – НАРУШЕНИЕ ПИТАНИЯ* – ДЕЛИРИЙ – ПОЛИПРАГМАЗИЯ – ЦЕРЕБРОВАСКУЛЯРНЫЕ ЗАБОЛЕВАНИЯ – ДЕПРЕССИВНЫЕ СИМПТОМЫ См. схему организации помощи при нарушении питания Определить причину (расстройства здоровья, токсическое воздействие психоактивных веществ, употребление лекарственных средств) и принять соответствующие меры по ее искоренению Изучить список принимаемых препаратов и произвести отмену надлежащим образом Изучить анамнез сосудистых заболеваний головного мозга (инсульт/транзиторное ишемическое явление) и провести профилактику рецидивов См. схему организации помощи при депрессивных симптомах 6 9 РЕЗУЛЬТАТ УДОВЛЕТВОРИТЕЛЕН Мультимодальные упражнения Проведение когнитивной стимуляции ОЦЕНКА КОГНИТИВНЫХ СПОСОБНОСТЕЙ 1 РЕЗУЛЬТАТ НЕУДОВЛЕТВОРИТЕЛЕН РЕЗУЛЬТАТ НЕУДОВЛЕТВОРИТЕЛЕН вероятно снижение когнитивных способностей РЕЗУЛЬТАТ УДОВЛЕТВОРИТЕЛЕН СОПУТСТВУЮЩЕЙ ПАТОЛОГИИОЦЕНКА И ВЕДЕНИЕ i С СОЦИАЛЬНОЙ И ФИЗИЧЕСКОЙ СРЕДОЙ ОЦЕНКА И РАБОТА ПРОФИЛАКТИКА ДАЛЬНЕЙШЕГО СНИЖЕНИЯ ФИЗИЧЕСКИХ ВОЗМОЖНОСТЕЙ Оценить потребности в социальной помощи и поддержке Выдать рекомендации для дальнейшего поддержания навыка самостоятельного пользования туалетом Оценить нагрузку или затруднения, которые создаются для лица, осуществляющего уход (см. схему организации помощи лицам, осуществляющим уход) Разработать план социальной помощи и поддержки для лиц, осуществляющих уход Если снижение когнитивных способностей отрицательно сказывается на автономии и независимости, см. раздел технического руководства mhGAP, посвященный деменции Оказать помощь и поддержку в повседневном быту 11 10 СЕРДЕЧНО-СОСУДИСТЫХ ЗАБОЛЕВАНИЙ И ФАКТОРОВ РИСКА** ОЦЕНКА И ВЕДЕНИЕ Простая проба на память и ориентированность 1. Запоминание трех слов: Попросите человека запомнить три слова, которые вы назовете. Называйте простые конкретные слова, такие как «цветок», «дверь», «рис» 2. Ориентированность в пространстве и времени: Затем предложите человеку ответить: «Назовите сегодняшнюю дату» и «Где вы сейчас находитесь?» (в доме, клинике, и т.д.)? 3. Припоминание трех слов: Попросите человека повторить три слова, которые вы назвали Удовлетворителен или неудовлетворителен результат пробы? В случае, если человек не может ответить на один из двух вопросов, которые характеризуют ориентированность, ИЛИ не может вспомнить всех трех слов, вероятно снижение когнитивных способностей и показано проведение более подробной оценки Испытываете ли вы проблемы с памятью или ориентированностью (например, затрудняетесь определить свое местонахождение или день недели)? ВОПРОС ? ДА 4.1 4.2 5.1 * Дефицит витаминов, электролитные нарушения, выраженная степень дегидратации ** Сердечно-сосудистые факторы риска: гипертензия, высокий уровень холестерина, диабет, курение, ожирение, заболевания сердца, инсульт или транзиторная ишемическая атака в анамнезе. Сокращение риска снижения когнитивных способностей и возникновения деменции: рекомендации ВОЗ – WHO Guidelines – https://apps.who.int/iris/handle/10665/312180 Комплексное ведение заболеваний Сокращение числа сердечно-сосудистых факторов риска: – предложить отказ от курения – приступить к лечению гипертензии и диабета – выдать рекомендации по рациону для контроля веса ДА НЕТ Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ 4 Рекомендации для систем и служб Механизм реализации концепции СКРИНИНГ НА ПРЕДМЕТ СНИЖЕНИЯ КОГНИТИВНЫХ СПОСОБНОСТЕЙ 4ОЦЕНКА КОГНИТИВНЫХ СПОСОБНОСТЕЙ При углубленной оценка когнитивных способностей по возможности пользуются локальным валидизированным инструментом. Ниже справа перечислены возможности оценки когнитивных функций у пожилых людей в учреждениях здравоохранения первичного звена. Отсутствие школьного образования. Практически все стандартные инструменты скрининговой или диагностической оценки когнитивных нарушений ориентированы на пациента с минимальным уровнем школьного образования. Оценка когнитивных функций может осложняться в случае, если объем школьного образования пациента составляет менее пяти или шести лет. В таких случаях следует опираться на результаты собеседования и суждение клинициста. Настоятельно рекомендуется привлечение таких лиц к участию в программах ликвидации неграмотности среди взрослого населения (по возможности), поскольку это содействует укреплению когнитивного здоровья. В случае, если стандартный инструмент оценки недоступен или непригоден, медицинский работник может справиться у самого пациента или у людей, хорошо с ним знакомых, о фактах нарушения памяти, ориентированности, речевой и языковой активности, а также о любых трудностях при выполнении ключевых для человека задач и задач в повседневном быту. Неудовлетворительный результат когнитивной оценки или информация о нарушениях памяти или ориентированности свидетельствует о когнитивных нарушениях. Необходимо изучить, до какой степени для такого человека затруднителен повседневный быт или инструментальные действия для удовлетворения повседневных нужд. Эти сведения важны для планирования мероприятий по социальной помощи и поддержке в составе индивидуализированного плана помощи. Если снижение когнитивных способностей отрицательно сказывается на способности эффективного взаимодействия пожилого человека с его окружением, может потребоваться специализированная оценка на предмет постановки диагноза деменции или болезни Альцгеймера (наиболее частая причина деменции). Протоколы для оценки и ведения деменции представлены в техническом руководстве ВОЗ mhGAP по ссылке https://apps.who.int/iris/handle/10665/250239 1 Дополнительная информация: Техническое руководство ВОЗ mhGAP (https://apps.who.int/iris/handle/10665/250239) КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ • Постановка диагноза и лечение деменции. • Лечение множественных сопутствующих расстройств, например, делирия, цереброваскулярных и сердечно-сосудистых заболеваний. Тест Mini-Cog http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf Краткий, без сложных инструкций, исключает предвзятое отношение по причине образовательного уровня или расовой принадлежности Применение различных списков слов может влиять на оценку 2–4 мин. ИНСТРУМЕНТ/ПРОВЕРКА ПРЕИМУЩЕСТВА НЕДОСТАТКИ ВРЕМЕННЫЕ РАМКИ Монреальская шкала когнитивной оценки (MoCA) https://www.mocatest.org/ Позволяет выявлять легкие когнитивные нарушения, существует на многих языках Остается поле для образовательных или культурных предубеждений; ограниченное количество опубликованных сведений 10–15 мин. Краткая шкала оценки психического статуса (MMSE) https://www.parinc.com/products/pkey/237 Широко применяется и хорошо изучена Остается поле для возрастных и культурных предубеждений; «эффект потолка» 7–10 мин. Определение когнитивных функций врачом общей практики (GPCOG) http://gpcog.com.au/index/downloads Минимальное пространство для образовательных или культурных предубеждений; существует на многих языках Получение сведений от информанта может быть затруднительным 5–6 мин. ПРИМЕРЫ ИНСТРУМЕНТОВ ОЦЕНКИ КОГНИТИВНЫХ СПОСОБНОСТЕЙ ДЛЯ ПРИМЕНЕНИЯ В УЧРЕЖДЕНИЯХ ЗДРАВООХРАНЕНИЯ ПЕРВИЧНОГО ЗВЕНА Что такое деменция? Деменция – это длительно протекающий и развивающийся с течением времени синдром, обусловленный изменениями в головном мозге. Деменция приводит к снижению когнитивных функций и отрицательно сказывается на выполнении задач в повседневном быту, таких как стирка, одевание, прием пищи, личная гигиена и пользование туалетом. Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ 21 4 Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ Важным этапом до начала диагностического поиска по поводу снижения когнитивных функций является выявление любых ассоциированных расстройств и купирование их проявлений. 4.1 РАССТРОЙСТВА ЗДОРОВЬЯ, ПРИВОДЯЩИЕ К СИМПТОМАМ НАРУШЕНИЯ КОГНИТИВНЫХ ФУНКЦИЙ Распространенные обратимые состояния, приводящие к снижению когнитивных способностей, включают обезвоживание, нарушения питания, инфекционные процессы и проблемы, вызванные приемом лекарственных средств. Принятие надлежащих мер в отношении данных состояний обычно приводит к исчезновению симптомов снижения когнитивных функций. Тяжелое обезвоживание. Тяжелое обезвоживание и другие проблемы, обусловленные питанием, могут вызывать проявления делирия (напоминает деменцию) и, в особенно тяжелых случаях, приводить к гибели. Делирий. Делирий проявляется внезапным развитием выраженной неспособности к концентрации внимания. Кроме того, возникает яркое нарушение ориентированности в окружающей обстановке и времени. Делирий развивается стремительно, и его проявления в течение суток могут носить волнообразный характер. Он может провоцироваться остро возникшими органическими причинами, например, инфекционным процессом, приемом лекарственных средств, нарушениями обмена веществ (например, гипогликемией или гипонатриемией), употреблением психоактивных веществ или абстиненцией. Полипрагмазия. Два и более препарата могут вступать в лекарственные взаимодействия, приводя к возникновению нежелательных эффектов (см. врезку в Главе 3, стр. 18). Седативные и снотворные средства – это препараты, которые наиболее часто приводят к когнитивным нарушениям у пожилых людей. Обширные хирургические вмешательства и общий наркоз. Известно, что обширные хирургические вмешательства и общий наркоз влекут за собой риск снижения когнитивных способностей. Специалист должен установить возможный факт снижения когнитивных способностей после обширного хирургического вмешательства. В таком случае в исходе любого другого обширного хирургического вмешательства существует достаточно высокий риск дальнейшего снижения когнитивных функций. Необходимо точно определить степень такого риска и обсудить данный вопрос с хирургической бригадой и анестезиологом до выполнения любых других операций или анестезиологического пособия. Цереброваскулярная болезнь. Сосудистые заболевания головного мозга тесно связаны со снижением когнитивных способностей. В случае, если у пациента имеется анамнез инсульта / микроинсульта /транзиторного ишемического явления, профилактика дальнейших расстройств такого рода является первоочередной задачей в борьбе с дальнейшим снижением когнитивной функции. ОЦЕНКА И РАБОТА С АССОЦИИРОВАННЫМИ РАССТРОЙСТВАМИ Выявление обратимого снижения когнитивных функций в связи с приемом препаратов предполагает полномасштабный диагностический поиск. Для корректного выбора плана ухода может потребоваться несколько диагностических гипотез, объясняющих наличие симптомов. 4 Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ 22 4 Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ • Когнитивная стимуляция может благотворно сказываться на состоянии лиц со снижением когнитивных функций. • Другие мероприятия, предусмотренные концепцией ICOPE, например мультимодальные упражнения (см. Главу 5, посвященную ограничению подвижности), также могут благотворно сказываться на состоянии здоровья головного мозга. • Утрата других компонентов индивидуальной жизнеспособности, в частности слуха, зрения и настроения, может влиять на когнитивную функцию. Для достижения наилучших результатов следует обращать внимание на состояние этих компонентов. У лиц со снижением когнитивных функций встречаются разнообразные варианты одновременной утраты нескольких таких компонентов. 4.2 КОГНИТИВНАЯ СТИМУЛЯЦИЯ Когнитивная стимуляция может замедлить снижение когнитивных способностей (7). Целью когнитивной стимуляции является оказание стимулирующего воздействия на участников через посредство когнитивной деятельности и припоминания, стимуляция различных сенсорных путей и поощрение контакта с другими людьми. Мероприятия по когнитивной стимуляции могут проводиться индивидуально или в группе. Работа в группе может лучше подходить некоторым людям; социальный контакт в группе может быть полезным. Кроме того, группы могут оказаться полезными и эффективными в случае, если участники группы имеют общие цели, например, повышение санитарной грамотности. При стандартном групповом подходе проводится до 14 тематических сеансов длительностью около 45 минут каждый, два раза в неделю. Сеансы проходят под контролем ведущего. Как правило, сеанс может начинаться с разминки, не имеющей непосредственного отношения к когнитивной стимуляции, а затем продолжаться разнообразными когнитивными упражнениями, включая упражнения на ориентированность в реальности (например, табло, на котором выведено место, дата и время проведения сеанса). Сеансы имеют различную тематическую направленность, включая, например, период детства, пользование денежными средствами, пантомимы и сценки. При этих видах деятельности, как правило, не требуется припоминания фактов, напротив, акцент делается на таких вопросах как «Что общего в этих [словах или предметах]?» Кто может проводить сеансы когнитивной стимуляции? В странах с высоким уровнем дохода сеансы когнитивной терапии проводят, как правило, психологи. При условии соответствующей адаптации метода сеансы могут проводить надлежащим образом подготовленные неспециалисты при условии поддержки. Однако разработка и реализация индивидуализированного мероприятия для человека с существенным уровнем утраты функций может потребовать детальной оценки и планирования – задач, которые требуют специальных навыков. Таким образом, в локальных протоколах должны содержаться критерии направления на консультацию по поводу когнитивной терапии к специалисту в области психического здоровья. Члены семьи и лица, осуществляющие уход, могут сыграть важную роль в когнитивной стимуляции. Важно поощрять регулярное сообщение пожилым людям информации о дне недели, дате, погоде, времени, именах людей и так далее со стороны членов семьи и лиц, осуществляющих уход, Такая информация помогает им сохранять ориентированность в месте и времени. Кроме того, газеты, радио- телепередачи, семейные альбомы и предметы домашнего обихода могут содействовать коммуникации, ориентировать пожилого человека в текущих событиях, вызывать воспоминания и давать возможность делиться своим опытом и осознавать его значение. ВЕДЕНИЕ СЛУЧАЕВ СНИЖЕНИЯ КОГНИТИВНЫХ ФУНКЦИЙ 5 23 4 Схемы организации ухода при снижении когнитивных способностей КОГНИТИВНЫЕ СПОСОБНОСТИ В случае, если снижение когнитивных функций ограничивает самостоятельность и независимость человека, вероятнее всего, у такого человека будут значительные потребности в социальной помощи. Медицинский работник может помочь лицам, осуществляющим уход, в разработке плана ежедневных мероприятий, который помогает нарастить объем действий, самостоятельно совершаемых человеком, повышает степень его функционирования, помогает в адаптации и развитии навыков, а также минимизирует потребность в поддержке. Члены семьи и лица, осуществляющие уход, могут: • предоставлять информацию, необходимую для ориентированности, например, о дате, текущих событиях в общине, личности посетителей, погоде, новостях о членах семьи; • содействовать формированию и поддерживать существующие контакты с друзьями и членами семьи дома и в общине; • повышать и поддерживать на достаточном уровне безопасность домашней обстановки для сокращения риска падений и травм; • размещать в доме информационные таблички, например, в туалете, спальне, на уличной двери – с тем чтобы помочь пожилому человеку ориентироваться в окружающей обстановке; и • организовывать и содействовать трудовым занятиям (сообразно способностям человека). ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ К лицам, осуществляющим уход за людьми с выраженными когнитивными нарушениями, предъявляются повышенными требования. Стрессовые условия могут создавать угрозу для их собственного здоровья. См. Главу 11 о потребностях лиц, осуществляющих уход. 11 24 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности Двигательная активность является определяющим фактором здорового старения. Она важна для поддержания самостоятельности и профилактики зависимости от посторонней помощи. Физическая способность человека к перемещению из одного места в другое носит название способности к движению. Многие пожилые люди и члены их семей относятся к утрате способности к движению и боли как к неизбежным явлениям. Однако эти явления таковыми не являются. В самом деле, существуют эффективные стратегии совершенствования и поддержания подвижности в пожилом возрасте. ОСНОВНЫЕ ПОЛОЖЕНИЯ Ограничение подвижности часто встречается у пожилых, однако оно не является неизбежным. Общинные медико-санитарные работники могут проводить скрининг ограничения подвижности при помощи простых проб. Программа регулярных физических упражнений, составленная с учетом индивидуальных возможностей и потребностей, является наиболее важным мероприятием для улучшения или поддержания способности к движению. Модификация окружения человека и применение вспомогательных приспособлений – хорошие способы поддержания подвижности несмотря на снижение способности к движению. 25 Оценить физические характеристики окружающей среды с целью минимизации риска падений Включить мероприятия по профилактике падений, например, переоборудование жилья Рассмотреть возможность назначения ассистивных устройств для улучшения двигательной активности и предоставить их Предусмотреть безопасные зоны для перемещения ОЦЕНКА ДВИГАТЕЛЬНОЙ АКТИВНОСТИ Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода (Батарея тестов SPPB или другие тесты для оценки физических возможностей) Может ли испытуемый выполнить пять подъемов со стула подряд без помощи рук в течение 14 секунд? СКРИНИНГ НА ПРЕДМЕТ СНИЖЕНИЯ ДВИГАТЕЛЬНОЙ АКТИВНОСТИ Вставание со стула НЕТ Пересмотреть лекарственные назначения и запланировать минимизацию применения препаратов Комплексное лечение заболеваний Рассмотреть возможность обезболивания ДА – ПОЛИПРАГМАЗИЯ – ОСТЕОАРТРИТ, ОСТЕОПОРОЗ И ДРУГИЕ НАРУШЕНИЯ СТРУКТУРЫ И ФУНКЦИИ КОСТНО-СУСТАВНОГО АППАРАТА – СТАРЧЕСКАЯ НЕМОЩЬ И САРКОПЕНИЯ – БОЛЕВОЙ СИНДРОМ ответ НЕТ на все вопросы ДА Назначить мультимодальные упражнения под тщательным контролем Рассмотреть возможность направления на реабилитацию Рассмотреть возможность повышения потребления белка Рассмотреть возможность назначения и предоставления ассистивных устройств для улучшения мобильности Рекомендовать выполнение мультимодальных упражнений на дому Содействовать самопомощи для повышения приверженности назначенным мероприятиям Мультимодальные упражнения Программа мультимодальных упражнений для лиц с ограничением подвижности позволяет сочетать физические упражнения и развитие смежных навыков с упором на укрепление основных групп мышц туловища, живота и нижних конечностей. Следует адаптировать программу мультимодальных упражнений к индивидуальным физическим возможностям и потребностям пожилого человека. В рамках проекта Vivifrail предлагается практическое руководство по разработке программы упражнений, адаптированной к физическим возможностям http://www.vivifrail.com/resources Глобальные рекомендации ВОЗ в отношении физической активности представлены во вставке на стр. 30 5.3 5.2 5.1 5.4 5.5 5.6 1 2 Нормальный уровень двигательной активности (оценка по тестам SPPB составляет 10-12 баллов) Снижение двигательной активности (оценка по тестам SPPB составляет 0–9 баллов) СОПУТСТВУЮЩЕЙ ПАТОЛОГИИ ОЦЕНКА И ВЕДЕНИЕ С СОЦИАЛЬНОЙ И ФИЗИЧЕСКОЙ СРЕДОЙ ОЦЕНКА И РАБОТА Требуется специализированная помощь СПОСОБНОСТЬ К ДВИЖЕНИЮ 5 Схемы организации ухода для улучшения двигательной активности Рекомендации для систем и служб Механизм реализации концепции КРАТКАЯ БАТАРЕЯ ТЕСТОВ ФИЗИЧЕСКОГО ФУНКЦИОНИРОВАНИЯ (SPPB) Хотя существует большое количество тестов для исследования физических возможностей, рекомендуется выполнение батареи тестов SPPB, поскольку они характеризуются более высокой эффективностью измерений и пригодны для оценки широкого спектра физических возможностей. Батарея тестов SPPB позволяет определить время выполнения трех заданий, каждое из которых оценивается по шкале из четырех баллов, с последующей оценкой общей суммы набранных баллов: от нуля (худший результат) до 12 (лучший результат). Прежде всего, следует объяснить сущность каждого теста и задать вопрос, может ли испытуемый выполнить его. Если нет, выполнение следует оценить соответствующим образом и перейти к следующему этапу. 1. Тесты на определение способности удерживать равновесие: попросите испытуемого поставить ноги поочередно в каждую из трех следующих позиций, удерживая положение в течение 10 секунд. Сформируйте общую оценку по сумме баллов за каждую из трех позиций. 2. Тест на определение скорости ходьбы: время прохождения дистанции в четыре метра. Время прохождения дистанции в четыре метра. < 4.82 секунды 4 балла 4.82 – 6.20 секунды 3 балла 6.21 – 8.70 секунды 2 балла > 8.70 секунды 1 балл Невозможность выполнения 0 баллов 3. Тест на определение скорости ходьбы: время прохождения дистанции в четыре метра. < 11.19 секунды 4 балла 11.2 – 13.69 секунды 3 балла 13.7 – 16.69 секунды 2 балла 16.7 – 59.9 секунды 1 балл > 60 секунд или невозможность выполнения 0 баллов 1 2КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ Оценка способности к движению должна производиться параллельно с оценкой других компонентов индивидуальной жизнеспособности, например, когнитивных способностей, сенсорного восприятия, активности и психологических возможностей. В случае, если назначение физических упражнений осложняется выраженным снижением физических или психических возможностей либо сопутствующими заболеваниями, могут потребоваться специальные познания для разработки подходящей программы упражнений. Может потребоваться направление на реабилитацию. A. Положение «стопы вместе» Удержание положения в течение 10 секунд 1 балл Отсутствие удержания положения в течение10 секунд 0 баллов Не предпринято попытки удержания положения 0 баллов В случае если попытки не предпринято – закончить выполнение тестов на определение способности удерживать равновесие. B. Полутандемное положение стоп Удержание положения в течение10 секунд 1 балл Отсутствие удержания положения в течение 10 секунд 0 баллов Не предпринято попытки удержания положения 0 баллов В случае если попытки не предпринято – закончить выполнение тестов на определение способности удерживать равновесие. C. Тандемное положение стоп Удержание положения в течение 10 секунд 2 балла Удержание положения от 3 до9.99 секунд 1 балл Удержание положения в течение < 3 секунд 0 баллов Не предпринято попытки удержания положения 0 баллов Несложный тест позволяет ответить на вопрос о том, нуждается ли пожилой человек в углубленной оценке на предмет ограничения двигательной активности. Инструкции: Задайте пожилому человеку следующий вопрос: «Как вы думаете, вы смогли бы без вреда для себя подняться со стула пять раз подряд, не помогая себе руками?». (Продемонстрировать пожилому человеку, что имеется в виду.) Если испытуемый отвечает «ДА», попросите: – полностью сесть на стул – сложить руки на груди крест-накрест – полностью подняться со стула в положение стоя и затем сесть – повторить пятикратно, как можно быстрее, не останавливаясь. Определите время выполнения пробы – требуется углубленное обследование в случае, если испытуемый не может выполнить вставание со стула пять раз подряд в течение 14 секунд. ВСТАВАНИЕ СО СТУЛА Итоговая сумма баллов по результатам теста SPPB = сумма баллов по результатам трех тестов, описанных выше. Подробнее о тесте SPPB: http://hdcs.fullerton.edu/csa/research/documents/sppbinstructions_scoresheet.pdf 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности 27 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности Проверка с подъемом со стула входит в число одного из этих тестов. Ее следует провести повторно после проведения двух других тестов: • определение способности пациента к удержанию равновесия – удержание равновесия на протяжении 10 секунд в каждом из трех положений ног • определение скорости ходьбы – тест на определение времени, за которое пациент проходит расстояние в 4 метра Баллы за выполнение каждого из тестов суммируются. Низкое общее количество баллов свидетельствует об ограничении двигательной активности. В схеме показаны два возможных пути осуществления ухода в зависимости от совокупного количества баллов. Подробнее об этих тестах и о том, каким образом их следует оценивать, можно прочитать на предыдущей странице. КОГДА ТРЕБУЕТСЯ СПЕЦИАЛИЗИРОВАННАЯ ПОМОЩЬ (ПОДРОБНАЯ ИНФОРМАЦИЯ) Специализированная помощь может также потребоваться лицам, которые: • страдают от персистирующей боли, влияющей на настроение или другие компоненты функционирования • страдают выраженными нарушениями функции суставов • имеют перелом кости после минимальной травматизации • находятся в группе риска (см. вставку на следующей странице) • нуждаются в помощи при подборе подходящего ассистивного устройства для поддержания двигательной активности Произвести подробную оценку двигательной активности испытуемого можно по баллам на основании результатов трех простых тестов. Эти тесты имеют общее наименование краткой батареи тестов физического функционирования (SPPB). ОЦЕНКА ДВИГАТЕЛЬНОЙ АКТИВНОСТИ 28 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности 5.1 ПРОГРАММА МУЛЬТИМОДАЛЬНЫХ УПРАЖНЕНИЙ Для лиц с ограничением подвижности необходимо составить индивидуальную программу мультимодальных упражнений сообразно их потребностям и индивидуальному уровню физических возможностей. Программа мультимодальных упражнений для лиц с ограничением двигательной активности может включать: • упражнения на развитие силы/упражнения с отягощением, при которых тренировка мышц производится с нагрузкой, используются снаряды различного веса, эспандеры или собственный вес тела, как например в случае приседаний, выпадов или упражнений с попеременным принятием положений стоя и сидя; • аэробные упражнения/упражнения для укрепления сердечно- сосудистой системы, например ходьба в быстром темпе или езда на велосипеде с повышением частоты сердечных сокращений до такой, при которой человек интенсивно дышит, но это не мешает ему поддерживать разговор; • упражнения на развитие равновесия, которые вовлекают в работу вестибулярную сенсорную систему, предполагают статические и динамические упражнения; они могут выполняться на различной поверхности, как с открытыми, так и с закрытыми глазами; примерами могут служить удержание положения на одной ноге и ходьба по прямой линии с выполнением переката с пятки на носок; а также • упражнения на развитие гибкости, которые повышают растяжимость мягких тканей, например, мышц, и увеличивают объем движений в суставе; примерами могут служить потягивание и другие упражнения йоги или Пилатеса. Питание. Повышение потребления белка и другие мероприятия в области питания могут дополнить преимущества программы физических упражнений. См. Главу 6, посвященную проблемам нарушения питания. ВЕДЕНИЕ СЛУЧАЕВ СНИЖЕНИЯ ДВИГАТЕЛЬНОЙ АКТИВНОСТИ Безопасность физических упражнений. До выдачи рекомендаций в части физических упражнений или планирования программы физических упражнений следует расспросить о тех расстройствах здоровья, которые могут повлиять на продолжительность или интенсивность выполнения таких упражнений. В случае ответа «Да» на любой из перечисленных ниже вопросов, опытный медицинский работник должен разработать для пациента индивидуализированную программу физических упражнений. • У вас бывают боли в области груди в состоянии покоя? • Был ли у вас сердечный приступ за последние полгода? • У вас были эпизоды обморока или потери сознания? • Вы падали за прошедшие 12 месяцев? • Был ли у вас перелом костей за последний месяц? • Возникает ли у вас одышка при выполнении повседневных действий в доме, например, когда вы одеваетесь? • Есть ли у вас заболевание суставов или мышц, которое ограничивает возможность выполнения упражнений? • Рекомендовал ли ваш поставщик услуг здравоохранения ограничение физических нагрузок? В проекте Vivifrail представлены практические рекомендации по разработке индивидуальной программы упражнений. http://www.vivifrail.com/resources 6 29 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности Работа в условиях ограничений. В условиях, когда боль вызывает ограничение двигательной активности, дозированная физическая активность в течение посильного промежутка времени с постепенным увеличением сложности заданий помогает усилить выносливость организма и справляться с болью. Для лиц, подвижность которых значительно ограничена, выполнение физических упражнений можно начинать с положения лежа в кровати или сидя на стуле. Для лиц с ограничением когнитивных функций, например, с деменцией, может в большей степени подойти упрощенная и менее структурированная программа упражнений. 5.2 ПОДДЕРЖКА СПОСОБНОСТИ К САМООБСЛУЖИВАНИЮ Поддержка способности к самообслуживанию повышает приверженность мультимодальной программе упражнений и позволяет извлечь из нее большую пользу. Лица с результатами оценки по тестам SPPB в диапазоне 10-12 баллов могут выполнять упражнения на дому или в группе. Лицам с более выраженным ограничением подвижности может потребоваться наблюдение и помощь при выполнении упражнений. Руководство ВОЗ по программе mAgeing может дополнить регулярные усилия медицинских работников, поскольку содействует самообслуживанию и самопомощи. Дополнительная информация: http://www.who.int/ageing/health-systems/mAgeing ГЛОБАЛЬНЫЕ РЕКОМЕНДАЦИИ ВОЗ ПО ФИЗИЧЕСКОЙ АКТИВНОСТИ Всем пожилым людям может пойти на пользу консультация по вопросам физической активности, рекомендованная для соответствующего возраста, с учетом состояния здоровья. В этой вставке обобщены глобальные рекомендации ВОЗ по физической активности для лиц в возрасте 65 лет и старше. В течение каждой недели необходимо выполнение аэробной физической нагрузки умеренной интенсивности общей продолжительностью не менее 150 минут либо высокой интенсивности общей продолжительностью не менее 75 минут, либо в эквивалентном сочетании. Продолжительность отдельного сеанса не должна быть менее 10 минут. Дополнительную пользу могут принести аэробные упражнения умеренной интенсивности общей продолжительностью 300 минут в неделю или упражнения высокой интенсивности продолжительностью 150 минут в неделю, либо в эквивалентном сочетании. Следует выполнять упражнения на укрепление мышц два дня в неделю или чаще. При низком уровне двигательной активности следует выполнять упражнения на развитие равновесия не реже, чем трижды в неделю. При невозможности выполнять рекомендуемый объем физической нагрузки следует поддерживать ее максимально возможный уровень. http://www.who.int/dietphysicalactivity/pa/en/index.html 30 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности 5.3 ПОЛИПРАГМАЗИЯ Ряд препаратов может ухудшить двигательную активность или сказаться на равновесии, при этом необходимость их назначения конкретному человеку или их эффективность у конкретного человека может быть крайне малой (8). К числу таких препаратов относятся, в том числе: • противосудорожные средства; • бензодиазепины; • небензодиазепиновые снотворные средства; • трициклические антидепрессанты; • антидепрессанты из группы селективных ингибиторов обратного захвата серотонина (СИОЗС); • антипсихотики; • опиоиды. Выраженность полипрагмазии можно снизить за счет исключения ненужных, неэффективных препаратов, а также препаратов, которые дублируют действие друг друга. В случае сомнения относительно возможности безопасной отмены какого-либо из препаратов, следует получить консультацию специалиста соответствующего профиля. 5.4 БОЛЬ Оценка боли. Выраженная боль, которая провоцируется движениями, может ограничивать или полностью исключать возможность выполнения физических упражнений. Оценка выраженности боли, связанной с двигательной активностью, может оказаться полезной как для разработки программы упражнений, так и для лечения боли. Можно воспользоваться кратким инструментарием, посвященным проблеме боли: https://www.aci.health.nsw.gov. au/__data/assets/ pdf_file/0015/212910/Brief_Pain_Inventory_Final.pdf Лечение боли (9). Заболевания опорно-двигательного аппарата, которые снижают уровень двигательной активности, часто сопровождаются персистирующей болью. Впрочем, специфические биологические причины возникновения персистирующей боли редко удается достоверно определить. Согласно передовой практике, подход к лечению боли должен включать воздействие на целый ряд факторов, вносящих вклад в возникновение боли: физические факторы (такие как сила мышц, объем движений и выносливость), психологическое благополучие, питание и сон. В случаях, когда боль оказывается значительным препятствием для осуществления двигательной функции и деятельности, медицинский работник, обладающий специальными познаниями в области лечения боли, должен разработать план лечения боли. Мероприятия для купирования болевого синдрома должны включать: • самопомощь; 5.2 • упражнения и другую физическую активность; • прием препаратов, начиная от парацетамола и нестероидных противовоспалительных препаратов до габапентина и опиоидов; • мануальную терапию, например, массаж, манипуляции на суставах и мобилизацию суставов; • психотерапию и когнитивную поведенческую терапию (см. Главу 9, посвященную симптомам депрессии); • акупунктуру; • спинальные инъекции/эпидуральные инъекции; • радиочастотную денервацию. ОЦЕНКА И РАБОТА С АССОЦИИРОВАННЫМИ РАССТРОЙСТВАМИ Ряд этих мероприятий может осуществляться на уровне общины. Другие могут потребовать направления в крупные учреждения. 9 31 5 СПОСОБНОСТЬ К ДВИЖЕНИЮ Схемы организации ухода для улучшения двигательной активности ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ Некоторым лицам с ограничением двигательной активности может потребоваться помощь в повседневной деятельности. Первым этапом является оценка потребностей в социальной помощи (см. Главу 10). К особым потребностям в социальной помощи у пожилых людей, страдающих утратой двигательной активности, могут относится потребности, выявленные при оценке характеристик физического окружения или при оценке потребности в ассистивных устройствах. Программа упражнений может помочь в профилактике падений. 5.5 ОЦЕНКА ФИЗИЧЕСКОГО ОКРУЖЕНИЯ С ЦЕЛЬЮ СНИЖЕНИЯ РИСКА ПАДЕНИЙ Оценка физического окружения предполагает изучение домашней обстановки с целью выявления вероятных угроз и выработки решений. Примеры возможных решений: упорядочить предметы обстановки, убрать незакрепленные коврики, выровнять уровень пола и устранить ступенчатые переходы, переставить мебель таким образом, чтобы получился широкий удобный проход, улучшить качество освещения и доступ в туалетную комнату, особенно в ночное время (например, прикрепив к стене поручни). Организация пологого подъема перед главным входом поможет людям, пользующимся креслами-колясками и всем тем, кто испытывает затруднения при пользовании лестницами. Наиболее важные изменения в окружающей обстановке будут определяться конкретными ограничениями двигательной активности пожилого человека. При условии специальной подготовки общинный медико-санитарный работник или работник лечебного учреждения может оценить особенности домашней обстановки пожилого человека. При невозможности осуществления визита медицинский работник первичного звена может дать пожилому человеку или лицу, осуществляющему уход, рекомендации общего характера в отношении того, как создать безопасную обстановку дома. Полномасштабная оценка и управление рисками падений требует специальных познаний. 5.6 РАССМОТРЕТЬ ВОЗМОЖНОСТЬ НАЗНАЧЕНИЯ АССИСТИВНЫХ УСТРОЙСТВ И ПРЕДОСТАВИТЬ ИХ Людям с ограничением двигательной активности для передвижения могут потребоваться ассистивные устройства. Ассистивные устройства – это такие устройства, которые в первую очередь предназначены для поддержания или улучшения функциональной способности человека, а также повышения уровня его самостоятельности, социальной вовлеченности и общего благополучия (10). К этим изделиям относятся трости, костыли, ходунки, кресла-коляски, а также протезы и ортезы. Выбор может быть ограничен наличием и стоимостью, однако медицинский работник с познаниями в области физиотерапии, при его доступности, может порекомендовать наиболее подходящий вариант соответствующего изделия и проинструктировать в отношении безопасного применения. Риск падений может возрастать при снижении индивидуальной жизнеспособности любого рода. Физические свойства среды проживания человека, а также способы выполнения им различных задач или ведения активности также являются значимыми факторами. Помимо оценки физического окружения, оценка риска падений включает в себя: • сбор анамнеза падений, включая подробности происходившей в тот момент деятельности; • оценка походки, равновесия, подвижности, функции и гибкости мышц и суставов; • выявление боязни падений, оценка зрения, когнитивной функции, состояния сердечно-сосудистой и нервной систем, выявление острых позывов на мочеиспускание или никтурии (пробуждение ночью с целью помочиться); а также • изучение списка назначенных препаратов на предмет полипрагмазии (см. Главу 3, посвященную проведению оценок и разработке плана ухода). Некоторым людям потребуется дальнейшая диагностика и лечение таких расстройств, как синкопальные состояния (обмороки), эпилепсия и нейродегенеративные расстройства, например, болезнь Паркинсона. 32 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания ВОЗ пользуется термином «бодрость» для описания физиологических факторов, являющихся составной частью индивидуальной жизнеспособности человека. К ним могут относиться энергетический баланс организма и обмен веществ. В данном руководстве подробно освещена одна важная причина снижения бодрости у пожилых – нарушения питания. ОСНОВНЫЕ ПОЛОЖЕНИЯ Работники здравоохранения первичного звена могут без труда провести первичную оценку нутритивного статуса. Такая оценка должна входить в любую характеристику состояния здоровья пожилого человека. Полная оценка нутритивного статуса требует специальных познаний и, иногда, исследования анализов крови. Как нерациональное питание, так и недостаток физической активности приводят к утрате мышечной массы и силы. Сбалансированный рацион в необходимом объеме, как правило, обеспечивает пожилых людей достаточным количеством витаминов и минералов, впрочем, дефицит витаминов D и B12 не является редкостью. Нарушения питания зачастую приводят к потере веса, однако не всегда. Жировая масса может заместить мышечную массу, при этом масса тела останется неизменной. Еще одним аспектом нарушений питания является ожирение, которое не рассматривается в рамках данного руководства. 33 Вы теряли без явной причины больше 3 килограммов веса за последние три месяца? У вас пропадал аппетит? ? ? Нормальный нутритивный статус (Баллы по шкале MNA: 24-30 баллов) В группе риска по недостаточности питания (Баллы по результатам краткой оценки статуса питания MNA: 17-23,5 балла) Страдает от недостаточности питания (Баллы по результатам краткой оценки статуса питания MNA: < 17 баллов) – после острого эпизода или перенесенного заболевания – один раз в год для пожилых людей, проживающих в общине – каждые три месяца для пожилых людей с потребностями в социальной помощи ОЦЕНКА НУТРИТИВНОГО СТАТУСА ВОПРОС НЕТ НЕТ (при ответе на любой из вопросов) ДА Дать рекомендации по питанию Рассмотреть вопрос о назначении дополнительного энтерального питания при невозможности увеличить потребление пищи Тщательно контролировать массу тела Рассмотреть возможность назначения мультимодальных упражнений Необходима нутритивная поддержка Назначить дополнительное энтеральное питание с повышенным потреблением белка (400-600 ккал/день) Дать рекомендации по питанию Тщательно контролировать массу тела ПОВТОРНАЯ ОЦЕНКА Пример: Краткая оценка статуса питания (MNA) (8) Дополнительное энтеральное питание Дополнительное энтеральное питание является дополнительным источником высококачественного белка, калорий и необходимого количества витаминов и минералов сообразно потребностям, вкусовым предпочтениям и физическим ограничениям человека i Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода 6 С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ ОЦЕНКА И РАБОТА Устранить препятствия для достижения алиментарного здоровья Поощрять семейные и социальные обеды Организовать помощь в подготовке и обеспечении продовольствием 6.2 6.3 6.2 СОПУТСТВУЮЩЕЙ ПАТОЛОГИИ ОЦЕНКА И ВЕДЕНИЕ – НЕМОЩЬ – САРКОПЕНИЯ 1 1 2 1 Комплексное лечение заболеваний Рассмотреть возможность назначения реабилитационных мероприятий для повышения мышечной силы СКРИНИНГ НАРУШЕНИЙ ПИТАНИЯ НА УРОВНЕ ОБЩИНЫ Требуется специализированная помощь БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания Рекомендации для систем и служб Механизм реализации концепции 6РЕКОМЕНДАЦИИ ПО ПИТАНИЮ • Работники первичного звена могут выдать пожилым людям рекомендации и поощрить применение здорового рациона питания. Эти рекомендации могут оказаться полезными для всех пожилых, включая лиц, находящихся в группе риска или страдающих от недостаточности питания, независимо от потребности в специализированной помощи. Придерживаться здорового питания проще тем людям, которые ежедневно ведут дневник своего рациона, отмечая пищу, принятую в основные приемы и между ними. • Следует помочь пожилым людям выбрать доступную в месте проживания пищу, которая обеспечивает необходимое поступление энергии (углеводы), белков и микронутриентов, таких как витамины и минералы. Следует выдать рекомендации по соразмерному количеству такой пищи. • Поскольку усвоение белка снижается с возрастом, пожилым людям следует выдать рекомендации по его обильному потреблению. Для здоровых пожилых людей рекомендуется потребление белка в количестве 1,0-1,2 г на килограмм массы тела. В период восстановления после потери массы тела, острого заболевания или травмы потребности могут доходить до 1,5 г на килограмм массы тела. Следует проводить контроль функции почек, поскольку высокое потребление белка может приводить к повышению внутриклубочкового давления и клубочковой гиперфильтрации. • Следует рекомендовать физическую активность, которая позволяет использовать белки в качестве строительного материала для мышц, а также стимулирует аппетит. • Следует поощрять пребывание на солнце для синтеза витамина D. Пожилым людям не достаточно поступающего с пищей витамина D для поддержания его оптимального уровня. Необходимо выполнение анализов крови для определения уровня витамина D у конкретного человека. • Зачастую пожилые люди не потребляют достаточного количества пищи. С тем чтобы содействовать более высокому потреблению пищи пожилым человеком, следует предлагать семейные обеды и социальные обеды, в особенности, для пожилых людей, проживающих самостоятельно или находящихся в социальной изоляции. 1 Общинные медико-санитарные работники и медицинские работники первичного звена могут дать рекомендации и оказать поддержку, помогая всем пожилым людям поддерживать здоровый рацион. Лицам с нарушениями питания или находящимся в группе риска требуется поставщик услуг, обладающий специализированными познаниями, с тем чтобы выявить причины и факторы риска, а также назначить индивидуальныйплан питания. По показаниями следует провести или направить человека на углубленное обследование по поводу патологических состояний, которые могут лежать в основе или приводить к нарушению питания – даже если текущий нутритивный статус кажется нормальным. К возможным признакам таких патологических состояний относятся снижение мышечной массы, быстрая потеря массы тела, боль в полости рта, боль при глотании или затруднение глотания, хроническая рвота или диарея, а также абдоминальная боль. КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ В оценке нутритивного статуса может помочь ряд действенных инструментов (11). ОЦЕНКА НУТРИТИВНОГО СТАТУСА 2 ВАЖНО!! Медицинский работник должен информировать как членов семьи и других лиц, осуществляющих уход, так и самого пожилого человека. Краткая оценка статуса питания (MNA) (8) Оценка риска нарушений питания DETERMINE (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Универсальный инструмент скрининга нарушений питания (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Оценка риска, связанного с питанием, для пожилых людей в общине и опросник по питанию (https://www. intbox.com/public/project/2750/) Краткий опросник для оценки статуса питания 65+ (SNAQ65+) (http://www. ghtmalnutrition.eu/toolkits/ summary-screening-tools). В схеме организации помощи на противоположной странице применяется краткая оценка статуса питания (MNA). БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания 35 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания Большая часть инструментов для оценки нутритивного статуса предусматривает ответы на следующие вопросы: • потребление пищи и жидкости; • недавняя потеря веса (тот же вопрос, что и для скрининга); • двигательная активность; • недавно перенесенный психологический стресс или остро протекающее заболевание; • психологические проблемы; • бытовые условия. Кроме того, в них учитываются: • масса тела; • рост; • индекс массы тела (ИМТ – масса тела в кг/рост в см2); • окружность плеча и голени. ОЦЕНКА НУТРИТИВНОГО СТАТУСА СОСТАВ ТЕЛА И СТАРЕНИЕ Как правило, в возрасте около 70 лет мышечная масса может уменьшаться, что сказывается важным и, вероятно, отрицательным образом на бодрости. Как нерациональное питание, так и недостаток физической нагрузки приводят к утрате мышечной массы и силы. В то же время, жировая масса тела может возрастать. Масса тела может снижаться или оставаться на прежнем уровне, маскируя вероятные отрицательные изменения. Таким образом, человек с недостаточностью питания может утратить полезный объем тканей, формирующих безжировую массу тела, и при этом иметь ИМТ в приемлемом диапазоне или даже в диапазоне, соответствующем избыточной массе тела. Подготовленный неспециалист может достоверно оценить функцию мышц и, соответственно, недостаточность потребления белка с пищей при помощи такого инструмента как ручной динамометр, определяющий силу хвата. Данное устройство определяет, насколько сильно испытуемый может сжать его одной рукой. Низкая сила хвата указывает на необходимость выполнения физических упражнений и потребления питания, более богатого белком. 36 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания 6.2 ДЛЯ ПОЖИЛЫХ ЛЮДЕЙ, ИМЕЮЩИХ НАРУШЕНИЯ ПИТАНИЯ У лиц с выявленными нарушениями питания (например, менее 17 баллов по опроснику MNA) необходимо безотлагательно начинать нутритивную поддержку. Работник здравоохранения первичного звена может дать стандартные рекомендации в отношении питания (см. вставку на стр. 35). Необходимо, чтобы специально подготовленный медицинский работник как можно скорее дал собственные рекомендации в отношении питания и, при необходимости, назначил дополнительное энтеральное питание (см. ниже). Данное мероприятие должно стать частью всеобъемлющего плана ухода, нацеленного на основные факторы, вследствие которых развивается недостаточность питания, наряду с иными мероприятиями, нацеленными на другие компоненты индивидуальной жизнеспособности, такие как ограничение двигательной активности. В частности, надлежащее потребление калорий и белка повысит эффективность программ мультимодальных физических упражнений (см. Главу 5, посвященную ограничению двигательной активности). ДОПОЛНИТЕЛЬНОЕ ЭНТЕРАЛЬНОЕ ПИТАНИЕ Дополнительное энтеральное питание обеспечивает дополнительное поступление высококачественного белка, калорий и необходимого количества витаминов и минералов. Для разработки плана дополнительного энтерального питания, индивидуально подобранного под нужды, вкусовые предпочтения и физические ограничения конкретного лица, требуются специальные познания. Проведение оценки позволяет подобрать наилучший метод дополнительного питания, будь то за счет пищи богатой питательными веществами, витаминных или минеральных добавок в виде таблеток или специализированных Сенсорные нарушения (снижение вкусовых ощущений и обоняния), ухудшение состояния полости рта, например, проблемы с жеванием и затруднения глотания, изоляция, одиночество, низкий уровень дохода и длительное течение нескольких расстройств здоровья повышают риск нарушений питания в пожилом возрасте. 6.1 ДЛЯ ПОЖИЛЫХ ЛЮДЕЙ, ИМЕЮЩИХ РИСК ВОЗНИКНОВЕНИЯ НАРУШЕНИЙ ПИТАНИЯ Пожилому человеку с риском нарушений питания (например, 17-23,5 балла по опроснику MNA) могут пойти на пользу рекомендации в отношении питания (см. вставку на стр. 35). Лицам с риском возникновения нарушений питания также предпочтительно назначить нутритивную поддержку для профилактики развития нарушений питания. ВЕДЕНИЕ НАРУШЕНИЙ ПИТАНИЯ У ПОЖИЛЫХ 5 37 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания Дополнительное энтеральное питание должно назначаться только в тех случаях, когда человек не может потреблять достаточное количество обычной пищи с необходимой энергетической ценностью и содержанием питательных веществ или когда дополнительное энтеральное питание явля- ется временной мерой в дополнение к обычным методикам наращивания потребления калорий с пищей. коммерческих продуктов или некоммерческих питательных смесей. Общинный медико-санитарный работник может оказывать поддержку и вести мониторинг пациента, находящегося на дополнительном энтеральном питании (см. вставку). Анализы крови Данные анализа крови ложатся в основу разработки индивидуального плана питания. Анализ крови позволяет выявить недостаток отдельных витаминов и минералов. Специализированные комплексы для перорального или инъекционного приема могут устранить этот недостаток. Например, для устранения частого дефицита витаминов D и B12 необходимы таблетированные или инъекционные препараты. ОСНОВНЫЕ ПОЛОЖЕНИЯ, КАСАЮЩИЕСЯ ДОПОЛНИТЕЛЬНОГО ЭНТЕРАЛЬНОГО ПИТАНИЯ В первую очередь необходимо уделять внимание рациону. За исключением случаев, когда переход на дополнительное энтеральное питание нужен незамедлительно, в первую очередь следует по возможности улучшить качество рациона и увеличить кратность приемов пищи. Дополнительное энтеральное питание является добавкой к пище. Оно не является заменой пищи. Важно, чтобы человек, которому назначено дополнительное энтеральное питание, осознавал необходимость продолжения как можно более плотного питания обычной пищей. При назначении дополнительного энтерального питания необходимо инструктировать пожилого человека о том, каким образом готовить смесь, какое ее количество принимать за один раз и в какое время. Дополнительное энтеральное питание употребляют между приемами пищи, но не одновременно с пищей. Зачастую человеку, которому назначено дополнительное энтеральное питание, необходима постоянная поддержка и поощрение приема такого питания (со стороны членов семьи, лиц, осуществляющих уход, и медицинских работников) а также акцент на необходимости продолжать как можно более интенсивно питаться обычной пищей. По прошествии определенного времени вкус и консистенция одного и того же препарата для дополнительного энтерального питания может надоедать. В таком случае полезно периодически разнообразить вкус препарата и заменять его другим. На регулярной основе необходимо контролировать и фиксировать показатель массы тела. В идеальном случае необходимо стремиться к отмене дополнительного энтерального питания, как только минует риск нарушений питания, а рацион будет обеспечивать необходимую потребность в питательных веществах. 38 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания 6 БОДРОСТЬ Схемы организации ухода для коррекции нарушений питания ОЦЕНКА И РАБОТА С АССОЦИИРОВАННЫМИ РАССТРОЙСТВАМИ 6.3 САРКОПЕНИЯ И СТАРЧЕСКАЯ НЕМОЩЬ Саркопения и старческая немощь – это расстройства, которые могут быть связаны с неудовлетворительным питанием. Мероприятия по изменению образа жизни, включая улучшение питания и физические упражнения, могут воздействовать на обе эти проблемы. Саркопения. Этим термином описывают генерализованную и прогрессирующую потерю мышечной массы, силы и функции. Причинами могут быть заболевания, неудовлетворительное питание или недостаток физической активности (например, продолжительное пребывание в постели), либо данное состояние может возникать без очевидных причин и быть связанным с процессом старения. Старческая немощь. Под этим понятием может подразумеваться потеря массы тела, мышечная слабость, низкий уровень физической активности, утомляемость и медлительность (например, медленное перемещение шагом). Причинами могут быть физический или психологический стресс, например травма, заболевания или утрата любимого человека. Немощный человек может утрачивать функциональные способности и становиться зависимым от посторонней помощи. ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ Лица, осуществляющие уход, и представители общин могут содействовать в преодолении препятствий к достижению алиментарного здоровья пожилыми людьми. Например, общинные учреждения могут организовывать социальные обеды для пожилых людей. Общинные работники здравоохранения могут со своей стороны содействовать в обеспечении доступа в продовольственные магазины, в получении помощи в управлении финансами или в доступе к источникам пособий, могут содействовать в получении помощи при приготовлении пищи или получении готовой пищи, например, через общинную кейтеринговую службу. 39 40 7 ЗРЕНИЕ Схемы организации ухода при ухудшении зрения Зрение является важным компонентом индивидуальной жизнеспособности и позволяет людям быть мобильными, а также безопасно взаимодействовать с другими людьми и предметами окружающей обстановки. С возрастом все чаще отмечается действие ряда факторов, вызывающих ухудшение зрения: близорукость и дальнозоркость, катаракты, глаукома и дегенерация макулы. Нарушения зрения могут создавать трудности для поддержания семейных и других взаимоотношений, доступа к информации, безопасного передвижения (в особенности, имея в виду удержание равновесия и риск падений), а также при выполнении ручной работы. Из-за этих трудностей может возникать тревожность и депрессия. Оценка зрения является важной составляющей оценки, ориентированной на индивидуальные нужны человека. ОСНОВНЫЕ ПОЛОЖЕНИЯ При помощи простой таблицы для проверки остроты зрения работники здравоохранения первичного звена, а также общинные работники здравоохранения могут провести обследование на предмет выраженной потери зрения. У многих людей расстройства, связанные с потерей зрения, поддаются коррекции. Важно расспросить о наличии, оценить или достоверно установить наличие заболевания органа зрения. Очки часто могут помочь в коррекции снижения ближнего зрения или зрения вдаль. Вспомогательные устройства (увеличительные стекла, телескопические очки) могут помочь лицам с такими нарушениями зрения, которые не поддаются коррекции при помощи обычных очков. Дома и на уровне сообщества простые меры, например, улучшение уровня освещенности, могут повысить функциональную способность пожилых людей с ухудшением зрения. 41 Требуется специализированная помощь 7 ДАЛЬНЕЕ ЗРЕНИЕ БЛИЖНЕЕ ЗРЕНИЕ ОЦЕНКА НАРУШЕНИЙ ЗРЕНИЯ И ЗАБОЛЕВАНИЯ ОРГАНА ЗРЕНИЯ Приступить к лечению заболеваний глаз Приступить к ведению нарушений зрения Пересмотреть и при необходимости выписать новый рецепт на очки или предложить новые очки Рассмотреть вопрос офтальмологической реабилитации, включая назначение ассистивных офтальмологических устройств, например, настольных и переносных увеличительных стекол Сохранить прежние рекомендации в отношении ухода за глазами, образа жизни, гигиены зрения, касающиеся как поведения человека, так и модификации окружающей его обстановки НЕТ ДА Помогают ли Вам обычные очки для чтения, приобретенные без рецепта? ПРОВЕРКА ОСТРОТЫ ЗРЕНИЯ с применением простой таблицы ВОЗ для проверки остроты зрения 1 2 3 4 СОПУТСТВУЮЩЕЙ ПАТОЛОГИИ ОЦЕНКА И ВЕДЕНИЕ Воздействие на сердечно-сосудистые факторы риска Ежегодно направлять на специализированную офтальмологическую консультацию по поводу патологии сетчатки Пересмотреть лекарственные назначения во избежание нежелательных лекарственных реакций, связанных с органом зрения ДА – ГИПЕРТЕНЗИЯ – ДИАБЕТ – ПРИМЕНЕНИЕ СТЕРОИДОВ СОЦИАЛЬНОЙ И ФИЗИЧЕСКОЙ СРЕДОЙ ОЦЕНКА И РАБОТА С Предоставить очки для чтения Предоставить рекомендации в отношении повседневного быта на фоне слабого зрения Произвести переоборудования жилья (освещение, контрастирующие цвета) для профилактики падений Устранить препятствия на маршруте, по которому регулярно перемещается пожилой человек ВОПРОС Есть ли у вас проблемы со зрением: затруднения при смотрении вдаль или чтении, заболевания глаз, получаете ли вы в настоящее время лечение по какому-либо поводу (например, в связи с диабетом, повышением артериального давления)? РЕЗУЛЬТАТ НЕУДОВЛЕТВОРИТЕЛЕН ДА – До исследования ближнего зрения следует всякий раз исследовать дальнее зрение – Провести исследование без очков, если пациент регулярно их носит – Сначала исследовать каждый глаз по отдельности, затем оба глаза вместе Ухудшение дальнего зрения всегда требует направления на полноценное лечение НАРУШЕНИЕ ЗРЕНИЯ (14) Ухудшение дальнего зрения: • легкое – острота зрения ниже 6/12 • умеренное – острота зрения ниже 6/18 • тяжелое – острота зрения ниже 6/60 • слепота – острота зрения ниже 3/60. Ухудшение ближнего зрения: • острота зрения вблизи ниже N6 или M.08 на фоне существующей коррекции. i 7.4 7.5 7.9 7.10 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ Повторять тест ежегодно даже при отсутствии ухудшения зрения ПОВТОРНАЯ ОЦЕНКА Рекомендации для систем и служб Механизм реализации концепции РЕЗУЛЬТАТ НЕУДОВЛЕТВОРИТЕЛЕН 7ИССЛЕДОВАНИЕ ДАЛЬНЕГО ЗРЕНИЯ С ПРИМЕНЕНИЕМ ПРОСТОЙ ТАБЛИЦЫ ВОЗ ДЛЯ ПРОВЕРКИ ОСТРОТЫ ЗРЕНИЯ Продемонстрируйте вблизи, что при выполнении пробы с изображениями символа «Е» необходимо указывать, в какую сторону обращен каждый символ. Оцените дальнее и ближнее зрение и определите наименьший размер символа «Е», который человек зрительно различает. 1. Выполните пробу с расстояния 3 м., используя изображение четырех малых символов «Е». Зрение в норме (6/18 и выше), в случае если человек зрительно различает, в какую сторону обращены по меньшей мере три из четырех символов «Е». В случае если человек зрительно не различает по меньшей мере три больших символа «Е», проба с большими символами «Е» на расстоянии 3 метров. 2. Проба с большими символами «Е» на расстоянии 3 метров. В случае если человек зрительно различает символы «Е», острота зрения составляет 6/60. В случае если человек зрительно не различает по меньшей мере три больших символа «Е», проба с большими символами «Е» на расстоянии 3 метров. 3. Проба с большими символами «Е» на расстоянии 1,5 метра. В случае если человек зрительно различает символы «Е», острота зрения составляет 3/60. 2 1 ИССЛЕДОВАНИЕ БЛИЖНЕГО ЗРЕНИЯ С ПРИМЕНЕНИЕМ ПРОСТОЙ ТАБЛИЦЫ ВОЗ ДЛЯ ПРОВЕРКИ ОСТРОТЫ ЗРЕНИЯ Дайте испытуемому возможность рассмотреть карточку для оценки ближнего зрения с удобного для расстояния. Начинайте проверку с самых больших символов «Е», постепенно переходя к более мелким. Испытуемый должен предоставить не менее трех правильных ответов касательно ориентации символов, прежде чем перейти к следующей строке. В случае если испытуемый зрительно различает только самые крупные символы (N48), следует оценить, помогают ли испытуемому обычные очки для чтения, приобретенные без рецепта. Если такие очки не помогают, пациента следует направить на полное офтальмологическое обследование с определением остроты зрения и последующее лечение. Символы среднего размера (N20) похожи на крупный типографский шрифт в книгах. Самые мелкие символы (N8) похожи на типографский шрифт в книгах и журналах. 3 ГИГИЕНА ЗРЕНИЯ Гигиена зрения зависит как от поведения самого человека, так и от характеристик окружающей его среды. Факторы окружающей среды и различные виды поведения могут как помогать зрительному восприятию (например, освещение, контраст, использование различных цветов), так и вредно сказываться на нем (например, продолжительный просмотр цифрового контента, продолжительное использование ближнего зрения). К личной гигиене относится целый спектр видов поведения, которые способствуют гигиене органа зрения, например, частое мытье рук, избегание потирания глаз, использование для умывания только щадящего мыла и отказ от косметических средств, наносимых на область глаз. 4 КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ При наличии установленного заболевания глаз или впервые выявленном заболевании специалист-офтальмолог принимает решение о кратности и виде обследований. • Следует проводить простой скрининг на предмет ухудшения зрения не реже одного раза в год для лиц в возрасте 50 лет и старше. • Скрининговое исследование дальнего и ближнего зрения может производиться с применением простой таблицы ВОЗ для проверки остроты зрения. Инструкции приведены справа. • Скрининговое исследование может проводить поставщик услуг здравоохранения в первичном звене. Для этого не требуется официальной подготовки в области оценки качества офтальмологической помощи (13). • В случае если обычных очков для чтения, приобретенных без рецепта, достаточно для решения имеющихся проблем со зрением, полное офтальмологическое обследование может не требоваться. ИССЛЕДОВАНИЕ ОСТРОТЫ ЗРЕНИЯ В ПЕРВИЧНОМ ЗВЕНЕ 7.1 7.2 7.2 7.3 ЗРЕНИЕ Схемы организации ухода при ухудшении зрения ПОВТОРНАЯ ОЦЕНКА 43 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 ПРОСТАЯ ТАБЛИЦА ВОЗ ДЛЯ ПРОВЕРКИ ОСТРОТЫ ЗРЕНИЯ (ЧЕТЫРЕ СИМВОЛА В ФОРМЕ СТРОЧНОЙ БУКВЫ «E» ДЛЯ ОЦЕНКИ ЗРЕНИЯ ВДАЛЬ) • Строчные буквы «E» имеют линейные размеры 1,3 см. x 1,3 см. и отстоят друг от друга на 1,3 см. • Изображение буквы «Е» равномерно нанесено черным цветом на гладкую белую бумагу. 44 7 ЗРЕНИЕ Схемы организации ухода при ухудшении зрения 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 ПРОСТАЯ ТАБЛИЦА ВОЗ ДЛЯ ПРОВЕРКИ ОСТРОТЫ ЗРЕНИЯ (ЧЕТЫРЕ ФИГУРЫ В ФОРМЕ ПРОПИСНОЙ БУКВЫ «E» ДЛЯ ОЦЕНКИ ЗРЕНИЯ ВДАЛЬ) • Прописные буквы «E» имеют линейные размеры 4,2 см. x 4,2 см. и отстоят друг от друга на 4,5 см. • Изображение буквы «Е» равномерно нанесено черным цветом на гладкую белую бумагу. 45 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 ПРОСТАЯ ТАБЛИЦА ВОЗ ДЛЯ ПРОВЕРКИ ОСТРОТЫ ЗРЕНИЯ (БЛИЖНЕЕ ЗРЕНИЕ) 46 7 ЗРЕНИЕ Схемы организации ухода при ухудшении зрения 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ • Пожилой человек может рассматривать объекты вблизи при помощи очков для чтения. Однако подобные очки могут помочь далеко не всем. Например, лицам с дальнозоркостью или астигматизмом необходимы очки, выписанные специалистом по результатам обследования. • Стандартное диагностическое обследование предполагает выполнение процедуры специалистом, при этом для подробного исследования органа зрения используется щелевая лампа. Применение лампы позволяет, например, выявить катаракту и принять решение о необходимости хирургического вмешательства. Обследование сетчатки и зрительного нерва требует применения других инструментов, а иногда – проведения визуализации для выявления ранних изменений и подбора терапии, нацеленной на профилактику потери зрения. Регулярное обследование сетчатки особенно важно для лиц с диабетом. 7.4 ОЦЕНКА НАРУШЕНИЙ ЗРЕНИЯ И ЗАБОЛЕВАНИЙ ОРГАНА ЗРЕНИЯ • Внезапная или быстро прогрессирующая потеря зрения на один или оба глаза требует первичного офтальмологического осмотра и оценки зрительной функции, а также направления к профильному специалисту. • Обследовать орган зрения может специалист первичного звена. При наличии изменений, таких как покраснение глаз, выделения из глаз, рубцы, болевой синдром, непереносимость солнечного света или катаракта, необходима консультация специалиста по заболеваниям глаз (офтальмолога или оптометриста). • Специалист первичного звена может обследовать орган зрения на предмет проявлений характерных заболеваний глаз. Как правило, такое обследование не является полным и требует дальнейшего осмотра специалистом. Если проявления любого из перечисленных выше расстройств зрения продолжают сохраняться, рекомендуется специализированная офтальмологическая помощь. ОЦЕНКА НАРУШЕНИЙ ЗРЕНИЯ И ЗАБОЛЕВАНИЙ ОРГАНА ЗРЕНИЯ КАТАРАКТА Катаракта – это помутнение хрусталика глаза, которое мешает ясному зрению и часто связано с процессом старения. Катаракта по-прежнему остается ведущей причиной слепоты. Снижение потребления табака и ограничение воздействия ультрафиолетового излучения может препятствовать развитию катаракты или отсрочить ее возникновение. Диабет и ожирение являются дополнительными факторами риска. Поскольку операция по поводу катаракты безопасна и позволяет восстановить зрение, нарушений зрения и слепоты вследствие катаракты можно избежать. 47 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ 7.6 НЕОБРАТИМОЕ СНИЖЕНИЕ ЗРЕНИЯ У многих людей имеется такое снижение зрения, при котором специально изготовленные очки не позволяют добиться достаточной степени коррекции. Таким людям могут пригодиться вспомогательные устройства, например, настольные или переносные увеличительные стекла, которые дают большее увеличение по сравнению с очками. Благодаря этим приспособлениям становятся возможными те виды деятельности, где требуется зрение вблизи, например, чтение книги или газеты, подсчет наличных денег, чтение этикеток, рассмотрение мелких предметов или элементов крупных предметов. Общинные работники здравоохранения или специалисты по реабилитации могут помочь людям, нуждающимся в получении таких устройств. Реабилитация зрительных функций. Для лиц с необратимым снижением зрения будут полезными услуги по всесторонней реабилитации зрительных функций, которые включают психологическую поддержку, а также упражнения на улучшение ориентированности, двигательной активности и выполнение повседневных бытовых действий. Офтальмологи и специалисты по реабилитации зрительных функций могут обучить людей со снижением зрения навыкам, которые позволят больше полагаться на зрение: осознание зрительного стимула, фиксация на нем, изучение взглядом и слежение за стимулом. Как правило, эти навыки необходимы для эффективного применения увеличительных стекол, хотя могут пригодиться и в других обстоятельствах. 7.5 ОЧКИ ДЛЯ ЧТЕНИЯ Многие лица в возрасте 50 лет и старше испытывают затруднения при рассмотрении предметов и чтении на близком расстоянии. Таким людям могут помочь очки для чтения. Обычные очки для чтения доступны по цене. Как правило, можно найти целый ассортимент моделей с разной степенью увеличения. Очки для чтения увеличивают изображение близко расположенных объектов. В случае, если обычные очки для чтения не могут помочь, рекомендуется проведение полного обследования органа зрения и его функции. По возможности, всем лицам в возрасте от 50 лет и старше следует проводить регулярное специализированное офтальмологическое обследование. Простые тесты на определение остроты зрения и пробы с чтением текста не являются заменой полному специализированному офтальмологическому обследованию. ВЕДЕНИЕ НАРУШЕНИЙ ЗРЕНИЯ 48 7 ЗРЕНИЕ Схемы организации ухода при ухудшении зрения 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ ОЦЕНКА И РАБОТА С АССОЦИИРОВАННЫМИ РАССТРОЙСТВАМИ 7.9 ПРИМЕНЕНИЕ СТЕРОИДОВ У ряда людей длительная терапия стероидами может приводить к повышению давления в глазном яблоке (внутриглазное давление) или приводить к возникновению катаракты. В связи с таким повышением давления может развиваться потеря зрения, при которой происходит повреждение зрительного нерва, и в отсутствие лечения может возникать слепота. Лицам, получающим длительную терапию стероидами, требуется регулярное проведение офтальмологического обследования и определение внутриглазного давления. 7.7 ГИПЕРТЕНЗИЯ Гипертензия является важным фактором риска развития заболеваний сетчатки и глаукомы. 7.8 ДИАБЕТ Лицам с диабетом необходимо ежегодно проходить специализированное офтальмологическое обследование на предмет диабетической ретинопатии. 49 7 Схемы организации ухода при ухудшении зрения ЗРЕНИЕ ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ Создание контрастности. Хорошее контрастирование различных частей одного объекта, а также различных объектов между собой упрощает зрительную идентификацию и нахождение объектов, а также препятствует столкновению с ними. Например, можно обозначать яркими цветами края ступеней (в особенности для лиц с одним зрячим глазом), использовать цветные тарелки, которые отличаются по цветовому контрасту от пищи, и пользоваться пастой черного цвета при письме. Лица со сниженным зрением, члены семьи и лица, осуществляющие уход, могут раскрасить ручки хозяйственной и кухонной утвари для ее лучшего зрительного различения и повышения степени безопасности: например, можно обернуть ручку ножа яркой изоляционной лентой или раскрасить ее. Применение наиболее удобного шрифта для чтения. Для чтения печатных изданий и текста на электронном дисплее компьютера или телефона самым удобным является крупный шрифт без засечек (такой же, как в данном руководстве), четко выделяющийся на однотонном фоне. Выбор предметов быта с надписями, сделанными крупным шрифтом и с хорошим контрастированием. Нередко в магазинах продаются продукты, на которых текст и цифры нанесены крупным шрифтом и с хорошим контрастом. Такими примерами могут служить настенные и наручные часы, а также книги, напечатанные крупным шрифтом. Для проведения досуга можно приобрести или изготовить настольные игры с крупными фигурами на крупных досках, игральные карты с крупным шрифтом и изображениями. Применение устройств со специальными возможностями зрительного и звукового оповещения. Многие имеющиеся в продаже устройства имеют функцию речевого оповещения, например, говорящие часы, термометры и весы. В настоящее время многие мобильные телефоны и компьютерные программы оснащены функцией преобразования текста в речь. Существует немало способов улучшить функциональные возможности людей со снижением зрения. Оказать содействие могут члены семьи и лица, осуществляющие уход. В зависимости от обстоятельств на местах необходимо адаптировать данные рекомендации к локальному контексту в смысле конкретизации рекомендаций о получении вспомогательных оптических приспособлений и необходимых услуг. 7.10 АДАПТАЦИЯ К СНИЖЕНИЮ ЗРЕНИЯ Помимо снабжения вспомогательными оптическими приспособлениями, существуют простые меры, благодаря которым можно помочь людям со снижением зрения поддерживать уровень активности и, таким образом, качество жизни. Одним из возможных вариантов является изменение домашней обстановки и обстановки в местах, где обычно перемещается пожилой человек, чтобы обезопасить и упростить привычные занятия и досуг. Ниже приведен ряд примеров. Улучшение освещения. Хорошее освещение крайне важно при рассмотрении близко расположенных предметов. Лучше всего подойдет расположение источника света сбоку от человека, так чтобы при этом не создавалось тени. Устранение бликов. Яркий свет, как правило, обладает преимуществами. Однако отблески солнца или яркие блики могут мешать некоторым людям. Устранение физических препятствий. Опасные предметы, например, мебель и другие твердые предметы, можно передвинуть, чтобы они не создавали препятствий при перемещении по одному и тому же маршруту, а при необходимости нахождения таких предметов на конкретном месте, наоборот, можно сделать их размещение постоянным. 50 8 СЛУХ Схемы организации ухода при потере слуха Возрастная потеря слуха, вероятно, является самым частым сенсорным нарушением у пожилых людей. В отсутствие лечения потеря слуха затрудняет коммуникацию и может приводить к социальной изоляции. Ограничение других физических возможностей, например, снижение когнитивных способностей, может усугублять эти социально значимые последствия. Потеря слуха связана со многими другими расстройствами здоровья, включая снижение когнитивных способностей и риск возникновения деменции, депрессии и тревожности, нарушения равновесия, падения, госпитализации и раннюю смерть. Таким образом, оценка слуха является важным элементом мониторинга индивидуальной жизнеспособности пожилых в общинах. Углубленное исследование слуха также является важной составляющей всесторонней оценки состояния потребностей пожилого человека в услугах здравоохранения и в социальной помощи. ОСНОВНЫЕ ПОЛОЖЕНИЯ Общинные работники первичного звена здравоохранения и работники медицинских учреждений первичного звена могут проводить скрининг на предмет потери слуха при помощи простых портативных инструментов или исследования восприятия речи шепотом. Отрицательные последствия потери слуха можно смягчить за счет принятия простых мер в домохозяйстве и в общине. Стремясь облегчить слуховое восприятия в ходе коммуникации, можно воспользоваться рядом приемов и средств, к которым относится членораздельная речь, поворот лицом к собеседнику в момент обращения к нему и снижение фонового уровня шума. Улучшение слуха предполагает использование ассистивных устройств, таких, как слуховые аппараты и кохлеарные имплантаты. Снабжение ими требует специальных познаний и оборудования. 51 Требуется специализированная помощь Потеря слуха от умеренной до тяжелой степени (Аудиометрия: 36–80 дБ) Глухота (Аудиометрия: ≥ 81 дБ) Нормальная способность слышать (Аудиометрия: ≤ 35 дБ) 8 РАССПРОС О: – ФАКТОРАХ РИСКА (например, шумовые воздействия в анамнезе и прием ототоксических препаратов) – БОЛИ В УХЕ – НАЛИЧИИ В АНАМНЕЗЕ обильных жидких выделений из уха, внезапной или быстро прогрессирующей потере слуха – ГОЛОВОКРУЖЕНИИ – ХРОНИЧЕСКОМ СРЕДНЕМ ОТИТЕ – ОДНОСТОРОННЕЙ ПОТЕРЕ СЛУХА Снабдить слуховым аппаратом При недоступности слуховых аппаратов – проконсультировать в отношении техник чтения по губам и жестового языка, а также других приемах и методах повышения эффективности коммуникации НЕТ РЕЗУЛЬТАТ УДОВЛЕТВОРИТЕЛЕН Сохранить прежние рекомендации в отношении ухода за ушами или общего ухода Сохранить общие рекомендации в отношении ухода за ушами или в отношении ухода в целом RПОВТОРНАЯ ОЦЕНКА – один раз ежегодно РЕЗУЛЬТАТ НЕУДОВЛЕТВОРИТЕЛЕН ИССЛЕДОВАНИЕ СЛУХА – Проверка с речью шепотом: человек слышит речь шепотом i 3 ИЛИ – Скрининговое аудиометрическое исследование: 35 дБ или менее – результат удовлетворителен ИЛИ – Автоматизированный тест на распознавание цифр в шуме на слух в специальном приложении Схемы организации ухода при потере слуха СЛУХ С СОЦИАЛЬНОЙ И ФИЗИЧЕСКОЙ СРЕДОЙ ОЦЕНКА И РАБОТА ОЦЕНКА СПОСОБНОСТИ СЛЫШАТЬ (Диагностическая аудиометрия) 2 1 3 Оказать психологическую поддержку и содействовать в борьбе с эмоциональным дистрессом Разместить в доме средства звукового оповещения (телефон, дверные звонки) Информировать человека, страдающего потерей слуха, членов его семьи и лиц, осуществляющих уход, о приемах и методах дальнейшего поддержания взаимодействия и сохранения взаимоотношений (на любой из вопросов) ДА Направить к профильному специалисту для получения аудиологической помощи Провести оценку степени тяжести и снабдить слуховым протезом (слуховые аппараты или кохлеарные имплантаты) 8.1 8.5 8.4 8.4 2 – (на любой из вопросов) Рекомендации для систем и служб Механизм реализации концепции 1Для начальной оценки применяется одна из трех проб. ПРОВЕРКА РЕЧЬЮ ШЁПОТОМ это скрининговый инструмент, позволяющий определить, в норме ли острота слуха у человека или необходима диагностическая аудиометрия. СКРИНИНГОВАЯ АУДИОМЕТРИЯ (15) Скрининговую аудиометрию следует выполнять при наличии соответствующего оборудования. При скрининговой аудиометрии предъявляются тоны речевого спектра (от 500 до 4 000 Гц) на максимальном пороге слышимости в норме. Возможные результаты пробы: «результат удовлетворителен» или «направить к специалисту». Показатель 35 дБ или менее свидетельствует о нормальном слухе. Точно определять уровень слуха при помощи этого оборудования может неспециалист после прохождения непродолжительного курса тематической подготовки. АВТОМАТИЗИРОВАННЫЙ ТЕСТ НА РАСПОЗНАВАНИЕ ЦИФР В ШУМЕ НА СЛУХ В СПЕЦИАЛЬНОМ ПРИЛОЖЕНИИ Автоматизированная проверка на распознавание цифр в шуме может применяться для уточнения необходимости диагностической аудиометрии. Доступно в виде мобильного приложения для телефона, например: Доступно в виде онлайн-сервиса, например: hearWHO: https://www.who.int/deafness/hearWHO (бесплатно, на английском языке) hearZA: https://www.hearza.co.za/ (бесплатно, на английском языке) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (бесплатно, для пользователей iPhone, на английском, французском, немецком и испанском языках). HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (бесплатно, на нидерландском, английском, немецком, польском и шведском языках). ПРОБА НА ОСТРОТУ СЛУХА ОЦЕНКА СПОСОБНОСТИ СЛЫШАТЬ (Диагностическая аудиометрия) ОБЩИЕ РЕКОМЕНДАЦИИ В ОТНОШЕНИИ УХОДА ЗА УШАМИ НЕ СЛЕДУЕТ чистить слуховой проход загрязненными пальцами, приступать к приготовлению пищи или принимать пищу, не вымыв рук СЛЕДУЕТ ВСЯКИЙ РАЗ мыть руки после посещения туалета НЕ СЛЕДУЕТ плавать или выполнять гигиенические процедуры в загрязненной воде НЕ СЛЕДУЕТ ничего вводить в слуховой проход: – горячее или холодное масло; – средства на основе трав; – такие жидкости как керосин. 2 ПРОВЕРКА С РЕЧЬЮ ШЕПОТОМ Встаньте у испытуемого за спиной справа или слева на расстоянии вытянутой руки. Попросите человека или ассистента закрыть противоположное ухо, надавив на козелок. (козелок – это выступ в передней части ушной раковины, который частично закрывает отверстие наружного слухового прохода). Сделайте выдох и шепотом произнесите четыре слова. Это должны быть самые обычные и не связанные между собой слова. Попросите человека повторить эти слова. Следует произносить слова по одному и дожидаться ответа испытуемого. В случае, если испытуемый повторяет больше трех слов и вы уверены, что он (она) вас отчетливо слышит, вероятно, слух испытуемого на это ухо в норме. Встаньте с другой стороны от испытуемого и выполните проверку на другом ухе. 3 Произносите шепотом слова, которые наверняка знакомы человеку. Примеры: – фабрика – небо – огонь – номер – рыба – велосипед – сад – желтый КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ • Оценка состояния человека с выраженной потерей слуха/глухотой. • Подбор ассистивного слухового устройства. • Лечение основного заболевания, которое вызывает или усугубляет потерю слуха. 8 СЛУХ Схемы организации ухода при потере слуха 53 8 Схемы организации ухода при потере слуха СЛУХ Речевая аудиометрия. Для пожилых людей окажется полезным еще одно исследование – речевая аудиометрия. В ходе теста с нарастающей громкостью воспроизводят аудиозапись, на которой повторяется серия простых слов. Испытуемого просят повторить эти слова, как только он их отчетливо услышит. Данная проверка позволяет перепроверить результаты тональной аудиометрии. Она позволяет определить, соразмерно ли распознавание речи результатам тональной аудиометрии, имеется ли асимметрия речевого восприятия, не выявленная при тональной аудиометрии, а также позволяет определить, для какого уха требуется слуховой аппарат в случае, если пациента снабжают только одним таким устройством. Тимпанометрия. Наконец, тимпанометрия определяет комплаенс (или подвижность) барабанной перепонки. Эта проверка способна дополнить результаты тональной и речевой аудиометрии в части определения типа нарушения слуха. 8.1 ТРИ ПРОВЕРКУ ДЛЯ ПРОВЕДЕНИЯ ПОЛНОЙ ОЦЕНКИ Оценка слуха может включать три теста с использованием специализированного оборудования – диагностическую аудиометрию для определения восприятия чистого тона, речевую аудиометрию и тимпанометрию для оценки состояния среднего уха. Эти тесты могут помочь в выявлении необходимости реабилитации. Выполнение этих проверок требует специальной подготовки. Тональная аудиометрия. Тональная аудиометрия выявляет способность испытуемого слышать чистые тоны разной частоты (высоты). Исследование представляет собой воспроизведение звуковой записи нарастающей громкости до тех пор, пока испытуемый не начнет ее слышать, благодаря чему будет установлен порог слышимости. Исследование определяет воздушную и костную проводимость звуков с целью оценки порогов слышимости на частотах от 125 Гц (очень низкие) до 8000 Гц (очень высокие). Проверка позволяет определить выраженность и тип потери слуха. ОЦЕНКА СОСТОЯНИЯ СЛУХА 54 8 Схемы организации ухода при потере слуха СЛУХ 8 СЛУХ Схемы организации ухода при потере слуха При потере слуха необходимо прибегать как к приемам и средствам повышения эффективности коммуникации, так и к использованию слухопротезирования. Необходимо вырабатывать оптимальный подход к ведению потери слуха с учетом результатов всесторонней оценки индивидуальной жизнеспособности человека. Следует принимать в расчет любое снижение когнитивных способностей, любое снижение способности к движению или ухудшение моторики рук или кистей, а также возможность получения помощи от членов семьи и общины. 8.2 ПОЖИЛЫМ ЛЮДЯМ С ПОТЕРЕЙ СЛУХА ОТ УМЕРЕННОЙ ДО ВЫСОКОЙ СТЕПЕНИ ВЫРАЖЕННОСТИ • Следует разъяснять людям с потерей слуха и членам их семей преимущества слухопротезирования, например, с использованием слуховых аппаратов, доводить до их сведения, где можно получить такие устройства и каким образом их применять. При получении человеком слухового аппарата работник здравоохранения может содействовать и всячески поощрять его использование. • Для решения вопроса о необходимости рекомендовать слуховой аппарат не следует полагаться на результаты одной только аудиометрии. Большинство людей с потерей слуха предъявляет жалобы на затруднения в коммуникации при наличии фонового шума. Следует произвести совокупную оценку потребностей человека, прежде чем рекомендовать слухопротезирование. • Необходимо дать четкие разъяснения людям с потерей слуха, членам их семей и людям, осуществляющим уход, в отношении приемов и средств повышения эффективности коммуникации, которые могут повысить функциональную способность. • Ряд препаратов может отрицательно воздействовать на внутреннее ухо, что приведет к потере слуха и(или) нарушению равновесия. К таким препаратам относятся антибиотики, такие как стрептомицин и гентамицин, а также противомалярийные препараты, такие как хинин и хлорохин. Другие препараты также могут отрицательно воздействовать на слух. По возможности, менее интенсивное применение этих препаратов способно предотвратить дальнейшую потерю слуха. 8.3 ПОЖИЛЫМ ЛЮДЯМ, СТРАДАЮЩИМ ГЛУХОТОЙ Пожилым людям с выраженной степенью потери слуха (тяжелой или глубокой) либо тем, кому вышеупомянутые мероприятия не приносят пользу, потребуется специализированная аудиологическая помощь, например, установка слухового протеза. Обеспечение слуховыми протезами требует специальных навыков тестирования, назначения и установки. ВЕДЕНИЕ ПОТЕРИ СЛУХА ДРУГИЕ ПОВОДЫ ДЛЯ ОБРАЩЕНИЯ ЗА СПЕЦИАЛИЗИРОВАННОЙ АУДИОЛОГИЧЕСКОЙ ПОМОЩЬЮ Ряд расстройств здоровья, которые могут быть причиной потери слуха, требуют специализированной диагностики и лечения. К ним относятся: • боль в ухе; • хронический средний отит (инфекция среднего уха); • внезапная или быстро прогрессирующая потеря слуха; • головокружение, сопровождающееся потерей слуха от умеренной до тяжелой степени; • постоянное появление жидкого отделяемого из уха (ушей); • наличие факторов риска, таких как вредное воздействие шумов или прием препаратов, способных негативно воздействовать на слух. 8.5 55 8 Схемы организации ухода при потере слуха СЛУХ 8.4 СЛУХОВЫЕ ПРОТЕЗЫ Слуховые аппараты, как правило, являются наилучшим технологическим решением для пожилых людей с потерей слуха. Слуховые аппараты усиливают звуки. Они могут оказаться полезными для многих людей и удобны в применении, поскольку их носят на ухе или вставляют в ухо. Важно разъяснять, что слуховые аппараты не излечивают потерю слуха и не воздействуют на ее причины. Кохлеарные имплантаты. Кохлеарные имплантаты могут помочь людям с высокой степенью потери слуха, которым не помогает использование слуховых аппаратов. Кохлеарный имплантат устанавливают в ухо хирургическим способом. Аппарат преобразует звуки в электрические импульсы и направляет их к нервам органа слуха. Необходимо тщательное обследование пациента для ответа на вопрос о возможной эффективности кохлеарного имплантата. При недоступности или невозможности кохлеарной имплантации пожилого человека и членов семьи необходимо информировать и обучать чтению по губам, а также жестовому языку. Индукционные петли для слабослышащих и персональные звукоусилители. Индукционные петли для слабослышащих и персональные звукоусилители также оказываются действенными. Индукционная петля для слабослышащих представляет собой кабель или кабели, установленные в определенном месте (например, зале для заседаний или у информационной стойки). Через их посредство сигнал с микрофона и усилителя передается на некоторые типы слуховых аппаратов. Более подробные рекомендации можно найти в документе The WHO Guidelines for hearing aids and services for developing countries (Рекомендации ВОЗ в отношении слуховых аппаратов и аудиологических услуг для развивающихся стран): http://apps.who.int/iris/handle/10665/43066 56 8 Схемы организации ухода при потере слуха СЛУХ 8 СЛУХ Схемы организации ухода при потере слуха ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ Сведение к минимуму влияния потери слуха может помочь в сохранении независимости и уменьшении потребности пожилых людей в помощи по месту жительства в повседневных бытовых нуждах. Члены семьи, другие лица, осуществляющие уход, и община в целом могут оказать содействие. Потеря слуха зачастую приводит к психологическому дистрессу и социальной изоляции. По этой причине в аудиологической реабилитации все больший упор делается на психологические аспекты с учетом потребностей пожилого человека и лиц, осуществляющих за ним уход. • Регулярное социальное взаимодействие может снизить риск когнитивных нарушений, депрессии и других эмоциональных и поведенческих последствий потери слуха. В периоды особенно значимого дистресса могут помочь сети социальной поддержки. • Участвовать в профилактике состояния одиночества и изоляции могут партнеры и члены семей. Им может потребоваться консультирование по поводу того, как именно это сделать. Например, от них может требоваться поддержание коммуникации с человеком, потерявшим слух, и организация таких видов деятельности, которые помогут сохранить включенность человека в общественное взаимодействие. Рекомендации о том, каким образом осуществлять коммуникацию с человеком, потерявшим слух, представлены на вставке справа. • К модификации окружающей обстановки может относиться установка дверных звонков и телефонов таким образом, чтобы они были слышны во всем доме. 8.5 ПРИЕМЫ И СРЕДСТВА ПОВЫШЕНИЯ ЭФФЕКТИВНОСТИ КОММУНИКАЦИИ ДЛЯ ПРИМЕНЕНИЯ ЧЛЕНАМИ СЕМЬИ И ЛИЦАМИ, ОСУЩЕСТВЛЯЮЩИМИ УХОД Медицинские работники могут рекомендовать членам семьи и лицам, осуществляющим уход, следовать простым правилам ведения коммуникации с человеком, потерявшим слух (14). На протяжении всего разговора с человеком сохраняйте положение лицом к нему. Постарайтесь расположиться так, чтобы вам на лицо попадало достаточно света – это позволит слушателю следить за движениями губ. До начала разговора привлеките внимание человека. Постарайтесь избегать отвлекающих факторов, особенно громких шумов и фонового шума. Говорите членораздельно и неторопливо. Не повышайте голоса. Не прерывайте разговор с человеком, если для него затруднительно вас расслышать. В противном случае создается риск изоляции и возникает почва для появления депрессии. Эти стратегии могут принести пользу независимо от того, имеется ли у человека слуховой протез. 8.5 57 58 Термин «депрессивные симптомы» (или подавленное настроение) применяется в отношении пожилых людей, у которых на протяжении двух недель постоянно или большую часть времени отмечается одновременное наличие двух или более симптомов депрессии, однако они не удовлетворяют критериям постановки диагноза большого депрессивного расстройства. Депрессивные симптомы чаще наблюдаются у пожилых лиц с длительным течением расстройств здоровья, вызывающих функциональные ограничения, у лиц, находящихся в социальной изоляции, или лиц, осуществляющих уход, в связи с чем к ним предъявляется повышенная ответственность. Эти аспекты следует рассматривать как часть всеобъемлющего подхода к ведению депрессивных симптомов. Депрессивные симптомы являются важной составляющей психической жизни человека, однако это лишь один компонент. Существуют другие компоненты, такие как тревожность, характеристики личности, способность к совладанию и контролю, которым посвящены отдельные комплексные мероприятия. В данной главе приводятся рекомендации в отношении профилактики и ведения депрессивных симптомов у пожилых людей. Дальнейшие рекомендации по вмешательствам в связи с депрессией изложены в руководстве ВОЗ mhGAP (Комплекс основных мероприятий по психическому здоровью) https://apps.who. int/iris/handle/10665/250239 ОСНОВНЫЕ ПОЛОЖЕНИЯ Общинный медико-санитарный работник может задать ряд вопросов и при их помощи выявить лиц с депрессивными симптомами, а также отграничить депрессивные симптомы от депрессии. Применяя краткие структурированные психологические вмешательства, подготовленный и работающий под наблюдением медицинский работник- неспециалист может помочь лицам с депрессивными симптомами в условиях общины и в других условиях оказания первичной помощи. Депрессия требует всеобъемлющего и, как правило, специализированного подхода к лечению. Утрата других компонентов индивидуальной жизнеспособности, например, слуха или двигательной активности, может подорвать функциональную активность, снизить степень вовлеченности в общественную жизнь и способствовать развитию депрессивных симптомов. 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 59 Предложить краткие структурированные психологические вмешательства: – когнитивно-поведенческую терапию – консультирование или терапию, направленные на решение проблем – поведенческую активацию – реминисцентную терапию Мультимодальные упражнения Практику осознанного наблюдения * Пожилые люди пользуются различными формулировками для описания сниженного настроения, например, «грусть», «подавленность», «упадок». эмоциональный упадок, чувство подавленности или безнадежности?* Отсутствие интереса или удовольствия от своей деятельности? ? ? ДЕПРЕССИЯ (≥ 3 дополнительных симптомов) ДЕПРЕССИВНЫЕ СИМПТОМЫ (0–2 дополнительных симптома) ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ 9 НЕТ НЕТ (на любой из вопросов выше) (на все вопросы) ДАСхемы организации ухода для ведения депрессивных симптомов https://apps.who.int/iris/handle/10665/250239 Сохранить прежние рекомендации в отношении поддержания общего состояния здоровья и образа жизни или в отношении ухода Вы испытывали за последние две недели – Тяжелая утрата в предшествующие шесть месяцев – Наличие мании в анамнезе – Когнитивные нарушения – Потеря слуха – Нарушения зрения – Ограничение возможностей по причине болезни или травмы Пересмотреть лекарственные назначения антидепрессантов, антигистаминных средств и антипсихотиков Комплексное ведение соответствующих состояний Провести оценку и начать лечение боли – ПОЛИПРАГМАЗИЯ – АНЕМИЯ, НАРУШЕНИЯ ПИТАНИЯ, ГИПОТИРЕОЗ – БОЛЕВОЙ СИНДРОМ НЕТ 9.1 9.2 9.3 Снизить уровень стресса и усилить социальную поддержку Мотивировать пожилых людей к поддержанию двигательной активности и социальной включенности Пропагандировать поддержание активности через повседневный быт Стимулировать участие в общинных программах физических упражнений и развития навыков Выявить проблему одиночества и социальной изоляции и приступить к их решению (рассмотреть возможность вмешательств с применением технологических решений) ОЦЕНКА ЭМОЦИОНАЛЬНОГО СОСТОЯНИЯ 1 2 СОПУТСТВУЮЩЕЙ ПАТОЛОГИИ ОЦЕНКА И ВЕДЕНИЕ С СОЦИАЛЬНОЙ И ФИЗИЧЕСКОЙ СРЕДОЙ ОЦЕНКА И РАБОТА Приступить к лечению депрессии Пожилые люди с диагнозом большого депрессивного расстройства, как правило, нуждаются в специализированной помощи. Рекомендации и лечение для них должны быть предложены в соответствии с техническим руководством ВОЗ mhGAP. 9.4–9.7 СКРИНИНГ НА ПРЕДМЕТ ДЕПРЕССИВНЫХ СИМПТОМОВ ВОПРОС 6 Требуется специализированная помощь Рекомендации для систем и служб Механизм реализации концепции 12 * Эти вопросы содержатся в опроснике о состоянии здоровья пациента Patient Health Questionnaire (PHQ-9), который является одним из инструментов для оценки депрессивных симптомов. Кроме тогорекомендуется обратиться к разделу, посвященному депрессии, в техническом руководстве mhGAP, размещено по ссылке https://apps.who.int/iris/handle/10665/250239. КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ • Лечение депрессии требует более всеобъемлющего и, как правило, специализированного подхода к разработке индивидуального плана оказания помощи. • Для лечения депрессивных симптомов медицинским работникам требуется специальная подготовка в области кратких психологических вмешательств. • Ряд сопутствующих патологий, таких как гипотиреоз, могут потребовать постановки диагноза и лечения специалистом. • Трудности с засыпанием, сном или избыточно долгий сон. • Ощущение усталости или бессилия. • Снижение аппетита или избыточное потребление пищи. • Угрызения совести, ощущение собственной несостоятельности, ощущение, что вы выставили себя в невыгодном свете или подвели свою семью. • Трудности с концентрацией внимания, например, при чтении газеты или просмотре телевизора. • Заторможенность движений или речи, заметная для окружающих. • Суетливость и беспокойство, которые приводят к избыточной подвижности. • Желание умереть или каким-либо образом навредить себе. ОЦЕНКА ЭМОЦИОНАЛЬНОГО СОСТОЯНИЯ Если человек сообщает о наличии по меньшей мере одного из основных симптомов – ощущения эмоционального упадка, чувства подавленности или безнадежности, либо отсутствия интереса или удовольствия от своей деятельности, следует провести тщательную оценку эмоционального состояния. Человек может пользоваться другими формулировками в случае, если ему (ей) неизвестны формулировки, представленные в двух скрининговых вопросах выше. ДЕПРЕССИВНЫЕ СИМПТОМЫ Если у человека отмечается по меньшей мере один основной симптом и один или два дополнительных, можно говорить о наличии депрессивных симптомов. Если у человека отмечается более двух симптомов, это может соответствовать критериям депрессивного расстройства. Важно отличать депрессивные симптомы от депрессивного расстройства, поскольку лечение этих состояний различается. • Снижение когнитивных способностей и деменция могут иметь взаимосвязь с депрессивными симптомами, поэтому степень их выраженности также необходимо оценить. Лица с деменцией зачастую обращаются за медицинской помощью с жалобами на нарушения настроения или поведения, например, апатию, утрату эмоционального контроля или затруднения при выполнении обычных задач, при занятии домашними делами или при взаимодействии в обществе. • В то же самое время утрата других компонентов индивидуальной жизнеспособности, например, сенсорных функций или двигательной активности, может подорвать функциональную активность и снизить степень общественной вовлеченности, таким образом способствуя развитию депрессивных симптомов. • Мероприятия в связи с утратой других компонентов индивидуальной жизнеспособности, например, когнитивных способностей или слуха, могут оказаться более действенными, если их проводить одновременно с лечением депрессивных симптомов. Следует рассмотреть такую возможность при разработке индивидуальногоплана ухода. ВОПРОС: «Вы испытывали за последние две недели какую-либо из следующих проблем?»”* 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 61 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов Когнитивная поведенческая терапия Когнитивная поведенческая терапия основана на принципе о том, что на эмоциональную сферу человека влияют как верования, так и поведение. Лица с депрессивными симптомами (или диагностированными психическими расстройствами) могут страдать от не подтвержденных реальностью искаженных негативных представлений, которые, будучи оставленными без внимания, могут приводить к вредным для здоровья формам поведения. Таким образом, в когнитивной поведенческой терапии имеется когнитивный компонент: человеку предлагается развить способность выявлять и сомневаться в не подтвержденных реальностью негативных представлениях, а также поведенческий компонент: содействовать развитию полезных форм поведения и снижать проявления вредных. Этапы могут включать. (1) определение жизненных проблем, (2) осознание мыслей, эмоций и убеждений, относящихся к этим проблемам, (3) определение негативных или недостоверных представлений, (4) перенаправление представлений в более реалистичное русло. Консультирование или терапия, направленная на решение проблем У лиц, страдающих от депрессивных симптомов, дистресса или нарушений социального функционирования той или иной степени, необходимо рассмотреть возможность применения подхода, ориентированного на решение проблем (в отсутствие установленного диагноза депрессивного эпизода или расстройства). В рамках терапии, направленной на решение проблем, человеку предлагается непосредственная и практическая помощь. Медицинский работник, выступающий в роли терапевта, и пожилой человек совместно выявляют и анализируют основные поводы для беспокойства, которые подпитывают существование депрессивных симптомов. Намечая пути решения конкретных проблем и подбирая стратегии совладающего поведения, они стремятся сообща представить эти поводы как серию конкретных посильных задач. ВЕДЕНИЕ ДЕПРЕССИВНЫХ СИМПТОМОВ 9.1 КРАТКИЕ СТРУКТУРИРОВАННЫЕ ПСИХОЛОГИЧЕСКИЕ ВМЕШАТЕЛЬСТВА Краткие структурированные психологические вмешательства, такие как когнитивная поведенческая терапия, подходы, нацеленные на решение проблем, поведенческая активация и реминисцентная терапия, могут значительно снизить выраженность депрессивных симптомов у пожилых людей. Мультимодальные упражнения и практика осознанного наблюдения также могут снизить выраженность депрессивных симптомов. При условии разрешения и согласия пожилого человека могут выполняться разнообразные психологические вмешательства с учетом проблемных аспектов, таких как затруднения в решении проблем. Следует рассмотреть возможность дополнения структурированных психологических вмешательств физическими упражнениями ввиду благотворного воздействия физических упражнений на настроение (см. Главу 5, посвященную ограничениям двигательной активности). Не рекомендуется назначение антидепрессантов в условиях первичного звена врачами, не имеющими специальных познаний в психиатрии. 5 Как правило, такие вмешательства проводятся медицинскими работниками, подготовленными в области психиатрии. Общинные медико-санитарные работники также могут осуществлять подобные вмешательства при условии достаточных навыков и подготовки в сфере расстройств психического здоровья у пожилых. Не выявлено вреда от осуществления подобных вмешательств. 62 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 5 9.2 МУЛЬТИМОДАЛЬНЫЕ ФИЗИЧЕСКИЕ УПРАЖНЕНИЯ В краткосрочной перспективе и, возможно, в долгосрочной перспективе выраженность депрессивных симптомов может быть снижена за счет программы физических упражнений, подобранных индивидуально, сообразно физическим возможностям и предпочтениям человека. См. Главу 5, посвященную проблемам нарушения двигательной активности. 9.3 ПРАКТИКА ОСОЗНАННОГО НАБЛЮДЕНИЯ Осознанное наблюдение предполагает внимание к событиям настоящего вместо упорных размышлений о прошлом, будущем, собственных желаниях, своей ответственности или поводах для личного сожаления. Последнее может увлечь человека с депрессивными симптомами в своеобразный эмоциональный штопор. Существует множество разновидностей практики осознанного наблюдения. Широко распространена практика, когда пациент сидит или лежит в спокойном состоянии и концентрируется на своих ощущениях или дыхании. Осознание физического движения при выполнении упражнений йоги или прогулке также помогает некоторым людям. Поведенческая активация Поведенческая активация предполагает стимулирование участия человека в мотивирующей деятельности как способ снизить выраженность депрессивных симптомов. Этот подход удается освоить быстрее, чем любые другие основанные на доказательных данных психологические вмешательства. Неспециалисты могут освоить этот подход, тем самым увеличивая доступность помощи при депрессивных симптомах. Данное вмешательство изучалось преимущественно в контексте его проведения специалистами на протяжении серии сеансов. Возможно, данное вмешательство может быть преобразовано в краткую модификацию, проводимую подготовленными медицинскими работниками в качестве дополнительного терапевтического мероприятия или в составе первого этапа помощи при ее оказании согласно принципам всеобъемлющего подхода в первичном звене. Реминисцентная терапия Реминисцентная терапия предполагает припоминание и оценку человеком своего прошлого под руководством терапевта с целью достижения чувства умиротворенности и принятия опыта жизни. Этот вид терапии позволяет увидеть собственный жизненный опыт в широком контексте и с новой силой вспомнить о друзьях и близких людях. Реминисцентная терапия может помочь в лечении депрессии у пожилых людей, а также помочь людям, находящимся на конечной стадии жизни. В ходе реминисцентной терапии терапевт может делать акцент на теме общечеловеческих ценностей либо адресоваться к воспоминаниям об определенных периодах жизни человека, например, когда тот был ребенком, родителем, дедушкой или бабушкой либо активно работал. 63 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов ОЦЕНКА И РАБОТА С АССОЦИИРОВАННЫМИ РАССТРОЙСТВАМИ • Потеря слуха. Пожилые люди с потерей слуха зачастую могут предъявлять жалобы на неловкость, тревожность и снижение самооценки, при этом они неохотно включаются в социальную и физическую активность, в связи с чем развивается социальная изоляция и одиночество, а в конечном итоге – депрессия (15). • Нарушения зрения и наличие серьезных возрастных заболеваний глаз, таких как возрастная дегенерация макулы и глаукома, сопряжены с повышенным риском развития депрессии (16). Лица с нарушением функции органа зрения зачастую предъявляют жалобы на тягостные ощущения, чувство одиночества или безнадежности. • Реакция на ограничение возможностей по причине болезни или травмы. Депрессия часто развивается вторично у лиц с ограниченными возможностями. Лица с ограниченными возможностями по причине заболеваний или травм испытывают стресс; кроме того, им приходится мириться с изменениями привычного жизненного уклада. Этапы адаптации к ограничению возможностей включают потрясение, отрицание, злобу/депрессию и адаптацию/принятие. У пожилых людей с недавно возникшим ограничением возможностей существует риск возникновения тревожности и депрессии. Наличие следующих ассоциированных расстройств означает необходимость особого подхода к лечению депрессии. • Тяжелая утрата в предшествующие шесть месяцев. • Наличие мании в анамнезе. Мания – это эпизод приподнятого настроения, повышенной энергичности и активности. В случае, если маниакальные эпизоды имели место ранее, такое состояние классифицируется как биполярное расстройство. Анамнез мании выявляется при опросе на предмет одновременного наличия ряда симптомов продолжительностью не менее недели, степень выраженности которых создает значительные препятствия для трудовой деятельности и социальной активности или требует госпитализации, либо помещения в изолятор (см. руководство ВОЗ mhGAP (Комплекс основных мероприятий по психическому здоровью https://www.paho.org/mhgap/en/ bipolar_flowchart.html). • Снижение когнитивных способностей. Взаимосвязь депрессии и снижения когнитивных способностей сложна. В эпидемиологических исследованиях на протяжении длительного времени прослеживают связь депрессии с развитием болезни Альцгеймера. При депрессии страдают такие когнитивные функции, как внимание, обучаемость и зрительная память наряду с исполнительными функциями. Депрессия может стать психологическим ответом индивидуума на имеющиеся у него и известные ему легкие когнитивные нарушения, интенсивность которых мала и не препятствует повседневной активности. 64 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов 9.6 ГИПОТИРЕОЗ Гипотиреоз является частой патологией у пожилых людей, в особенности у женщин. Симптомы гипотиреоза могут быть неспецифичными и различаться у разных людей, тем не менее, они могут включать в себя симптомы депрессии. Оценка и ведение гипотиреоза должны производиться медицинскими работниками, обладающими специальными познаниями. 9.7 БОЛЬ Лица, предъявляющие жалобы на хроническую боль, чаще страдают от депрессивных симптомов. Необходимо проводить оценку выраженности и проводить лечение боли (см. Главу 5, посвященную проблемам ограничения двигательной активности). 9.4 ПОЛИПРАГМАЗИЯ Полипрагмазия может приводить к возникновению депрессивных симптомов, которые, в свою очередь, могут вызывать полипрагмазию. Разорвать порочный круг можно только одновременно решая проблему полипрагмазии и депрессивных симптомов. Взаимосвязь с депрессивными симптомами существует не только у препаратов с точкой приложения в центральной нервной системе, но и у препаратов, обладающих психотропными свойствами, таких как антигистаминные и антипсихотические средства, миорелаксанты и другие непсихотропные препараты с антихолинергическими свойствами. Выраженность полипрагмазии можно снизить за счет исключения ненужных, неэффективных препаратов, а также препаратов, которые дублируют действие друг друга. 9.5 АНЕМИЯ, НАРУШЕНИЯ ПИТАНИЯ По причине недостатка витаминов – фолата, витаминов В6 и В12, анемия и нарушения питания могут приводить к возникновению депрессивных симптомов. Депрессивные симптомы также могут играть роль в развитии анемии. Способствовать возникновению анемии и нарушений питания может снижение аппетита и утрата интереса к повседневной активности (например, к совершению покупок и приготовлению пищи), в связи с чем может ухудшаться качественный и количественный состав рациона пожилого человека. Для ведения симптомов депрессии важно принимать меры по поводу анемии и улучшать состояние питания (см. Главу 6, посвященную проблемам нарушения питания). 5 6 65 9 ПСИХОЛОГИЧЕСКИЕ ВОЗМОЖНОСТИ Схемы организации ухода для ведения депрессивных симптомов ОЦЕНКА И РАБОТА С СОЦИАЛЬНЫМ И ФИЗИЧЕСКИМ ОКРУЖЕНИЕМ Члены семьи и лица, осуществляющие уход, могут обратить особое внимание на профилактику социальной изоляции в случае, если пожилые люди страдают от снижения физических возможностей, например, потери слуха или ограничения способности к движению. Социальная изоляция может приводить к возникновению депрессивных симптомов. Для профилактики одиночества следует рассмотреть возможность реализации мер с использованием различных технологий, например, мобильных телефонов или сети Интернет. При депрессии характерна утрата интереса к видам деятельности, которые ранее вызывали интерес или удовольствие. Члены семьи и лица, осуществляющие уход, могут осторожно поощрять и содействовать включению пожилых людей в физическую активность и общественную жизнь, например, в общинные программы физических упражнений и развития навыков. 66 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА Люди со значительной утратой индивидуальной жизнеспособности могут вести достойную жизнь только при условии помощи, поддержки и содействия со стороны других лиц. Доступность социальной помощи и поддержки играет главенствующую роль в обеспечении достойной и полноценной жизни. Социальная помощь и поддержка состоят не только в содействии в повседневном быту и самообслуживании, но и в обеспечении доступа к объектам общественного пользования и государственным службам, снижении степени изоляции и одиночества, помощи в вопросах финансовой безопасности, обеспечении жильем надлежащего качества, свободе от притеснений и злоупотреблений, а также в участии в видах деятельности, которые наполняют жизнь смыслом. Вопрос о потребностях пожилого человека в социальной помощи и поддержке следует адресовать разным людям в зависимости от специфики вопроса. В случае, если пожилой человек страдает от снижения когнитивных способностей, вопросы, касающиеся повседневного быта и финансов, лучше всего задавать людям, хорошо знающим пожилого человека, например членам семьи, лицам, осуществляющим уход, или друзьям. ОСНОВНЫЕ ПОЛОЖЕНИЯ Утрата функциональной способности часто наблюдается среди пожилых людей, особенно среди тех, у кого отмечают снижение индивидуальной жизнеспособности, однако такая утрата не является неизбежной. Общинные медико-санитарные работники могут проводить скрининг на предмет снижения функциональных способностей при помощи простого вопросника. Мероприятия, разработанные в соответствии с приоритетами пожилого человека, могут повысить функциональные способности. К числу эффективных относятся те мероприятия, которые повышают уровень индивидуальной жизнеспособности, функциональной способности и содействуют получению социальной помощи и поддержки. 67 Схемы организации ухода, направленные на оказание социальной помощи и поддержки A B СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА 10 1. Вы испытываете трудности при передвижении в пределах помещения? 2. Вы испытываете трудности при пользовании туалетом (или стулом-туалетом)? 3. Вы испытываете трудности при одевании? 4. Вы испытываете трудности при пользовании ванной или душем? 5. Вы испытываете трудности с поддержанием опрятного внешнего вида? 6. Вы испытываете трудности с приемом пищи? 7. Вы испытываете трудности, связанные с местом вашего проживания (жильем)? 8. Вы испытываете финансовые трудности? 9. Вы чувствуете себя одиноким? ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОМОЩИ И ПОДДЕРЖКЕ СОДЕЙСТВИЕ В УДОВЛЕТВОРЕНИИ ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОМОЩИ (ЛИЧНАЯ ПОМОЩЬ) ОЦЕНКА ДА ДА Провести оценку и усовершенствовать условия физической среды с целью компенсации снижения индивидуальной жизнеспособности, повышения возможностей двигательной активности и профилактики падений Следует рассмотреть вопрос о применении ассистивных технологий, средств и приспособлений Рассмотреть возможность оказания помощи супругом, членом семьи или другими лицами, осуществляющими уход на безвозмездной основе, и включить результаты оценки потребностей лица, осуществляющего уход Изучить вопрос о необходимости помощи со стороны лиц, осуществляющих уход на возмездной основе Необходима доступность помощи со стороны лиц, осуществляющих уход, и соответствующих служб, например, помощь на дому, дневной уход, дом престарелых ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ Представляет ли для вас проблему: 1. Безопасность и физическая безопасность места вашего проживания? 2. Состояние вашего жилища? 3. Расположение вашего жилища? 4. Издержки на проживание? 5. Ремонт и эксплуатация жилища? 6. Независимое проживание в жилище? Рассмотреть вопрос: – переоборудования жилья – подбора альтернативного жилья – помощи по линии программ социального обеспечения или предоставления коммунального жилья, либо существующих сетей поддержки ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ 1. Каково ваше финансовое положение в конце месяца? 2. Вам удается распоряжаться средствами и решать финансовые вопросы? 3. Вам необходима консультация в отношении денежных пособий или льгот? ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ ДЛЯ ВЫЯВЛЕНИЯ ТРУДНОСТЕЙ: Вы не занимаетесь этим видом деятельности (...), потому что препятствием служит: 1. стоимость, 2. удаленность, 3. транспортная доступность, 4. отсутствие возможности, 5 другие причины? Предоставьте список услуг, доступных для пожилых людей на уровне местной общины, например, услуги досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских организаций и центров занятости Поощряйте пользование этими услугами с целью более активного участия пожилого человека в общественной жизни Рассмотреть возможности более интенсивного: – налаживания социальных взаимосвязей (супруги, члены семьи, друзья, питомцы) – использования местных ресурсов общины (клубы, религиозные группы, дневные центры, спортивные, досуговые, образовательные центры) – участия в общественной жизни (волонтерство, трудоустройство) – общения с применением технологий связи Рассмотреть вопрос: – о предоставлении специализированной консультации в области финансов – о предоставлении консультации по делегированию процесса принятия финансовых решений с защитой от финансового обмана При выявлении непосредственной угрозы – направить на консультацию по линии системы социальной работы, защиты взрослых или правоохранительных органов ВОПРОС ДА НЕТ ДА ДА Опираясь на данные наблюдений за поведением пожилого человека, поведением членов его семьи или родственников, а также обращая внимание на признаки физического насилия, следует выявлять случаи жестокого обращения. 10. Вы занимаетесь какой-либо важной для себя деятельностью на досуге, хобби, работой, волонтерством, помощью семье, образованием или духовной практикой? 11. Оценить риск жестокого обращения с пожилыми людьми 1 Рекомендации для систем и служб Механизм реализации концепции Схемы организации ухода, направленные на оказание социальной помощи и поддержки A B СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА 10 1. Вы испытываете трудности при передвижении в пределах помещения? 2. Вы испытываете трудности при пользовании туалетом (или стулом-туалетом)? 3. Вы испытываете трудности при одевании? 4. Вы испытываете трудности при пользовании ванной или душем? 5. Вы испытываете трудности с поддержанием опрятного внешнего вида? 6. Вы испытываете трудности с приемом пищи? 7. Вы испытываете трудности, связанные с местом вашего проживания (жильем)? 8. Вы испытываете финансовые трудности? 9. Вы чувствуете себя одиноким? ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОМОЩИ И ПОДДЕРЖКЕ СОДЕЙСТВИЕ В УДОВЛЕТВОРЕНИИ ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОМОЩИ (ЛИЧНАЯ ПОМОЩЬ) ОЦЕНКА ДА ДА Провести оценку и усовершенствовать условия физической среды с целью компенсации снижения индивидуальной жизнеспособности, повышения возможностей двигательной активности и профилактики падений Следует рассмотреть вопрос о применении ассистивных технологий, средств и приспособлений Рассмотреть возможность оказания помощи супругом, членом семьи или другими лицами, осуществляющими уход на безвозмездной основе, и включить результаты оценки потребностей лица, осуществляющего уход Изучить вопрос о необходимости помощи со стороны лиц, осуществляющих уход на возмездной основе Необходима доступность помощи со стороны лиц, осуществляющих уход, и соответствующих служб, например, помощь на дому, дневной уход, дом престарелых ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ Представляет ли для вас проблему: 1. Безопасность и физическая безопасность места вашего проживания? 2. Состояние вашего жилища? 3. Расположение вашего жилища? 4. Издержки на проживание? 5. Ремонт и эксплуатация жилища? 6. Независимое проживание в жилище? Рассмотреть вопрос: – переоборудования жилья – подбора альтернативного жилья – помощи по линии программ социального обеспечения или предоставления коммунального жилья, либо существующих сетей поддержки ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ 1. Каково ваше финансовое положение в конце месяца? 2. Вам удается распоряжаться средствами и решать финансовые вопросы? 3. Вам необходима консультация в отношении денежных пособий или льгот? ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ ДЛЯ ВЫЯВЛЕНИЯ ТРУДНОСТЕЙ: Вы не занимаетесь этим видом деятельности (...), потому что препятствием служит: 1. стоимость, 2. удаленность, 3. транспортная доступность, 4. отсутствие возможности, 5 другие причины? Предоставьте список услуг, доступных для пожилых людей на уровне местной общины, например, услуги досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских организаций и центров занятости Поощряйте пользование этими услугами с целью более активного участия пожилого человека в общественной жизни Рассмотреть возможности более интенсивного: – налаживания социальных взаимосвязей (супруги, члены семьи, друзья, питомцы) – использования местных ресурсов общины (клубы, религиозные группы, дневные центры, спортивные, досуговые, образовательные центры) – участия в общественной жизни (волонтерство, трудоустройство) – общения с применением технологий связи Рассмотреть вопрос: – о предоставлении специализированной консультации в области финансов – о предоставлении консультации по делегированию процесса принятия финансовых решений с защитой от финансового обмана При выявлении непосредственной угрозы – направить на консультацию по линии системы социальной работы, защиты взрослых или правоохранительных органов ВОПРОС ДА НЕТ ДА ДА Опираясь на данные наблюдений за поведением пожилого человека, поведением членов его семьи или родственников, а также обращая внимание на признаки физического насилия, следует выявлять случаи жестокого обращения. 10. Вы занимаетесь какой-либо важной для себя деятельностью на досуге, хобби, работой, волонтерством, помощью семье, образованием или духовной практикой? 11. Оценить риск жестокого обращения с пожилыми людьми 1 Рекомендации для систем и служб Механизм реализации концепции Медицинским работникам следует знать порядок направления пожилых людей на специализированную консультацию. В зависимости от доступности ресурсов протоколы направления различаются. В ряде случаев адекватной заменой социальному работнику может стать, например, глава деревенской общины, директор школы, монах или лидер религиозной группы. Важно регулярное проведение встреч с целью укрепления доверия среди специалистов и представителей служб, поскольку комплексное оказание социальной помощи и поддержки требует работы сразу по многим направлениям. Ниже приведен ряд сфер компетенции различных специалистов, занимающихся уходом за пожилыми людьми. • Жилищные условия: жилищные службы, социальный работник, трудотерапевт. • Финансовые вопросы: социальный работник, службы консультирования по вопросам пособий и льгот. КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ • Проблема одиночества: социальный работник, волонтер, врач первичного звена. • Участие в общественной жизни: социальный работник, службы организации досуга, службы занятости, волонтерские организации. • Проблема жестокого обращения: социальный работник, специалист по защите взрослых, правоохранительные органы. • Повседневный быт: трудотерапевт, социальный работник, медицинская сестра или мультидисциплинарная бригада специалистов в области помощи пожилым. • Передвижение в пределах помещения: физиотерапевт, трудотерапевт, социальный работник или мультидисциплинарная бригада специалистов в области помощи пожилым. • Передвижение на улице: физиотерапевт, социальный работник, волонтерские службы транспорта. ПОВЕДЕНИЕ ПОЖИЛОГО ЧЕЛОВЕКА • Создается впечатление, что пожилой человек опасается родственника или лица, осуществляющего профессиональный уход. • Отказывается отвечать на вопросы или беспокойно оглядывается на лицо, осуществляющее уход/родственника, прежде чем ответить. • Поведение пожилого человека меняется, когда лицо, осуществляющее уход/родственник, входит в кабинет или удаляется. • Описывает поведение лица, осуществляющего уход, понятиями наподобие «волевой человек» или «устает», «имеет дурной нрав», либо рассказывает о раздражительности/тревожности/стрессах или вспыльчивости лица, осуществляющего уход. • Преувеличенно вежлив или излишне почтителен в отношении лица, осуществляющего уход. ПОВЕДЕНИЕ ЛИЦА, ОСУЩЕСТВЛЯЮЩЕГО УХОД/РОДСТВЕННИКА • Препятствует или не позволяет специалисту беседовать с пожилым человеком наедине, либо постоянно стремится прервать ход беседы (например, регулярно заглядывая в кабинет). 1 • Настаивает на самостоятельном ответе на вопросы, адресованные пожилому человеку. • Препятствует оказанию помощи пожилому человеку на дому. • Выражает явную неудовлетворенность необходимостью осуществлять уход за пожилым человеком. • Пытается убедить специалистов в том, что пожилой человек «не в своем уме» или страдает деменцией, либо не осознает того, о чем говорит, по причине спутанности сознания в условиях, когда это не так. • Демонстрирует враждебность, усталость или нетерпение в ходе беседы, при этом пожилой человек в присутствии такого лица пребывает в состоянии крайнего беспокойства или безразличия. ФИЗИЧЕСКОЕ НАСИЛИЕ • Порезы, ожоги, синяки и царапины. • Повреждения, явно вызванные иным механизмом, чем предложенный в объяснении. • Повреждения, случайное возникновение которых маловероятно. НАБЛЮДАЕМЫЕ ПРИЗНАКИ ВОЗМОЖНОГО ФАКТА ЖЕСТОКОГО ОБРАЩЕНИЯ С ПОЖИЛЫМИ • Повреждения и раны на участках тела, закрытых одеждой. • Синяки в форме следов от пальцев, остающиеся после жесткого захвата (часто в области плеча). • Повреждения в интимной области, например, в зоне подмышек. • Необработанные повреждения. • Множественные повреждения на разных стадиях заживления. • Избыточное или недостаточное применение лекарственных средств. 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА 69 ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ ДЛЯ ВЫЯВЛЕНИЯ ТРУДНОСТЕЙ: Вы не занимаетесь этим видом деятельности (...), потому что препятствием служит: 1. стоимость, 2. удаленность, 3. транспортная доступность, 4. отсутствие возможности, 5 другие причины? Предоставьте список услуг, доступных для пожилых людей на уровне местной общины, например, услуги досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских организаций и центров занятости Поощряйте пользование этими услугами с целью более активного участия пожилого человека в общественной жизни 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА ОЦЕНКА И УДОВЛЕТВОРЕНИЕ ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОДДЕРЖКЕ 10.1 ОЦЕНКА И УДОВЛЕТВОРЕНИЕ ПОТРЕБНОСТЕЙ В САМООБСЛУЖИВАНИИ И ПОМОЩИ В БЫТОВЫХ НУЖДАХ (РАЗДЕЛ СХЕМЫ УХОДА) Предположение о том, что человек не может самостоятельно обслуживать себя без посторонней помощи, делается на основании ответов на шесть вопросов. Подобная оценка пойдет на пользу пожилому человеку со значительным снижением индивидуальной жизнеспособности. Нахождение в помещении предполагает целый ряд действий, например перемещение с кровати на стул, передвижение шагом, посещение туалета, пользование туалетом и пользование лестницей. Ограничение подвижности увеличивает риски и влечет за собой потребность в помощи при самообслуживании. Одевание, прием пищи, прием ванной и гигиенические процедуры относятся к повседневному быту. Неспособность самостоятельно справляться с повседневным бытом влечет за собой потребность в помощи при самообслуживании. Многие пожилые люди не хотят полагаться на постороннюю помощь в повседневном быту, предпочитая справляться с этими задачами самостоятельно. Для пожилых людей, испытывающих затруднения в повседневном быту и(или) имеющих расстройства двигательной активности, окажется полезной программа реабилитации. Такая программа может быть нацелена на укрепление физических возможностей, а также может предполагать использование ассистивных технологий и внесение изменений в окружающую обстановку с целью оптимизации функциональной способности несмотря на ограничения индивидуальной жизнеспособности. Транспортные службы могут помочь улучшить мобильность человека вне дома. При сохраняющихся трудностях следует рассмотреть возможность предоставления помощи членами семьи и другими лицами, осуществляющими безвозмездный уход, с учетом их собственных потребностей. При необходимости более полной поддержки следует воспользоваться услугами ухода на дому, которые оказывают волонтерские, частные или государственные службы. 10.2 ОЦЕНКА И УДОВЛЕТВОРЕНИЕ ПОТРЕБНОСТЕЙ В СОЦИАЛЬНОЙ ПОДДЕРЖКЕ (РАЗДЕЛ «В» СХЕМЫ ОРГАНИЗАЦИИ УХОДА) Пожилым людям пойдет на пользу оценка потребностей в социальной поддержке вне зависимости от уровня индивидуальной жизнеспособности и функциональной способности. Обеспечение социальной поддержки позволяет пожилому человеку выполнять важные для него задачи. Имеется в виду содействие в поддержании соответствующего состояния жилища, финансовой безопасности, преодолении состояния одиночества, доступе к объектам общественного пользования и государственным службам, а также защита от жестокого обращения. B7 ЖИЛИЩНЫЕ УСЛОВИЯ Место проживания пожилого человека может влиять на его состояние здоровья, независимость и благополучие. Проблемы могут быть связаны со многими аспектами, включая площадь жилого помещения, доступ к нему, его состояние, эксплуатационную и физическую безопасность. При помощи дополнительных вопросов можно выявить конкретные проблемные аспекты. 70 ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ ДЛЯ ВЫЯВЛЕНИЯ ТРУДНОСТЕЙ: Вы не занимаетесь этим видом деятельности (...), потому что препятствием служит: 1. стоимость, 2. удаленность, 3. транспортная доступность, 4. отсутствие возможности, 5 другие причины? Предоставьте список услуг, доступных для пожилых людей на уровне местной общины, например, услуги досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских организаций и центров занятости Поощряйте пользование этими услугами с целью более активного участия пожилого человека в общественной жизни 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА B9 ОДИНОЧЕСТВО Проблема одиночества часто встречается в пожилом возрасте и связана с большей вероятностью развития депрессии и ранней смерти. См. Главу 9, посвященную рекомендациям по скринингу для выявления депрессивных симптомов. Отдельное проживание и одиночество – разные понятия: пожилой человек может испытывать одиночество даже находясь в кругу других людей, например, если взаимоотношения с ними не прочны. Полезно узнать у пожилого человека, удается ли ему скрасить одиночество за счет более частого социального контакта с членами семьи и друзьями, встреч с людьми схожих интересов. Тем не менее, стараясь развеять возможные страхи, связанные с откровенностью на тему личных взаимоотношений, при подобных вопросах следует заверить пожилого человека в конфиденциальном характере вопроса. Многие пожилые люди имеют домашних питомцев, за счет чего справляются с одиночеством. Следует поощрять посещение местных объектов общественного пользования, например клубов, религиозных групп, дневных центров, спортивных, досуговых или образовательных учреждений. Кроме того, различные варианты содействия могут оказать волонтеры и наемные работники. Нарастить степень социальных взаимосвязей можно за счет коммуникационных технологий. Стремясь решить проблему одиночества, следует изучить результативность всех этих мер в совокупности. Лицам, производящим оценку, должен быть известен спектр доступных на местном уровне возможностей. Смягчить проблемы, связанные с жилищными условиями, можно за счет внедрения новых мер безопасности, предоставления телефонного номера для обращения в неотложных ситуациях и введения усовершенствований для обеспечения независимого проживания. На цели оплаты проживания, ремонта и эксплуатации могут предоставляться пособия. В крайнем случае следует рассмотреть вопрос о переезде в более подходящее жилище. B8 ФИНАНСЫ Финансовые ресурсы и состояние здоровья, независимость и благополучие в пожилом возрасте существенно взаимосвязаны. Почвой для возможных проблем может становиться недостаток денежных средств на удовлетворение базовых нужд или для полноценного участия в общественной жизни, при этом пожилого человека может беспокоить вероятная нехватка денег или вероятная неспособность ими распоряжаться. При помощи дополнительных вопросов можно выявить конкретные проблемные аспекты. Снизить остроту финансовых проблем можно за счет независимого консультирования по финансовому планированию и управлению финансовыми средствами. При условии обеспечения соответствующей юридической защиты от финансового обмана управление финансовыми средствами может быть делегировано доверенному третьему лицу. 71 ДОПОЛНИТЕЛЬНЫЕ ВОПРОСЫ ДЛЯ ВЫЯВЛЕНИЯ ТРУДНОСТЕЙ: Вы не занимаетесь этим видом деятельности (...), потому что препятствием служит: 1. стоимость, 2. удаленность, 3. транспортная доступность, 4. отсутствие возможности, 5 другие причины? Предоставьте список услуг, доступных для пожилых людей на уровне местной общины, например, услуги досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских организаций и центров занятости Поощряйте пользование этими услугами с целью более активного участия пожилого человека в общественной жизни 10 Схемы организации ухода, направленные на оказание социальной помощи и поддержки СОЦИАЛЬНАЯ ПОМОЩЬ И ПОДДЕРЖКА B10 СОЦИАЛЬНАЯ ВОВЛЕЧЕННОСТЬ И УЧАСТИЕ В ОБЩЕСТВЕННОЙ ЖИЗНИ В основе концепции ICOPE лежит принцип содействия пожилым людям в том, что они находят для себя важным. То, что имеет значимость для пожилого человека, раскрывается в его образе жизни, приоритетах и предпочтениях, и знание об этом может помочь в нахождении способов привлечения к более активному участию в общественной жизни. Примерами участия в общественной жизни являются досуговая деятельность, хобби, работа, обучение и духовные практики. Приоритеты и важные аспекты жизни будут очень разными и очень специфичными для пожилых людей, ведь каждый из них уникален. О таких приоритетах следует осведомляться при составлении индивидуального плана ухода, документально их фиксировать и руководствоваться ими. Желая узнать о вероятных препятствиях, например по цене, доступности, возможности участия, следует задать дополнительные вопросы. Лицо, производящее оценку, должно располагать сведениями о доступности местных досуговых центров и клубов, образовательных учреждений для взрослых, волонтерских услуг и консультативных услуг в области трудоустройства, и предметно обсуждать с пожилым человеком возможную потребность в них. Серьезным препятствием может стать транспортная доступность, и для решения этой проблемы могут существовать специализированные услуги. Некоторые из таких услуг могут быть платными, и их субсидирование может помочь пожилым людям и людям с низким уровнем дохода активнее участвовать в общественной жизни. B11 ЖЕСТОКОЕ ОБРАЩЕНИЕ С ПОЖИЛЫМИ ЛЮДЬМИ Многие пожилые люди, нуждающиеся в посторонней помощи, подвержены риску жестокого обращения, и становятся его жертвами в той или иной форме примерно в одном случае из шести. Формы жестокого обращения многообразны и включают пренебрежительное отношение, психологическое насилие, физическое насилие, сексуальные надругательства и финансовый обман . Выявлять случаи жестокого обращения следует, опираясь на данные наблюдений за поведением пожилого человека, поведением членов его семьи или родственников, а также обращая внимание на признаки физического насилия. При подозрении на проявления насилия потребуется оценка и помощь специалиста. Пожилого человека будет необходимо проинформировать о предмете вашей обеспокоенности, а затем запросить помощь специалиста. Следует документально зафиксировать поводы для вашей обеспокоенности, а также факт информирования пожилого человека о запросе помощи у специалиста. При выявлении непосредственной угрозы следует обратиться за специализированной помощью по линии системы социального обслуживания, защиты взрослых или правоохранительных органов. 72 11 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Схемы организации помощи лицам, осуществляющим уход Страдая от снижения индивидуальной жизнеспособности и функциональной способности, человек начинает нуждаться в посторонней помощи, при этом уход за ним зачастую ложится на плечи супругов, кого-либо из членов семьи или других людей в домохозяйстве. При определенном уровне потребностей пожилого человека бремя ухода за ним может создавать риск для благополучия лиц, осуществляющих уход. Контроль за благополучием лиц, осуществляющих уход, а также за тем, получают ли они достаточный объем помощи в связи с состоянием собственного здоровья и в связи с уходом за пожилым человеком может осуществляться медицинским работником или общинным медико- санитарным работником. ОСНОВНЫЕ ПОЛОЖЕНИЯ Уход за пожилым человеком со снижением индивидуальной жизнеспособности и функциональной способности создает тяготы и стресс для членов семьи и друзей, которые берут на себя роль лиц, осуществляющих уход, что может подрывать состояние их собственного здоровья. Кроме того, подобная деятельность может препятствовать, особенно в случае женщин, выполнению оплачиваемой работы. Выявление пожилых людей со снижением физических возможностей требует одновременного выявления тех лиц из числа осуществляющих уход, которые сами нуждаются в помощи. Содействовать поддержанию удовлетворительных и здоровых отношений лица, осуществляющего уход, и пожилого человека призван ряд мероприятий: временный уход на период отдыха лица, осуществляющего уход, консультативная поддержка, просветительская работа и финансовая поддержка. Случается так, что уход за пожилым человеком начинает приобретать оттенки жестокого обращения. Признаки жестокого обращения может выявить патронажный работник при оценке состояния здоровья пожилого человека или лица, осуществляющего уход. В этом случае потребуется направление на консультацию специалиста. 73 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД 11 ДА ДА ДА Схемы организации помощи лицам, осуществляющим уход ВОПРОС ВОПРОС Вы испытывали за последние две недели: – эмоциональный упадок, чувство подавленности или безнадежности? – отсутствие интереса или удовольствия от своей деятельности? ВОПРОС Исполняя обязанности по уходу, вы сталкиваетесь с потерей доходов и (или) несете дополнительные траты в связи с осуществлением ухода? ПОВТОРНАЯ ОЦЕНКА КАЖДЫЕ 6 МЕСЯЦЕВ ОЦЕНКА ЭМОЦИОНАЛЬНОГО СОСТОЯНИЯ ЛИЦА, ОСУЩЕСТВЛЯЮЩЕГО УХОД Рассмотреть вопрос о содействии лицу, осуществляющему уход, через посредство обучения, психологического консультирования, наставничества, организации временного ухода за пожилым человеком на период отдыха лица, осуществляющего уход, например, в центре дневного ухода, привлечения ресурсов общины для оказания помощи, организации сети поддержки (возможные способы представлены в системе iSupport по ссылке https://www.isupportfordementia.org) Рассмотреть возможности финансовой поддержки на местном уровне Упрочить взаимодействие с официальными системами оказания долгосрочной помощи и системами поддержки на уровне общин, например, с волонтерскими ассоциациями Сказывается ли отрицательно на вашей жизни исполнение обязанностей по уходу за (...)? Исполняя обязанности по уходу, вы чувствуете нехватку поддержки? ? ? (при ответе на любой из вопросов) (при ответе на любой из вопросов) НЕТ НЕТ НЕТ ДА Приступить к ведению депрессии: см. Техническое руководство mhGAP https://apps.who.int/iris/handle/10665/250239 НЕТ 1 (при ответе на оба вопроса) Требуется специализированная помощь Предпринять попытку разрешения проблемного вопроса путем содействия и психовоспитания Провести психологическое консультирование, направленное на решение проблем Провести когнитивно-поведенческую терапию Рекомендации для систем и служб Механизм реализации концепции 11• При лечении депрессии. • При организации психологического консультирования, направленного на решение проблем, или когнитивной поведенческой терапии для страдающих депрессивными симптомами лиц, осуществляющих уход. • При подозрении на наличие элементов жестокого обращения во взаимоотношениях. КОГДА ТРЕБУЮТСЯ СПЕЦИАЛЬНЫЕ ПОЗНАНИЯ В случае, если человек сообщает о наличии по меньшей мере одного из основных симптомов – ощущения эмоционального упадка, чувства подавленности или безнадежности, либо отсутствия интереса или удовольствия от своей деятельности, – следует провести тщательную оценку эмоционального состояния. Человек может пользоваться другими формулировками в случае, если ему (ей) неизвестны формулировки, представленные в двух скрининговых вопросах выше. ВОПРОС: «Вы испытывали за последние две недели какую-либо из следующих проблем?»* • Трудности с засыпанием, сном или избыточно долгий сон. • Ощущение усталости или бессилия. • Снижение аппетита или избыточное потребление пищи. • Угрызения совести, ощущение собственной несостоятельности, ощущение, что вы выставили себя в невыгодном свете или подвели свою семью. • Трудности с концентрацией внимания, например при чтении газеты или просмотре телевизора. • Заторможенность движений или речи, заметная для окружающих. • Суетливость и беспокойство, которые приводят к избыточной подвижности. • Желание умереть или каким-либо образом навредить себе. ОЦЕНКА ЭМОЦИОНАЛЬНОГО СОСТОЯНИЯ ЛИЦА, ОСУЩЕСТВЛЯЮЩЕГО УХОД 1 РИСК ЖЕСТОКОГО ОБРАЩЕНИЯ Система взаимоотношений опекаемого лица и лица, осуществляющего уход, отличается сложностью. На фоне хорошего здоровья и благополучия лица, осуществляющие уход, могут оказывать крайне большой объем помощи, однако порой обязанности по уходу могут становиться бременем для одной или обеих сторон этого процесса. В связи с этим может возникать почва для конфликтов, в ходе которых для пожилого человека может создаваться угроза стать жертвой жестокого обращения. Жестокое обращение может выражаться в пренебрежении, получении материального преимущества (например, финансового), физическом или эмоциональном насилии или сексуальном надругательстве. Пренебрежительное отношение может, кроме того, возникать по причине недостатка навыков оказания ухода или недостатка внешней помощи или контроля. Случается, что ни пожилой человек, ни лицо, осуществляющее уход, не затрагивают тему жестокого обращения с медицинским работником. Выявлять случаи жестокого обращения следует, опираясь на данные наблюдений за поведением пожилого человека, поведением членов его семьи или родственников, а также обращая внимание на признаки физического насилия (см. Главу 10, посвященную социальной помощи и поддержке). Факторы, которые увеличивают риск жесткого обращения: • длительно существующие плохие отношения; • отмеченные ранее факты семейного насилия; • невозможность для лица, осуществляющего уход, регулярно оказывать помощь необходимого типа или уровня, а также • физические или психологические расстройства у лица, осуществляющего уход, в частности, депрессия и, особенно у мужчин, злоупотребление алкоголем и употребление психоактивных веществ. Вероятность жестокого обращения связана не только с сущностью оказываемой помощи или с факторами, часто приводящими к стрессу у лиц, осуществляющих уход, например, поведенческими особенностями людей с деменцией. При подозрении на жестокое обращение требуется проведение углубленной оценки специалистом согласно местным схемам маршрутизации пациентов. * Эти вопросы содержатся в опроснике о состоянии здоровья пациента Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), который является одним из инструментов для оценки депрессивных симптомов. Кроме того, рекомендуется обратиться к разделу, посвященному депрессии, в техническом руководстве mhGAP по адресу https://apps.who.int/iris/handle/10665/250239 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Схемы организации помощи лицам, осуществляющим уход 75 11 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Схемы организации помощи лицам, осуществляющим уход 11.1 ВОПРОСЫ К ЛИЦУ, ОСУЩЕСТВЛЯЮЩЕМУ УХОД В схеме на странице 74 показано, каким образом строится беседа с лицом, осуществляющим уход. Согласно схеме, каждому лицу, осуществляющему уход, во время беседы задают вопросы на три темы: 1. Тяготы, связанные с осуществлением ухода (два вопроса), которые могут требовать практической поддержки лиц, осуществляющих уход. 2. Два ключевых симптома депрессии, при которых может потребоваться полномасштабное обследование на предмет депрессии (см. Главу 9, посвященную депрессивным симптомам). 3. Финансовые издержки на уход, в связи с которыми, при доступности, может потребоваться обращение к локальным источникам финансирования и организованной социальной помощи. В ходе беседы с лицом, осуществляющим уход, медико-санитарному работнику следует обращать внимание на любые проявления утомления, гнева, раздражения или грубости. Кроме того, медико-санитарный работник может осведомиться, не нуждается ли человек, осуществляющий уход, в подробной беседе или поддержке поставщика социальной помощи. Тяготы ухода с течением времени могут становиться все более ощутимыми. Один раз в шесть месяцев требуется проведение повторной оценки. С тем чтобы человек, осуществляющий уход, не стеснялся и не боялся откровенной и подробной беседы, лучше всего проводить оценку роли и влияния этого лица в отсутствие пожилого человека. Пожилой человек и лицо, осуществляющее уход, могут излагать различные версии одних и тех же событий по целому ряду причин, например, в силу расстройств памяти у пожилого человека. В этой связи производить оценку следует в контексте сведений, полученных при всестороннем анализе индивидуальной жизнеспособности. 11.2 ПРЕДЛОЖЕНИЕ ПОДДЕРЖКИ ЛИЦУ, ОСУЩЕСТВЛЯЮЩЕМУ УХОД Надлежащим образом подготовленные специалисты, а также лица, осуществляющие уход на возмездной основе, пользуются поддержкой и действуют под контролем служб здравоохранения и социальных служб, и необходимо, чтобы эти специалисты оказывали помощь лицам, осуществляющим уход на безвозмездной основе. Для поддержки лиц, осуществляющих уход на безвозмездной основе, медицинские и социальные работники, как штатные, так и волонтеры, могут организовывать на уровне сообщества сетевое взаимодействие и вести обмен имеющимися ресурсами. ВОЗ предлагает обучающую онлайн программу iSupport, которая призвана помочь лицам, осуществляющим уход за людьми с деменцией, делать это на надлежащем уровне и, кроме того, следить за собственным состоянием https://www.isupportfordementia.org. Существенная доля поддержки приходится на основного человека, осуществляющего уход за членом семьи. С тем чтобы выяснить потребности лица, осуществляющего уход, поставщик помощи может уточнить, какие именно задачи выполняются, каким образом и как часто, уточнить, в каких аспектах ухода может потребоваться консультативная поддержка, практическая помощь или применение инновационных ассистивных технологий. Мероприятия, направленные на поддержку лица, осуществляющего уход, должны отражать его предпочтения и быть нацеленными на оптимизацию его благополучия. 76 11 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Схемы организации помощи лицам, осуществляющим уход 11 ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Схемы организации помощи лицам, осуществляющим уходМедицинские и социальные работники могут: • обучить лицо, осуществляющее уход, специальным навыкам ухода и содействовать закреплению этих навыков; • рассмотреть возможность практической поддержки или наладить ее, например, организовав временный отдых; • изучить вопрос о возможности назначения лицу с утратой функциональной способности каких-либо социальных льгот или других видов социальной или финансовой помощи из государственных или негосударственных источников. Предоставление рекомендаций. Следует сделать акцент на признании того факта, что осуществление ухода может стать чрезвычайно трудным опытом и привести к стрессу. Тяжесть этого опыта может усугубляться утратой прежнего качества взаимоотношений между пожилым человеком и лицом, осуществляющим уход, особенно если таким лицом является супруг или супруга. Со стороны лиц, осуществляющих уход, необходимо поощрять проявления уважения к достоинству пожилых людей, выражающиеся в как можно более активном привлечении пожилых к принятию решений в отношении их жизни и ухода за ними. Организация временного ухода на период отдыха. Возможно ли временно заменить лицо, осуществляющее уход и наблюдение за пожилым человеком, кем-либо другим, когда такой уход становится чрезмерно тягостным или тяжелым? Имеется в виду замена кем-либо из членов семьи или домохозяйства, специально подготовленным социальным работником из числа штатных или волонтеров. Подобный временный уход, например, в виде дневного ухода, может обеспечить возможность «передышки» для основного человека, обеспечивающего уход, создавая условия для отдыха или другой деятельности. Дневной уход – это одна из форм общинной помощи, которая доступна несколько раз в неделю в течение нескольких часов, когда пожилой человек может получить содействие в таких потребностях, как личная гигиена (прием ванной, прием пищи, бритье, посещение туалета), реабилитация, участие в рекреационных программах и социально- культурных мероприятиях, покупка пищи и пользование транспортом. Кроме того, система дневного ухода предусматривает поддержку лиц, осуществляющих уход, например в виде визитов на дом, организации семейных мероприятий, ведения групп поддержки и обучения. Временный отдых может помочь поддержанию отношений лица, осуществляющего уход, с пожилым человеком на удовлетворительном и здоровом уровне, при этом рассматривать периоды, когда уход осуществляет другое лицо, как негативные для пожилого человека будет неверно. Предложение психологической поддержки. Для борьбы с психологическим стрессом лицу, осуществляющему уход, следует предложить психологическую поддержку и психологическое консультирование, ориентированное на решение проблем, в особенности, когда требуется большой объем сложного ухода и нагрузка на человека крайне высока. ИННОВАЦИОННЫЕ АССИСТИВНЫЕ ТЕХНОЛОГИИ В инновационных ассистивных технологиях здравоохранения, таких как удаленный мониторинг и роботы-помощники, заключен большой потенциал, поскольку они могут укрепить функциональную способность пожилых, повысить качество их жизни и жизни людей, осуществляющих уход, обогатить жизнь, сделать ее более безопасной, обеспечить большую степень независимости и вселить ощущение уверенности и воплотить принцип «Старения у домашнего очага». Применение этих технологий должно основываться на потребностях и предпочтениях пожилых людей или лиц, осуществляющих за ними уход, и требует надлежащего уровня подготовки конечных пользователей. Следует уделять большое внимание разработке механизма финансирования научно-технической деятельности и внедренческим решениям на равноценной основе. К примерам инновационных ассистивных технологий относятся: • Робот PARO, используемый в учреждениях социальной помощи. Этот робот в виде детеныша тюленя играет роль питомца (22) http://www.parorobots.com • Гибридное ассистивное устройство для поддержки поясницы HAL lumbar type. Устройство представляет собой механический аналог мышц и помогает поднимать пациентов и перемещать их с кровати на стул и затем в ванную. https://www.cyberdyne.jp/english/products/Lumbar_CareSupport.html 77 ОСНОВНЫЕ ПОЛОЖЕНИЯ • Помощь, ориентированная на потребности человека, основывается на целостном и индивидуально ориентированном подходе, и ее оказанию способствуют отношения сотрудничества между медицинскими работниками, пожилыми людьми, а также членами семьи и друзьями, которые им содействуют. Помощь пожилым людям в целеполагании могут оказать мультидисциплинарные коллективы. Оказание помощи, ориентированной на потребности человека, необходимо согласовывать в свете приоритетных для пожилого человека потребностей и целей. Для достижения намеченных целей требуется неизменное и регулярное последующее наблюдение. РАЗРАБОТКА ИНДИВИДУАЛЬНОГО ПЛАНА УХОДА Концепция планирования индивидуальной помощи – это гуманистическая концепция, в которой предпринят отход от традиционных методов, ориентированных на конкретное заболевание, и уделено внимание потребностям, ценностям и предпочтениям пожилого человека. После того как сформулирован индивидуальный план ухода, согласно его положениям, выстраивают все компоненты медицинской и социальной помощи, а также намечают шаги для достижения реалистичных целей, ориентированных на потребности человека. ЭТАПЫ РАЗРАБОТКИ ИНДИВИДУАЛЬНОГО ПЛАНА УХОДА 1. Изучение результатов и анализ возможностей для укрепления функциональной способности, здоровья и благополучия На этом этапе мультидисциплинарные коллективы вместе с пожилыми людьми, членами их семей и (или) лицами, осуществляющими уход, проводят изучение результатов оценки, ориентированной на индивидуальные нужды человека, а также мероприятий, предложенных в схемах организации ухода. На основании оценки, ориентированной на индивидуальные нужды человека, формируют список рекомендуемых мероприятий, который может включаться в план оказания помощи и обсуждаться с пациентом. В ходе этого процесса хорошим подспорьем для работника здравоохранения станет приложение ICOPE. В состав мультидисциплинарных коллективов могут входить все те, кто задействован в оказании помощи пожилому человеку, например, врачи первичной помощи, врачи-специалисты, медицинские сестры, патронажные работники, социальные работники, терапевты (физиотерапевты, трудотерапевты, логопеды, физиотерапевты), лица, осуществляющие уход на возмездной и безвозмездной основе, фармацевты и волонтеры. 2. Целеполагание, ориентированное на потребности человека При разработке плана ухода ключевым элементом является целеполагание, ориентированное на потребности человека, которое позволяет определять, устанавливать и приоритизировать цели. Необходимо, чтобы мультидисциплинарный коллектив привлекал к процессу принятия решений об организации ухода самих пожилых людей, а также проявлял понимание и уважение к их потребностям, ценностям, предпочтениям и приоритетам. Этот подход может знаменовать преобразовательные изменения в способах взаимодействия медицинских работников с пациентами сегодня. Цели ухода могут выходить за рамки смягчения непосредственных проявлений заболеваний, и акцент может делаться на привнесении в жизнь пожилых людей значимых для них возможностей, например, сохранения собственной независимости и безопасного пребывания в своем доме на фоне старения, продолжения личностного развития, продуктивного участия в жизни своей общины без ущерба для собственной автономии и состояния здоровья. Для большей очевидности положительных изменений и преимуществ и поддержания уровня мотивации и вовлеченности пожилых людей рекомендуется, помимо средне- и долгосрочных целей (от шести до двенадцати месяцев) , также включать в план и краткосрочные (три месяца). 12 78 5. Мониторинг и последующее наблюдение Для достижения согласованных целей первоочередную важность имеет мониторинг реализации плана ухода с регулярным последующим наблюдением. Благодаря этому открываются возможности мониторинга хода работы, а также выявления на раннем этапе трудностей участия в мероприятиях, нежелательных явлений, связанных с проводимыми мероприятиями, а также изменений функционального статуса. Кроме того, создаются условия для сохранения синергизма во взаимодействии пожилых людей с лицами, осуществляющими уход. Процесс последующего наблюдения включает, но не ограничивается следующими аспектами: • обеспечение эффективной поэтапной реализации плана ухода; • повторное проведение оценки, ориентированной на индивидуальные нужды человека, и документирование любых изменений; • обобщение результатов, препятствий и затруднений на пути осуществления мероприятий в области охраны здоровья и социальной помощи; • выявление изменений и вновь возникших потребностей; • согласование дальнейших способов откликнуться на эти изменения и удовлетворить эти потребности, в том числе, включая по мере необходимости новые мероприятия и выполняя сообразный этому пересмотр и совершенствование плана; • повторение этого цикла. 3. Достижение договоренностей в отношении мероприятий При внесении предложений о включении конкретных мероприятий в план ухода по результатам проведения оценки, ориентированной на индивидуальные нужды человека, и формирования схемы организации ухода необходимо: a) согласие пожилого человека; b) соответствие предложений целям, потребностям, предпочтениям и приоритетам пожилого человека; c) учет особенностей физического и социального окружения пожилого человека. После этого медицинскому или социальному работнику следует провести обсуждение с пожилым человеком и согласовать место каждого отдельного мероприятия в итоговом плане организации ухода. 4. Заключительный этап составления плана организации ухода и доведение его до сведения участников процесса На этом этапе медицинскому работнику надлежит отразить результаты обсуждений в плане ухода и предоставить документ пожилому человеку, членам его семьи, лицам, осуществляющим уход, и, при наличии соответствующего согласия, другим лицам, участвующим в организации ухода. Способствовать этому процессу может мобильное приложение ICOPE, через которое всем участникам может направляться резюме плана ухода, где отражены приоритетные цели и определены условия. 12 КОМПОНЕНТЫ ФУНКЦИОНАЛЬНОЙ СПОСОБНОСТИ 1. Удовлетворение основных потребностей, таких как финансовая безопасность, проживание и личная безопасность. 2. Обучение, развитие и принятие решений, что включает стремления непрерывно повышать уровень собственных знаний и применять их на практике, участвовать в процессе решения задач, продолжать личностное развитие и сохранять способность к осознанному выбору. 3. Поддержание уровня двигательной активности, необходимого для выполнения повседневных действий в доме, посещения магазинов, учреждений сферы услуг и общественного пользования, а также участия в социальной, экономической и культурной деятельности. 4. Формирование и поддержание разнообразных взаимоотношений, в том числе, с детьми и другими членами семьи, неформальных социальных взаимоотношений с друзьями, соседями, коллегами, а также формальных взаимоотношений с патронажными работниками. 5. Личное участие в различных событиях, связанное непосредственно с общественной и культурной жизнью, например, помощь друзьям и соседям, наставничество для сверстников и молодежи, а также помощь членам семьи и общины. 79 12 ОПРЕДЕЛЕНИЕ ЦЕЛЕЙ: Определение целей совместно с пожилым человеком, членами его семьи и лицами, осуществляющими уход (23): • ВОПРОС 1 Назовите то, что в наибольшей степени затрагивает все стороны вашей жизни. • ВОПРОС 2 Назовите несколько конкретных целей, которые вы ставите перед собой в жизни. • ВОПРОС 3 Назовите несколько конкретных целей, связанных с состоянием вашего здоровья, которые вы ставите перед собой. • ВОПРОС 4 Мы только что обсудили жизненные цели и цели, связанные с состоянием здоровья; назовите три, которые будут для вас ведущими на ближайшие три месяца. Какие будут ведущими на ближайшие 6–12 месяцев? УСТАНОВЛЕНИЕ ЦЕЛЕЙ: Допускается модификация целей сообразно потребностям пожилых людей и их собственному пониманию проблем. • ВОПРОС 5 Каким именно элементам первой, второй или третьей цели вы бы хотели уделить особое внимание в ближайшие три месяца? В ближайшие 6 – 12 месяцев? • ВОПРОС 6 Как вы работаете над [элемент конкретной цели]? • ВОПРОС 7 Назовите оптимальную, но при этом посильную для вас задачу на пути к достижению этой цели. ПРИОРИТИЗАЦИЯ ЦЕЛЕЙ: Достижение согласия между пожилыми людьми и лицами, осуществляющими уход, в части приоритизации целей приведет к лучшим результатам. • ВОПРОС 8 Какой из перечисленных целей вы бы хотели уделить наибольшее внимание в ближайшие три месяца, самостоятельно или при содействии [доктора XX и его коллектива]? В ближайшие 6–12 месяцев? КАКИМ ОБРАЗОМ ПРОИСХОДИТ ПРОЦЕСС ЦЕЛЕПОЛАГАНИЯ, ОРИЕНТИРОВАННОГО НА ПОТРЕБНОСТИ ЧЕЛОВЕКА Источник: на основе материалов Health Tapestry (http://healthtapestry.ca) 80 ОСНОВНЫЕ ПОЛОЖЕНИЯ • Для эффективной реализации концепции ICOPE требуется комплексный подход, который позволит увязать оказание медицинских и социальных услуг. • Оптимизация индивидуальной жизнеспособности и функциональной способности пожилых людей начинается на уровне общин с усилий общинных работников. Необходимо, чтобы оказание помощи на уровне общин поддерживалось секторами здравоохранения и социальных услуг. • В основе концепции ICOPE лежат индивидуальные планы ухода. Лицам, ответственным за исполнение этих планов и организацию работы в соответствии с ними, может требоваться специальная подготовка в области ведения пациентов. Во Всемирном докладе ВОЗ о старении и здоровье заданы новые ориентиры для деятельности систем медицинской и долгосрочной помощи (1). В докладе содержится призыв к тому, чтобы деятельность этих систем была сосредоточена на вопросах оптимизации индивидуальной жизнеспособности пожилых людей с целью сохранения и повышения уровня их функциональной способности. Эти новые ориентиры преломляются в практические подходы к проведению оценки и оказанию помощи на общинном уровне в Рекомендациях ВОЗ по оказанию помощи на уровне общин при снижении индивидуальной жизнеспособности, опубликованных в 2017 г. (2). В своей совокупности эти документы способствуют развитию ориентированной на потребности человека комплексной системы охраны здоровья, социальной помощи и поддержки. Первыми шагами в реализации концепции является ориентированная на индивидуальные нужды оценка потребностей человека в медицинской и социальной помощи, которую могут проводить общинные работники. В данной главе изложен ряд важных соображений в части реализации концепции ICOPE. Подробно порядок реализации концепции ICOPE разъяснен в Руководстве ВОЗ для систем и служб по реализации концепции ICOPE (https://apps.who.int/iris/handle/10665/325669) КАКИМ ОБРАЗОМ СИСТЕМЫ МЕДИЦИНСКОЙ И ДОЛГОСРОЧНОЙ ПОМОЩИ МОГУТ СОДЕЙСТВОВАТЬ РЕАЛИЗАЦИИ КОНЦЕПЦИИ ICOPE 13 81 13.1 ПОДДЕРЖКА РЕАЛИЗАЦИИ КОНЦЕПЦИИ НА НАЦИОНАЛЬНОМ УРОВНЕ В первую очередь надлежит адаптировать рекомендации ВОЗ и данное руководство к местным условиям, культурным и языковым особенностям для практического применения патронажными, медицинскими работниками, лицами, осуществляющими уход, а также самими пожилыми людьми. Всесторонний процесс адаптации может дать начало полномасштабной поддержке новой концепции. Реализация подхода ICOPE потребует непрерывного взаимодействия на всех уровнях и этапах между участниками процесса, включая лиц, формирующих политику, специалистов здравоохранения, социальных работников, исследователей, представителей общин и других людей. Понимание местного контекста позволит найти действенные и эффективные пути внедрения рекомендаций глобального уровня. Содействие здоровому старению требует участия как сектора здравоохранения, так и сектора социальной помощи. При условии поддержки курса на интеграцию медицинской и социальной помощи на уровне национальной политики усилия обоих секторов по адаптации и практическому применению концепции ICOPE станут более эффективными. Стратегии, принятые на высоком уровне, могут определять конкретные режимы совместного функционирования секторов здравоохранения и социальной помощи в национальном, региональном и общинном масштабе. Система инициатив и поощрений, механизмы финансирования и мониторинг показателей эффективности могут содействовать смене приоритетов в пользу такой системы оказания помощи пожилым людям, которая позволяет оптимизировать индивидуальную жизнеспособность и функциональную способность. Следует ориентировать информационные системы на мониторинг этих преобразований на национальном и местном уровнях. 13.2 ТРЕБОВАНИЯ К БЮДЖЕТУ И ЧЕЛОВЕЧЕСКИМ РЕСУРСАМ С целью определения направлений для дополнительных инвестиций, например, таких как подготовка медицинских работников, применение технологий и адаптация систем информационного обеспечения здравоохранения, следует проанализировать следствия реализации концепции ICOPE. В частности, процесс изучения и практического внедрения нового подхода медицинскими и социальными работниками, а также коллективами первичного звена здравоохранения потребует содействия. В ходе этого процесса, предусматривающего привлечение всех заинтересованных сторон, важная роль может принадлежать национальным и локальным профессиональным обществам. 13 КЛЮЧЕВЫЕ ВОПРОСЫ РЕАЛИЗАЦИИ НА НАЦИОНАЛЬНОМ УРОВНЕ При планировании интеграции концепции ICOPE в системы медицинской и долгосрочной помощи необходимо обеспечить: • выполнимость условий – с финансовой и организационной точки зрения; • рациональность в долгосрочной перспективе – эффективность и кадровую обеспеченность; • согласованность – увязку с политикой в области поддержки здорового старения; • интегрированность – увязку работы системы здравоохранения и социальной помощи. 82 13.3 ИНТЕГРАЦИЯ УСЛУГ ПО ОКАЗАНИЮ ПОМОЩИ И ПОДДЕРЖКИ В СИСТЕМЫ ЗДРАВООХРАНЕНИЯ И СОЦИАЛЬНОГО ОБСЛУЖИВАНИЯ Необходимо, чтобы все мероприятия, направленные на оказание помощи, осуществлялись в соответствии с принципами практического применения знаний, которые ВОЗ определила как «обобщение, обмен и применение знаний соответствующими заинтересованными сторонами для активизации внедрения глобальных и местных достижений при укреплении систем здравоохранения и повышении уровня здоровья населения». Для применения этих принципов в деле оказания помощи пожилым людям, имеющим множественные сопутствующие заболевания и(или) испытывающим затруднения в доступе к услугам здравоохранения, был специально разработан руководящий документ ВОЗ, принятый в 2012 г., который касается практического применения знаний в области старения и здоровья (24). В докладе ВОЗ о механизме комплексного ориентированного на людей медицинского обслуживания от 2016 г. предложены основные принципы предоставления высококачественных комплексных услуг здравоохранения (6). Краеугольным камнем системы оказания комплексной помощи является тщательное ведение пациентов, что позволяет провести в жизнь принципы разработки, координации и мониторинга планов ухода, зачастую, опирающихся на целый ряд компонентов системы здравоохранения и социальной поддержки. Медицинским и социальным работникам может потребоваться специальное обучение, касающееся ведения пациентов, а также клинических аспектов рекомендаций ICOPE. В механизме реализации концепции ICOPE подчеркиваются ключевые меры на уровне служб и систем здравоохранения и социальной поддержки, необходимые для реализации концепции ICOPE (25). В этом руководящем документе освещены меры (стр. 84), которые следует принять ответственным лицам в службах и системах здравоохранения и социальной поддержки с целью оказания комплексной помощи. Механизмом рекомендованы конкретные меры сообразно объему предоставляемых в настоящее время услуг здравоохранения и социальной помощи. 13.4 ПОДГОТОВКА СЛУЖБ ЗДРАВООХРАНЕНИЯ И СОЦИАЛЬНОЙ ПОМОЩИ К РАБОТЕ В ПОРЯДКЕ РЕАЛИЗАЦИИ КОНЦЕПЦИИ Мероприятия, предусмотренные концепцией ICOPE, необходимо реализовывать в духе принципа «Старения у домашнего очага». Иными словами, оказание услуг в области здравоохранения и социальной помощи следует производить таким образом, чтобы пожилые люди имели возможность вести безопасное, независимое и комфортное существование в собственном доме и общине. Мероприятия предусматривают осуществление по моделям организации ухода, в которых приоритет отдан первичной помощи и помощи на базе общин. Имеется в виду, в том числе, курс на мероприятия, проводимые на дому, участие общины, а также полностью сформированная комплексная система маршрутизации пациентов. Невозможно взять этот курс без признания и согласия с решающей ролью общинных работников в обеспечении более широкого доступа к первичной помощи и всеобщему охвату услугами здравоохранения. В руководстве ВОЗ по поддержке политики и систем здравоохранения для оптимизации программ, проводимых общинными медико-санитарными работниками, содержатся научно обоснованные предложения и рекомендации по отбору, обучению, ключевым компетенциям, контролю деятельности и вознаграждению общинных медико-санитарных работников (26). 13 Рекомендации для систем и служб Механизм реализации концепции INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 При необходимости специализированной помощи деятельность общинных медико-санитарных работников должна дополняться усилиями медицинских работников в учреждениях сети специализированной и высокотехнологичной помощи. Всем сторонам процесса, ведущим работу на местах, надлежит достичь договоренности относительно четких критериев маршрутизации пациентов и схемы организации ухода, а впоследствии – вести мониторинг обеспечения качества. С тем, чтобы планы оставались действенными, а оказание услуг в области здравоохранения и социальной поддержки – эффективным, необходимы четкие договоренности в отношении последующего контроля. Дальнейшее наблюдение и поддержка могут приобретать особое значение после существенных изменений в состоянии здоровья пожилого человека или весомого события в жизни, например, смены места жительства или смерти супруга, либо лица, осуществляющего уход. 13 РЕЗЮМЕ МЕРОПРИЯТИЙ, ПРЕДУСМОТРЕННЫХ МЕХАНИЗМОМ РЕАЛИЗАЦИИ КОНЦЕПЦИИ ICOPE МЕРОПРИЯТИЯ НА УРОВНЕ СЛУЖБ • Взаимодействие с населением и общинами и оказание им поддержки. Привлечение пожилых людей, членов их семей и представителей гражданского общества к оказанию услуг; оказание поддержки и проведение подготовки лиц, осуществляющих уход. • Содействие скоординированному оказанию услуг многопрофильными поставщиками. Выявление в общине пожилых людей, нуждающихся в уходе, всесторонняя оценка и разработка всеобъемлющих планов ухода, налаживание сетевого взаимодействия медицинских и социальных работников. • Ориентация услуг на уход по месту жительства. Оказание эффективной помощи приемлемого уровня с упором на функциональную способность силами общинных работников, а также служб при соответствующей инфраструктурной поддержке. МЕРОПРИЯТИЯ НА УРОВНЕ СИСТЕМ • Укрепление систем управления и подотчетности. Привлечение всех участников процесса к разработке политики и служб, разработка стратегий и нормативной базы для содействия оказанию комплексной помощи и реагированию на проявления жестокого обращения с пожилыми людьми; непрерывная работа в области обеспечения качества и повышения качества; регулярная оценка потенциала с целью достижения равноправия в доступе к помощи. • Содействие повышению эффективности деятельности на уровне системы. Развитие системы управления потенциалом, финансовыми и людскими ресурсами; применение технологических решений для обмена информацией между поставщиками услуг; проведение сбора и представления данных, касающихся индивидуальной жизнеспособности и функциональной способности; применение цифровых технологий для содействия самопомощи. 84 13.5 УЧАСТИЕ ОБЩИН И ПОДДЕРЖКА ЛИЦ, ОСУЩЕСТВЛЯЮЩИХ УХОД Труд общинных работников должен поддерживаться дополнительными ресурсами общины. С целью обеспечения более активной и непосредственной поддержки и помощи пожилым людям в общинах и районах может потребоваться воля к организации и политическая воля на местном уровне, особенно, в смысле поощрения волонтерской деятельности и содействия участию в этом процессе представителей общины старшего поколения. Клубы и ассоциации для пожилых естественным образом дополнят такие усилия. В то же время, в деле поддержания здорового старения на системах здравоохранения лежит ответственность перед партнерами – общинами, местными организациями, членами семей, а также другими лицами, осуществляющими уход за пожилыми людьми на безвозмездной основе. Эта ответственность выражается в контроле за состоянием здоровья и благополучием лиц, осуществляющих уход, как указано в Главе 11, а также во взаимной поддержке, сотрудничестве и координации с сообществами и местными организациями с целью формирования здоровой окружающей среды для здорового старения. 85 БИБЛИОГРАФИЯ 10. Ассистивные устройства и технологии. Женева: ВОЗ; нет даты (https://www.who.int/disabilities/technology/ru/, по состоянию на 1 мая 2019 г.). 11. Texas Department of Aging and Disability Services. Instructions for completing the Nutrition Risk Assessment (NRA): DETERMINE Your Nutritional Health. Washington (DC): Nutrition Screening Initiative; 2010 (https://www.dads.state.tx.us/providers/AAA/Forms/standardized/ NRA.pdf, accessed 2 April 2019). 12. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: the mini nutritional assessment as part of the geriatric evaluation. Nutr Rev. 1996;54(1,part 2):S59–65. doi: 10.1111/j.1753-4887.1996.tb03793.x. 13. Camicelli AP, Keeffe JE, Martin K, Carbone J, Balding C, Taylor H. Vision screening for older people: the barriers and the solutions. Australas J Ageing. 2003;22(4):179–85. 14. Нарушения зрения и слепота Глобальная стратегия и план действий по проблемам старения и здоровья. Женева: ВОЗ; 2018 г. (https://www.who.int/ru/news-room/fact-sheets/ detail/blindness-and-visual-impairment, по состоянию на 2 апреля 2019 г.). 15. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I. Health Technology Assessment, 2007, 11(42). 16. Primary ear and hearing care training resource (Учебный ресурс по первичной помощи, по проблемам слуха и слуховых нарушений). Женева: ВОЗ; 2006 г. (https://apps.who.int/iris/ handle/10665/43333, по состоянию на 2 апреля 2019 г. (на английском языке). 17. Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in us adults, national health and nutrition examination survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4):293–302. doi: 10.1001/jamaoto.2014.42. 18. Zhang X, Bullard KM, Cotch MF, Wilson MR, Rovner BW, McGwin G Jr, et al. Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005–2008. JAMA Ophthalmol. 2013;131(5):573–81. doi: 10.1001/ jamaophthalmol.2013.2597. 1. Всемирный доклад о старении и здоровье. Женева: Всемирная организация здравоохранения (ВОЗ); 2015 г. (https://apps.who.int/iris/handle/10665/186463, по состоянию на 2 апреля 2019 г.). 2. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity (Оказание комплексной помощи пожилым людям: Рекомендации по оказанию помощи на уровне общин при снижении индивидуальной жизнеспособности) Женева: ВОЗ; 2017 г. (http://apps.who.int/iris/handle/10665/258981, по состоянию на 2 апреля 2019 г. (на английском языке). 3. World Population Ageing 2017: Highlights (Доклад о старении населения 2017 г. Основные факты): Нью-Йорк: Департамент по экономическим и социальным вопросам Организации Объединенных Наций; 2017 (https://sustainabledevelopment.un.org/index. html, по состоянию на 17 июня 2015 г. (на английском языке). 4. Цели в области устойчивого развития [веб-сайт]. Нью-Йорк: Организация Объединенных Наций; нет даты (https://sustainabledevelopment.un.org/sdgs, по состоянию на 2 апреля 2019 г. (на английском языке). 5. Глобальная стратегия и план действий по проблемам старения и здоровья. Женева: ВОЗ; 2017 г. (http://www.who.int/ageing/global-strategy, по состоянию на 2 апреля 2019 г.). 6. Framework on integrated, people-centred health services: report by the Secretariat (Механизм комплексного ориентированного на людей медицинского обслуживания: доклад Секретариата) Женева: ВОЗ; нет даты (A69/39; https://apps.who.int/iris/ handle/10665/252698, по состоянию на 2 апреля 2019 г. (на английском языке). 7. Rebok GW, Ball K, Guey LT, Jones RN, Kim HY, King JW, et al. Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc. 2014;62(1):16–24. doi: 10.1111/jgs.12607. 8. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-46. doi: 10.1111/jgs.13702. 9. painHEALTH. Pain management. East Perth: Department of Health, Western Australia; no date (https://painhealth.csse.uwa.edu.au/pain-management, accessed 1 May 2019). 19. Spotting the signs of harm, abuse and neglect Scotland. Streatham: Action on Elder Abuse; no date (https://www.elderabuse.org.uk/spotting-the-signs-of-harm-abuse-and-neglect, accessed 2 April 2019). 20. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/ S2214-109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128(6):3925–36. doi: 10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with dementia living in the community. J Am Med Dir Assoc. 2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/ s40814-018-0377-2. 24. Практическое применение знаний Женева: ВОЗ; нет даты (https://www.who.int/ageing/ projects/knowledge_translation/ru/, по состоянию на 2 апреля 2019 г.). 25. Оказание комплексной помощи пожилым людям: Руководство для систем и служб. Женева: ВОЗ; 2019 г. (https://apps.who.int/iris/handle/10665/325669, по состоянию на июнь 2019 г. (на английском языке). 26. Community-based health workers (Общинные медико-санитарные работники). Женева: ВОЗ; нет даты (https://www.who.int/hrh/community, по состоянию на 2 апреля 2019 г. (на английском языке). 86 87 www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int
إرشادات بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية كتيب الرعاية المتكاملة للمسنين
إرشادات بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية كتيب الرعاية المتكاملة للمسنين إرشادات بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية ]erac yramirp ni syawhtap dna tnemssessa dertnec-nosrep no ecnadiuG[ 1.91/CLA/CWF/OHW © منظمة الصحة العالمية 9102 بعض الحقوق محفوظة. هذا المصنف متاح بمقتضى ترخيص المشاع الإبداعي «نسب المصنف – غير تجاري – المشاركة بالمثل 0.3 لفائدة المنظمات الحكومية الدولية» OGI 0.3 AS-CN-YB CC، )/ogi/0.3/as-cn-yb/sesnecil/gro.snommocevitaerc//:sptth(. وبمقتضى هذا الترخيص يجوز أن تنسخوا المصنف وتعيدوا توزيعه وتحوروه للأغراض غير التجارية، وذلك شريطة أن يتم اقتباس المصنف على النحو الملائم كما هو مبين أدناه. ولا ينبغي في أي استخدام لهذا المصنف الإيحاء بأن المنظمة )OHW( تعتمد أي منظمة أو منتجات أو خدمات محددة. ولا ُيسمح باستخدام شعار المنظمة )OHW(. واإ ذا قمتم بتعديل المصنف فيجب عندئٍذ أن تحصلوا على ترخيص لمصنفكم بمقتضى نفس ترخيص المشاع الإبداعي )ecnecil snommoC evitaerC( أو ترخيص يعادله. واإ ذا قمتم بترجمة المصنف فينبغي أن تدرجوا بيان إخلاء المسؤولية التالي مع الاقتباس المقترح: «هذه الترجمة ليست من إعداد منظمة الصحة العالمية (المنظمة )OHW(). والمنظمة )OHW( غير مسؤولة عن محتوى هذه الترجمة أو دقتها. ويجب أن يكون إصدار الأصل الإنكليزي هو الإصدار الملزم وذو الحجية». ويجب أن تتم أية وساطة فيما يتعلق بالمنازعات التي تنشأ في إطار هذا الترخيص وفقًا لقواعد الوساطة للمنظمة العالمية للملكية الفكرية )/selur/noitaidem/ne/cma/tni.opiw.www//:ptth(. الاقتباس المقترح: إرشادات بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية ]erac yramirp ni syawhtap dna tnemssessa dertnec-nosrep rof ecnadiuG[. جنيف: منظمة الصحة العالمية: 1029 . )1.91/CLA/CWF/OHW( الترخيص OGI 0.3 AS-CN-YB CC. بيانات الفهرسة أثناء النشر. بيانات الفهرسة أثناء النشر متاحة في الرابط /siri/tni.ohw.sppa//:ptth. المبيعات والحقوق والترخيص. لشراء مطبوعات المنظمة )OHW( انظر الرابط sredrokoob/tni.ohw.sppa//:ptth. ولتقديم طلبات الاستخدام التجاري والاستفسارات الخاصة بالحقوق والترخيص انظر الرابط gnisnecil/tuoba/tni.ohw.www//:ptth. مواد الطرف الثالث. إذا كنتم ترغبون في إعادة استخدام مواد واردة في هذا المصنف ومنسوبة إلى طرف ثالث، مثل الجداول أو الأشكال أو الصور فإنكم تتحملون مسؤولية تحديد ما إذا كان يلزم الحصول على إذن لإعادة الاستخدام هذه أم لا، وعن الحصول على الإذن من صاحب حقوق المؤلف. ويتحمل المستخدم وحده أية مخاطر لحدوث مطالبات نتيجة انتهاك أي عنصر يملكه طرف ثالث في المصنف. بيانات عامة لإخلاء المسؤولية. التسميات المستعملة في هذا المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر ضمنًا عن أي رأي كان من جانب المنظمة )OHW( بشأن الوضع القانوني لأي بلد أو أرض أو مدينة أو منطقة أو لسلطات أي منها أو بشأن تحديد حدودها أو تخومها. وتشكل الخطوط المنقوطة على الخرائط خطوطًا حدودية تقريبية قد لا يوجد بعد اتفاق كامل بشأنها. كما أن ذكر شركات محددة أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة أو موصى بها من جانب المنظمة )OHW(، تفضيًلا لها على سواها مما يماثلها في الطابع ولم يرد ذكره. وفيما عدا الخطأ والسهو، تميز أسماء المنتجات المسجلة الملكية بالأحرف الاستهلالية (في النص الإنكليزي). وقد اتخذت المنظمة )OHW( كل الاحتياطات المعقولة للتحقق من المعلومات الواردة في هذا المطبوع. ومع ذلك فإن المواد المنشورة ُتوزع دون أي ضمان من أي نوع، سواء أكان بشكل صريح أم بشكل ضمني. والقارئ هو المسؤول عن تفسير واستعمال المواد. والمنظمة )OHW( ليست مسؤولة بأي حال عن الأضرار التي قد تترتب على استعمالها. dnalreztiwS ni detnirP. شكر وتقدير vi مسرد المختصرات v 1. الرعاية المتكاملة للمسنين 1 2. النهوض بالقدرات والطاقات: نحو تمتع الجميع بالصحة في مرحلة الشيخوخة 5 3. تقدير احتياجات المسنين ووضع خطة رعاية مشخصنة 9 4. مسالك الرعاية لإدارة التراجع المعرفي 91 5. مسالك الرعاية لتحسين التحرك 52 6. مسالك الرعاية لإدارة التغذية 33 7. مسالك الرعاية لإدارة الخلل البصري 14 8. مسالك الرعاية لإدارة فقد السمع 15 9. مسالك الرعاية لإدارة الأعراض الاكتئابية 95 01. مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية 76 11. مسالك الرعاية لمساندة مقدمي الرعاية 57 21. وضع خطة الرعاية المشخصنة 87 31. كيف يمكن لنظم الرعاية الصحية والطويلة الأجل مساندة تنفيذ نهج المنظمة للرعاية المتكاملة للمسنين 18 المراجع 68 المحتويات iii شكر وتقدير يجيء هذا الكتيب كثمرة لجهود العديد من الأشخاص حول العالم الذين كرسوا أنفسهم لرعاية المسنين ومساندتهم. واضطلعت ohlavraC ed ojuarA enelsI و imuS akuY من إدارة التشيخ ودورة الحياة في منظمة الصحة العالمية بقيادة أنشطة إعداد الكتيب. وشملت المجموعة الأساسية المسؤولة عن تحرير الكتيب ووضع المسالك كًلا من ohlavraC ed ojuarA enelsI، و draeB nhoJ، وimuS akuY، و sggirB werdnA (جامعة كورت، أستراليا)، و nitraM rrabniF (جامعة كينغز كوليدج، لندن، المملكة المتحدة). واضطلعت nosnhoJ haraS و traheniR draW من شركة secivreS lairotidE aruJ بمسؤولية كتابة النص النهائي. وساهم الكثير من موظفي المنظمة الآخرين من المكاتب الإقليمية ومن طائفة متنوعة من الإدارات بالفصول النوعية المتصلة بمجالات عملهم وكذلك في وضع مسالك الرعاية وهم: ahdahC yllehS (إدارة التدبير العلاجي للأمراض غير السارية، والإعاقة، والوقاية من العنف والإصابات)، و yrahdwohC ajreeN (إدارة الصحة النفسية ومعاقرة مواد الإدمان)، و auD nuraT (إدارة الصحة النفسية ومعاقرة مواد الإدمان)، و lasaC aicraG seveiN saL eD airaM (إدارة التغذية من أجل الصحة والتنمية)، و naH A eeZ (إدارة التدبير العلاجي للأمراض غير السارية، والإعاقة، والوقاية من العنف والإصابات)، و idavaJ aneD (التحالف من أجل السياسات الصحية وبحوث الُنظم التابع للمنظمة)، و oloaP oivliS ittoiraM (إدارة التدبير العلاجي للأمراض غير السارية، والإعاقة، والوقاية من العنف والإصابات)، و azeiC socralA (إدارة التدبير العلاجي للأمراض غير السارية، والإعاقة، والوقاية من العنف والإصابات)، و reciffO teragraM analA (إدارة التشيخ ودورة الحياة)، و sasoR-añeP olbaP nauJ (إدارة التغذية من أجل الصحة والتنمية)، و edaleyO alomadedA owiaT (وحدة الصحة الأسرية والإنجابية، المكتب الإقليمي لأفريقيا)، ورامز المهايني (الصحة الإنجابية وصحة الأمومة، المكتب الإقليمي لشرق المتوسط)، و ortsaC seyeR neraK (إدارة التدبير العلاجي للأمراض غير السارية، والإعاقة، والوقاية من العنف والإصابات)، و aicraG ageV euqirnE (مجرى الحياة الصحية، منظمة الصحة للبلدان الأمريكية/ منظمة الصحة العالمية). وحظي الكتيب بمساهمات ثرية من عدد من الخبراء والأكاديميين الذين شاركوا أيضًا في تحرير فصول مخصوصة وهم: iraseC oettaM (مؤسسة ocinilciloP eroiggaM eladepsO adnarG ’aC SCCRI enoizadnoF، إيطاليا)، و effeeK lliJ (المركز المتعاون مع المنظمة للوقاية من العمى، الهند)، و tneD aslE (جامعة كوينزلاند، أستراليا)، و odnoK ikoaN (جامعة طوكيو، اليابان)، و gnopareetiaL eenurA (جامعة شولالاونكورن، تايلاند)، و odreiuqzI lekiM (جامعة نافارا العامة، أسبانيا)، و kcolrehS-dyolL reteP (جامعة إيست أنغليا، المملكة المتحدة)، و odelboR zerreituG leugiM siuL (المعهد الوطني الصحي المكسيكي، المكسيك)، و nohaMcM enirehtaC، (جامعة ماكواري، أستراليا)، و awgedN hareS (جامعة نيروبي، كينيا)، و awagO ihsoriH (جامعة نييغاتا، اليابان)، و etteyaP enèléH (جامعة شيربروك، كندا)، و plihP naI (جامعة سترلينغ، المملكة المتحدة)، و sañaM-zeugirdoR oidacoeL (مستشفى خيتافي الجامعي، إسبانيا)، و rratS nhoJ (جامعة إدنبره، المملكة المتحدة)، و yalbmerT ylleK (جامعة واشنطن، الولايات المتحدة الأمريكية)، و aleuznelaV leahciM (جامعة سيدني، أستراليا)، و salleV onurB (المركز المتعاون مع المنظمة بشأن الهشاشة، والبحوث السريرية، والتدريب المتعلق بالشيخوخة، جيرونتوبل، مستشفى تولوز الجامعي، فرنسا)، و ressiV nielojraM (جامعة أمستردام الحرة، هولندا)، و synadZ anitsirK (جامعة كونكتيكت، الولايات المتحدة الأمريكية)، والمركز المتعاون مع المنظمة بشأن الهشاشة، والبحوث السريرية، والتدريب المتعلق بالشيخوخة (جيرونتوبل، مستشفى تولوز الجامعي، فرنسا)، والمركز المتعاون مع المنظمة بشأن الجوانب الصحية العمومية للصحة العضلية الهيكلية والشيخوخة (جامعة لييج، بلجيكا). ودعم المجلس الوطني الأسترالي للبحوث الصحية والطبية، والتحالف العالمي للصحة العضلية الهيكلية، وجامعة شولالونغكورن في تايلاند إعداد هذه الإرشادات عبر توفير الموظفين اللازمين لتطوير محتواها ومن خلال تنظيم اجتماعات الخبراء. كما استفدنا من مساهمات المشاركين في الاجتماع السنوي للاتحاد السريري العالمي المعني بالتمتع بالصحة في مرحلة الشيخوخة التابع للمنظمة في كانون الأول/ ديسمبر 8102. وتقر إدارة التشيخ ودورة الحياة بالدعم المالي الوارد من حكومة اليابان، وحكومة ألمانيا، وحكومة مقاطعة كاناغاوا اليابانية. تحرير شركة knI neerG vi مسرد المختصرات sLDA أنشطة الحياة اليومية IMB مؤشر كتلة الجسم TBC العلاج المعرفي السلوكي EPOCI الرعاية المتكاملة للمسنين ANM تقدير تغذوي وجيز NSO تغذية تكميلية فموية ATP مقياس سمع النغمات النقية BPPS مجموعة الأداء البدني القصير OHW منظمة الصحة العالمية يشير إلى الحاجة إلى معارف ومهارات متخصصة لتوفير الرعاية v
ُيعرِّف «التقرير العالمي بشأن الشيخوخة والصحة» لعام 5102 هدف التمتع بالصحة في مرحلة الشيخوخة على أنه مساعدة الأشخاص على تطوير وصون القدرة على الأداء التي تتيح التنعم بالعافية. وُتعرَّف القدرة على الأداء بأنها «الصفات المرتبطة بالصحة التي تتيح للأشخاص أن يكونوا وأن يفعلوا ما يحظى بالقيمة بالنسبة لهم». وتتألف القدرة على الأداء من القدرة الأساسية للشخص، وبيئته، والتفاعلات بينهما. أما القدرة الأساسية فهي «مجموعة الاحتياطيات البدنية والنفسية الإجمالية للشخص التي يمكن له الاستعانة بها» )1(. ويستحث هذا المفهوم للتمتع بالصحة في مرحلة الشيخوخة وجهة تركيز جديدة للرعاية الصحية للمسنين تنصب على القدرة الأساسية والقدرة على الأداء عند المسنين وهم يشيخون. وفي تشرين الأول/ أكتوبر 7102 نشرت منظمة الصحة العالمية (المنظمة) وثيقة «الرعاية المتكاملة للمسنين: مبادئ توجيهية بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية» )2(. وهذه الإرشادات تطرح 31 توصية مستندة إلى البيِّنات وموجهة إلى العاملين في ميدان الصحة والرعاية للمساعدة في تطوير وتنفيذ الرعاية المتكاملة للمسنين المتركزة على الأشخاص على مستوى المجتمع المحلي. ويجسد نهج الرعاية المتكاملة للمسنين التركيز على النهوض الأمثل بالقدرة الأساسية والقدرة على الأداء باعتباره العنصر الرئيسي اللازم للتمتع بالصحة في مرحلة الشيخوخة. وبالمستطاع الاستعانة بهذه التوصيات في إدراج الخدمات الرامية إلى الحيلولة دون الاتكال على الرعاية ضمن برامج الرعاية الأولية وحزم الرعاية الأساسية. النقاط الرئيسية بالنسبة للنظام الصحي فإن الشرط الأساسي لمساندة تمتع الجميع بالصحة في مرحلة الشيخوخة هو النهوض الأمثل بالقدرة الأساسية والقدرة على الأداء، رغم خفض الشيخوخة التدريجي للقدرات. يمكن الحيلولة دون الاتكال على الرعاية في حال القيام على الفور بتشخيص واإ دارة الظروف ذات الأولوية المرتبطة بتراجع القدرة الأساسية. بمقدور العاملين في الرعاية الصحية والاجتماعية في المجتمع المحلي وعلى مستوى الرعاية الأولية تحديد المسنين المعانين من خسائر في القدرات وتوفير الرعاية المناسبة لدحر أو إبطاء هذه الخسائر من خلال اتباع الإرشادات. ويتميز هذا النهج ببساطته وتكلفته الزهيدة. ثمة ترابط وثيق بين أوجه التراجع في القدرة الأساسية ولذا فإنها تتطلب نهجًا متكامًلا ومتركزًا على الأشخاص في التقدير والإدارة. الرعاية المتكاملة 1 للمسنين 1 لماذا نحتاج إلى الرعاية المتكاملة للمسنين؟ يشكل المسنون اليوم نسبة عالية لم يسبق لها مثيل في صفوف سكان العالم. وفي عام 7102 كان هناك ما يقدر بنحو 269 مليون شخص ممن تصل أعمارهم إلى 06 عامًا فأكثر، وهو ما يعادل نسبة 31% من سكان الكرة الأرضية. )3( وستشهد هذه النسبة ارتفاعًا سريعًا خلال العقود المقبلة، ولاسيما في البلدان المنخفضة والمتوسطة الدخل. وبحلول عام 0502 سيكون هناك شخص واحد من بين كل خمسة أشخاص بسن الستين أو أكثر. وقد بدأ هذا الاتجاه قبل قرابة 05 عامًا، وهو يعكس الأثر التضافري للوتائر السريعة لانخفاض معدلات الخصوبة وارتفاع مستويات متوسط العمر المتوقع في معظم أرجاء العالم، والمترافقة غالبًا مع التنمية الاقتصادية الاجتماعية. ويعد الحفاظ على صحة المسنين استثمارًا في رأس المال البشري والاجتماعي وهو يساند أهداف التنمية المستدامة للأمم المتحدة )4(. وفي الوقت ذاته فإن رعاية الأعداد المتزايدة من المسنين يخلق تحديات في وجه النظم الصحية. وتدعو الحاجة إلى إعادة موازنة موارد الرعاية الصحية على امتداد المجموعات العمرية. ويقتضي الأمر إجراء تغيير جذري في ُنهج الصحة العمومية المعنية بالشيخوخة. وتركز الُنهج التقليدية للرعاية الصحية للمسنين على الظروف الطبية، بحيث تتخذ من تشخيص هذه الظروف واإ دارتها محورًا لها. وتظل العناية بأمر هذه الأمراض مهمة، لكن الإفراط في التركيز عليها ينزع إلى إغفال الصعوبات الناجمة عن مصاعب السمع، والإبصار، والتذكر، والتحرك، والخسائر الشائعة الأخرى في القدرة الأساسية التي تترافق مع الشيخوخة. وستستفيد عافية كل شخص في مرحلة ما من حياته من تحديد هذه المشكلات واإ دارتها. وسيسهم الاهتمام في مختلف أنحاء النظام الصحي بالقدرات الأساسية للمسنين بشكل عام في رفاه قطاع واسع ومتنام من السكان. ويفتقر معظم مهنيي الرعاية الصحية إلى الإرشاد والتدريب اللازمين للتعرف على أوجه تراجع القدرة الأساسية واإ دارتها. ومع تقدم السكان في العمر فإن هناك حاجة ملحة إلى استحداث ُنهج مجتمعية شاملة تتضمن تدخلات للحيلولة دون تراجع القدرة الأساسية، ورعاية التمتع بالصحة في مرحلة الشيخوخة، ومساندة مقدمي الرعاية للمسنين. ويلبي نهج المنظمة للرعاية المتكاملة للمسنين هذه الحاجة. لمن تتوجه هذه الإرشادات؟ إن الجمهور المستهدف الأساسي لهذا الكتيب هم العاملون في الرعاية الصحية والاجتماعية في المجتمع وفي سياقات الرعاية الأولية. كما ينبغي أن توفر الإرشادات المعلومات للعاملين في الرعاية الصحية الذين سُتلتمس معارفهم المتخصصة، حسب الاقتضاء، لتقدير وتخطيط الرعاية اللازمة للأشخاص المعانين من خسائر في القدرة الأساسية والقدرة على الأداء. وستساعد الإرشادات المدرجة في هذا الكتيب العاملين المجتمعيين في ميدان الصحة والرعاية على وضع توصيات نهج الرعاية المتكاملة للمسنين موضع التنفيذ. وتوفر التوصيات مسالك للرعاية لإدارة الظروف الصحية ذات الأولوية المرتبطة بأوجه تراجع القدرة الأساسية وهي: فقد التحرك، وسوء التغذية، والخلل البصري، وفقد السمع، والتراجع المعرفي، والأعراض الاكتئابية. وتبدأ هذه المسالك باختبار للتحري بغرض تحديد المسنين الذين ُيرجح على الأغلب إصابتهم بالفعل ببعض الخسائر. ويمكن للعاملين في الرعاية الصحية والاجتماعية أن يقوموا بسهولة بعملية التحري هذه في المجتمع المحلي. ويشكل ذلك بوابة لتقدير أعمق لاحتياجات الرعاية الصحية والاجتماعية للمسنين. ويفضي هذا التقدير بدوره إلى خطة رعاية مشخصنة تدمج استراتيجيات دحر، أو إبطاء، أو توقي المزيد من التراجع في القدرة، وتعالج الأمراض، وتلبي احتياجات الرعاية الاجتماعية. ويتطلب التقدير المتركز على الأشخاص ووضع خطة الرعاية في العادة مهنيين صحيين مدربين في سياق الرعاية الصحية الأولية، مثل أطباء وممرضي الرعاية الأولية. على أن بالمستطاع إدارة أوجه التراجع في القدرة الأساسية في المجتمع المحلي الذي يعيش فيه المسنون ومقدمو الرعاية، بمساندة من فريق متعدد الاختصاصات. 2 المبادئ التوجيهية تستند الإرشادات إلى المبادئ التوجيهية التالية: للمسنين الحق بالتمتع بأكبر قدر من الصحة. ينبغي أن يحظى المسنون بفرصة متساوية فيما يتعلق بمحددات التمتع بالصحة في مرحلة الشيخوخة، بغض النظر عن الوضع الاقتصادي، أو مكان الولادة أو الإقامة، أو العوامل الاجتماعية الأخرى. توفير الرعاية على نحو عادل للجميع دون أي تمييز، ولاسيما فيما يتعلق بالجنس، أو العمر. وفضًلا عن ذلك فإن المهنيين المسؤولين عن تطوير الأنشطة التدريبية في ميادين الطب، والتمريض، والمجالات المساِعدة للصحة والصحة العمومية يمكن أن يستفيدوا سواء من المفاهيم أو من الُنهج العملية الموصوفة هنا. وتشمل قطاعات الجمهور الأخرى مدراء الرعاية الصحية وصنَّاع السياسات، مثل مدراء البرامج الوطنية، والإقليمية، والمحلية، ممن يضطلعون بالمسؤولية عن تخطيط وتنظيم خدمات الرعاية الصحية، وكذلك الوكالات التي تموِّل و/ أو تنفذ برامج الصحة العمومية، والمنظمات غير الحكومية والمؤسسات الخيرية التي ُتعنى بالمسنين في السياقات المجتمعية. ماذا توفر هذا الإرشادات؟ تسعى هذه الإرشادات إلى دعم العاملين في الرعاية الصحية والاجتماعية في السياقات المجتمعية في كشف أوجه التراجع في القدرة الأساسية واإ دارتها، بالاستناد إلى إرشادات المنظمة الخاصة بالتدخلات على مستوى المجتمع المحلي لإدارة التراجع في القدرة الأساسية )2(، وتلبية احتياجات الرعاية الصحية والاجتماعية للمسنين على نحو شامل. وتصف هذه الإرشادات سبل القيام بما يلي: • تحديد الأهداف المتركزة على الأشخاص (الفصل 2)؛ • دعم الإدارة الذاتية (الفصل 2)؛ • وضع خطة للرعاية تتضمن تدخلات متعددة لإدارة الظروف المرتبطة بخسائر القدرة الأساسية (الفصل 3)؛ • التحري عن خسائر القدرة الأساسية وتقدير احتياجات الرعاية الصحية والاجتماعية (الفصول 4–01)؛ • دعم مقدمي الرعاية (الفصل 11)؛ و • وضع خطة رعاية مشخصنة (الفصل 21). نهج الرعاية المتكاملة للمسنين في سياقه تشكل التغطية الصحية الشاملة الأساس لتحقيق الغاية الصحية لأهداف التنمية المستدامة )4(. ولبلوغ هدف التنمية المستدامة 3 فإن من الواجب العناية بأمر الرعاية الصحية والاجتماعية للمسنين على نحو متكامل مع مواصلة الرعاية في الأجل الطويل. وتحدد وثيقة «الاستراتيجية وخطة العمل العالميتان بشأن الشيخوخة والصحة» الصادرة عن المنظمة )5( دور النظم الصحية في ترويج التمتع بالصحة في مرحلة الشيخوخة عبر النهوض الأمثل بالقدرة الأساسية. وتسهم توصيات نهج الرعاية المتكاملة للمسنين )2( وهذه الإرشادات في تحقيق أهداف الاستراتيجية المذكورة. كما أن هذه الإرشادات تعتبر أداة لتنفيذ إطار المنظمة للخدمات الصحية المتكاملة )6(. ويدعو الإطار إلى إحداث تحول في طريقة إدارة الخدمات الصحية وتقديمها نحو اعتماد نهج متكامل مرتكز على الأشخاص. وفي سياق هذا الإطار فإن نهج الرعاية المتكاملة للمسنين يقترح أن تستند الرعاية المقدمة إلى المسنين إلى ما يلي: • تقدير للاحتياجات، والأفضليات، والأهداف الفردية؛ • وضع خطة رعاية مشخصنة؛ • خدمات منسقة محكومة بهدف وحيد هو الحفاظ على القدرة الأساسية والقدرة على الأداء، وُمقدمة قدر المستطاع عبر الرعاية الأولية والمجتمعية. 3 4 ُيعرِّف التقرير العالمي بشأن الشيخوخة والصحة لمنظمة الصحة العالمية التمتع بالصحة في مرحلة الشيخوخة على أنه تطوير وصون القدرة على الأداء التي تتيح التنعم بالعافية )1(. وتدعم هذه الإرشادات التمتع بالصحة في مرحلة الشيخوخة من خلال العناية بأمر الظروف التالية ذات الأولوية المرتبطة بالتراجع على امتداد ميادين القدرة الأساسية (الشكل 1)، واحتياجات الرعاية الاجتماعية للمسنين، ودعم مقدمي الرعاية. • التراجع الادراكي (الفصل 4) • محدودية التحرك (الفصل 5) • سوء التغذية (الفصل 6) • الخلل البصري (الفصل 7) • فقد السمع (الفصل 8) • الأعراض الاكتئابية (الفصل 9) • الرعاية والمساندة الاجتماعية (الفصل 01) • دعم مقدمي الرعاية (الفصل 11) النهوض بالقدرات والطاقات: نحو تمتع الجميع بالصحة في مرحلة الشيخوخة الشكل 1: الميادين الرئيسية للقدرة الأساسية كيف تتغير القدرة الأساسية على مدى العمر؟ يعرض الشكل 2 نمطًا تقليديًا للقدرة الأساسية والقدرة على الأداء على امتداد عمر البالغين. وتتراجع القدرة الأساسية والقدرة على الأداء مع ارتفاع العمر نتيجة عملية التشيخ وكذلك بفعل الأمراض المستبطنة. ويمكن تقسيم هذا النمط التقليدي إلى ثلاث فترات شائعة: فترة القدرة العالية والمستقرة نسبيًا، وفترة تراجع القدرة، وفترة الفقد الجسيم للقدرة المتسمة بالاتكال على الرعاية. 2 الحيوية القدرة البصرية القدرة السمعية القدرة الادراكية القدرة التحركية القدرة النفسية 5 التدخل للنهوض الأمثل بالقدرة الأساسية يتيح تحديد الظروف المرتبطة بخسائر القدرة الأساسية الفرصة للتدخل بغية إبطاء، أو وقف، أو دحر أوجه التراجع (الشكل 2). وبمقدور العاملين في الرعاية الصحية في السياقات السريرية وفي المجتمع المحلي اكتشاف الحالات القائفة المرتبطة بتراجع القدرة الأساسية. وتمكِّن عمليات التقدير المتكررة على مدى الزمن من رصد أية تغيرات تفوق ما هو متوقع بحيث يمكن القيام بتدخلات مخصوصة قبل فقد القدرة على الأداء. وبهذه الطريقة تستطيع التدخلات المنفَّذة في السياقات المجتمعية أن تحول دون إصابة الشخص بالضعف أو اتكاله على الرعاية. وعلى ما يبدو فإن التدخلات المتعددة المكونات هي أشد فعالية. وثمة طيف واسع من القدرة الأساسية يحيط بالنمط المتوسط. وتتجلى هذه الفوارق ضمن البلدان وفيما بينها على حد سواء. وتنعكس الفوارق في الفروق المستمرة في متوسط العمر المتوقع الذي يتراوح بين 28 عامًا أو أكثر في بلدان مثل أستراليا، واليابان، وسويسرا، إلى أقل من 55 عامًا في بلدان كجمهورية أفريقيا الوسطى، وتشاد، والصومال. والتغاير في القدرة الأساسية أوسع كثيرًا بين الأشخاص المسنين منه بين المجموعات الأصغر سنًا. وهذا التنوع هو مْعلم من معالم الشيخوخة. فقد يبلغ فارق العمر بين شخص وآخر عشر سنوات أو أكثر إلا أن لديهما ذات القدرة الأساسية و/ أو القدرة على الأداء. ولهذا فإن العمر الزمني يعد واسمًا رديئًا للحالة الصحية. القدرة الأساسية والقدرة على الأداء ُتعرِّف المنظمة القدرة الأساسية على أنها مجموع قدرات الشخص البدنية والعقلية، بما في ذلك القدرات النفسية. أما القدرة على الأداء فهي توليفة وتفاعل القدرة الأساسية مع البيئة التي يعيش فيها الشخص. 6 الشكل 2: إطار صحي عمومي للتمتع بالصحة في مرحلة الشيخوخة: الفرص المتاحة لتدابير الصحة العمومية خلال مجرى العمر وبالمستطاع تعديل الكثير من الخصائص التي تحدد القدرة الأساسية. ويشمل ذلك السلوكيات الصحية ووجود الأمراض. وثمة أساس منطقي قوي لتنفيذ تدخلات فعالية للنهوض الأمثل بالقدرة الأساسية. ويرتكز نهج الرعاية المتكاملة للمسنين وهذه الإرشادات على الأساس المذكور. وتتفاعل الظروف الصحية المختلفة المرتبطة بخسائر القدرة الأساسية على مستويات متعددة. وعلى سبيل المثال فإن فقد السمع مرتبط بالتراجع المعرفي. وُتعزز التغذية من تأثير التمارين البدنية ولها أثر مباشر على الكتلة العضلية وعلى القوة. وهذه التفاعلات تستدعي نهجًا متكامًلا للتحري عن أوجه تراجع القدرة الأساسية، وتقديرها، واإ دارتها. المصدر: منظمة الصحة العالمية، 5102 )1(. قـدرة عال�ة ومسـتقرة الخدمـات الصح�ـة: الرعا�ـة الطو�لـة الأجل: البيئــات تدهـور القدرةخسـارة جسـ�مة في القدرة القدرة الأساس�ة توقـي الظـروف المزمنة أو ضمان الكشـف الم��ر دحـر أو إ�طاء عنهـا وض�طها التراجـع فـي القدرة دعم السلو��ات المعززة للقدرات ترو�ج السلو��ات المعززة للقدرات إدارة الظـروف المزمنـة المتقدمة ضمـان الكرامة فـي مرحلـة العمـر المتقدمة إزالة الحواجز من أمام المشار�ين، والتعو�ض عن فقد القدرة نهج الرعا�ة المتكاملة للمسنين القدرة على الأداء 7 8 وتستند الرعاية المتركزة على الأشخاص إلى المنظور القائل بأن المسنين ليسوا مجرد مستوعبات من الاضطرابات أو الظروف الصحية؛ فكل الناس، بغض النظر عن أعمارهم، هم أفراد ذوو تجارب، واحتياجات، وأفضليات فريدة. وُتعنى الرعاية المتركزة على الأشخاص باحتياجات الرعاية الصحية والاجتماعية للأفراد عوضًا عن الخضوع للظروف أو الأعراض الصحية المعزولة. كما أن النهج المتكامل المتركز على الأشخاص يشتمل على سياق الحياة اليومية للأفراد، بما في ذلك أثر صحتهم واحتياجاتهم على القريبين منهم وعلى مجتمعاتهم المحلية. وهناك خمس خطوات لتلبية احتياجات الرعاية الصحية والاجتماعية بالاعتماد على نهج للرعاية المتكاملة، على النحو الموضح في المسلك العام التالي. تقدير احتياجات المسنين ووضع خطة رعاية مشخصنة النقاط الرئيسية يمكن تحديد هوية المسنين في المجتمع المحلي المعانين من حالات ذات أولوية مرتبطة بالتراجع في القدرة الأساسية بالاستعانة بأداة التحري الخاصة بنهج الرعاية المتكاملة للمسنين. ُيحال الأشخاص الذين يتم تحديدهم إلى عيادة للرعاية الطبية الأولية لإجراء تقدير معمق ينير عملية إعداد خطة رعاية مشخصنة. قد تتضمن خطة الرعاية تدخلات متعددة لإدارة أوجه التراجع في القدرة الأساسية وللنهوض الأمثل بالقدرة على الأداء، مثل التمارين البدنية، والتغذية التكميلية الفموية، والتنبيه المعرفي، وتدابير التكيف المنزلي للوقاية من السقطات. 3 9 تحرَّ انعدام التراجع فيعن التراجع في القدرة الأساسية القدرة الأساسية مشورة نمط الحياة أو الرعاية المعتادة نعم نعم لا لا لا الخطوة 1 التحري الخطوة 2 التقدير المتركز على الأشخاص في الرعاية الأولية تقدير واإ دارة البيئات الاجتماعية والمادية تقدير واإ دارة الأمراض المستبطنة فهم حياة الشخص، وقيمه، وأولوياته، وأفضلياته وسياقه الاجتماعي تقدير معمَّق للظروف المرتبطة بخسارة القدرة الأساسية التدخلات المجتمعية لإدارة أوجه التراجع في القدرة الأساسية الإدارة المتكاملة للأمراض التأهيل الرعاية الملطفة ورعاية نهاية العمر تقدير اجتياجات خدمات الرعاية الاجتماعية (منزل، مؤسسة) خطة الرعاية والمساندة الاجتماعية إزالة حواجز المشاركة الاجتماعية التكيف البيئي 3 مسلك الرعاية العامة التقدير المتركز على الأشخاص ومسالك الرعاية الأولية 01 الخطوة 3 وضع خطة رعاية مشخصنة إعداد الأهداف المتركزة على الأشخاص فريق متعدد الاختصاصات تصميم خطة رعاية تشتمل على تدخلات متعددة المكونات، واإ دارة الأمراض المستبطنة، والرعاية الذاتية والإدارة الذاتية، والرعاية والمساندة الاجتماعية الخطوة 5 إشراك المجتمعات المحلية ومساندة مقدمي الرعاية الخطوة 4 ضمان مسلك للإحالة ورصد خطة الرعاية مع صلات برعاية الشيخوخة المتخصصة 11 الظروف ذات الأولوية المرتبطة بتراجع القدرة الأساسية التقدير الكامل إذا ما حفز أي الاختبارات جواب في أي ميدان على ذلك التراجع الادراكي (الفصل 4) 1. تذكر ثلاث كلمات: زهرة، باب، أرز (مثًلا) 2. التوجه في الزمان والمكان: ما هو التاريخ الكامل لهذا اليوم؟ أين أنت الآن (المنزل، العيادة، إلخ...) إجابة خاطئة على كل سؤال أو عدم المعرفة العجز عن تذكر الكلمات الثلاث جميعًا3. هل تتذكر الكلمات الثلاث؟ محدودية التحرك (الفصل 5) اختبار القيام من الكرسي: القيام من الكرسي خمس مرات بدون استخدام المساند. لا سوء التغذية (الفصل 6) 1. فقد الوزن: هل فقدت أكثر من 3 كغ من وزنك دون أن تتعمد ذلك خلال الأشهر الثلاثة الماضية؟ نعم نعم2. فقد الشهية: هل عانيت من فقد الشهية؟ الخلل البصري (الفصل 7) هل واجهتك أية مشكلات تتعلق بعينيك: صعوبة الإبصار على مسافة بعيدة، أو في القراءة، أو من أمراض عيون، أو هل تخضع للمعالجة الطبية حاليًا (من حالات مثل داء السكري، وفرط ارتفاع ضغط الدم)؟ نعم فقد السمع (الفصل 8) القدرة على سماع الهمسات (اختبار الهمس) أو نتيجة قياس السمع الفحصي هي 53 ديسي بل أو أقل أو اجتياز الاختبار المؤتمت للأرقام في الضجيج المعتمد على تطبيقات الأجهزة المتنقلة فشل الأعراض الاكتئابية (الفصل 9) هل تضايقت خلال الأسبوعين الماضيين بسبب: - شعورك بالإحباط، أو الاكتئاب، أو اليأس؟ نعم نعم- قلة الاهتمام أو المتعة بالقيام بالأعمال؟ الجدول 1: أداة التحري الخاصة بنهج الرعاية المتكاملة للمسنين في المنظمة 21 الخطوة 1 التحري عن التراجع في القدرة الأساسية تتيح العملية والأدوات المعروضة في هذه الإرشادات للعاملين المدربين في الرعاية الصحية البدء بتحديد هوية الأشخاص المعانين من خسائر في القدرة الأساسية في المجتمع المحلي أو في المنزل. وللقيام بذلك فإن بمقدورهم الاستعانة بأداة التحري الخاصة بنهج الرعاية المتكاملة للمسنين (الجدول 1). وهذه الأداة تمثل الخطوة الأولى في كل مسلك للرعاية من المسالك المعروضة في الفصول من 4 إلى 9 وهي تغطي ستة ظروف ذات صلة على امتداد ميادين القدرة الأساسية (الشكل 1 على الصفحة 5). ويمكن استخدام استراتيجيات التواصل المجتمعية، مثل الزيارات المنزلية للعاملين الصحيين المجتمعيين والتقديرات الذاتية بالاعتماد على تكنولوجيات الهواتف المتنقلة، للعثور على الحالات. وينبغي أن يخضع الأشخاص الذين تظهر عليهم علامات الإصابة بخسائر في القدرة الأساسية أو ُيبلغون عنها أثناء الخطوة الأولى إلى تقدير كامل. وعلى الأرجح فإن هذا التقدير يتطلب مهنيين في الرعاية الصحية من ذوي التدريب الضروري، وهم في الغالب، وليس بالضرورة، من الأطباء. وعلى العاملين في ميدان الصحة والرعاية أن يكفلوا أن يؤدي أي قيد تكشف عنه أداة التحري الخاصة بنهج الرعاية المتكاملة للمسنين على الدوام إلى حفز تقدير معمق آخر. وينبغي أن تنير الاستنتاجات جهود تطوير خطة الرعاية المشخصنة. ويعتبر تشخيص المرض المستبطن، مثل الخرف، والاكتئاب، والُفصال العظمي (التهاب المفاصل والعظام)، وتخلخل العظام، والساد، والسكري، وفرط الضغط، ذا أهمية بالغة في التقدير المتركز على الأشخاص. وقد يتطلب مثل هذا التشخيص اختبارات تشخيصية معقدة لا تتوافر على الدوام في عيادات الرعاية الأولية. ورهنًا بالسياق فإن الأمر قد يقتضي الإحالة إلى المستوى الثاني أو الثالث من الرعاية المتخصصة للشيوخ. 2د- تقدير البيئات الاجتماعية والمادية والحاجة إلى الرعاية والمساندة الاجتماعية يتطلب الأمر تقديرًا للبيئات الاجتماعية والمادية وكذلك تحديدًا لأية احتياجات للخدمات الاجتماعية والداعمة فيما يتعلق بالمسنين المعانين من خسائر في القدرة الأساسية. ويشكل ذلك جانبًا أساسيًا من التقدير المتركز على الأشخاص للمسنين في الرعاية الأولية. ويمكن تحديد احتياجات الرعاية الاجتماعية بسؤال المسنين عما إذا كانوا يقومون بمهام يومية مختلفة دون مساعدة الآخرين. ويعرض المسلك المدرج في الفصل 01 مجموعة من الأسئلة لتقدير وتحديد احتياجات الرعاية الاجتماعية بشكل عام. وبالإضافة إلى ذلك فإن كل مسلك من مسالك الرعاية الواردة في الفصول من 4 إلى 9 يشير إلى احتياجات الرعاية الاجتماعية المحتملة الخاصة بالظروف ذات الأولوية. الخطوة 2 التقدير المتركز على الأشخاص أثناء الرعاية الأولية ُيعد التقدير المتركز على الأشخاص لاحتياجات المسنين للرعاية الصحية والاجتماعية أثناء الرعاية الأولية عنصرًا حاسمًا للنهوض الأمثل بالقدرة الأساسية. 2أ- فهم حياة المسن لا يبدأ التقدير المرتكز على الأشخاص باستخلاص التاريخ التقليدي فحسب، بل وبفهم شامل أيضًا لحياة الشخص، وقيمه، وأولوياته، وأفضلياته خلال مجرى صحته واإ دارتها. 2ب- تقدير معمَّق للظروف المرتبطة بخسارة القدرة الأساسية يقيم التقدير كذلك بشكل معمق الظروف المرتبطة بخسائر القدرة الأساسية. وقد تم تنظيم مسالك الرعاية للظروف الأساسية على امتداد ميادين القدرة الأساسية، والمعروضة في الفصول من 4 إلى 9، طبقًا للمكونات الثلاثة عمومًا، حيث يحتل التحري في المجتمع المحلي المرتبة العليا، والتقدير أثناء الرعاية الأولية المرتبة الوسطى، وتخطيط الرعاية المشخصنة المرتبة الدنيا. 2ج- تقدير الأمراض المستبطنة واإ دارتها ينبغي التحقيق في الأمراض المزمنة المستبطنة، وكذلك في أي تعديد دوائي (استخدام أدوية متعددة). ويمكن لتعديد الأدوية والتأثيرات الضارة الناجمة عن ذلك أن يتسببا في خسائر في ميادين متعددة للقدرة الأساسية وهما يستحقان على الدوام التحقيق (انظر الإطار، تعديد الأدوية، الصفحة 81). 31 الخطوة 3 تحديد هدف الرعاية ووضع خطة رعاية مشخصنة 3أ- تحديد هدف الرعاية مع المسن يساعد الهدف الجامع الرامي إلى النهوض الأمثل بالقدرة الأساسية والقدرة على الأداء على ضمان تكامل الرعاية ويتيح أيضًا الفرصة لرصد تقدم المسنين وأثر التدخلات. ومن الضروري أن يشارك المسنون ومقدمو الرعاية في اتخاذ القرارات وتحديد الأهداف منذ البداية، وأن ُتحدد هذه الأهداف وترتب من حيث الأولوية وفقًا لأولويات الشخص المعني، واحتياجاته، وأفضلياته. 3ب- تصميم خطة الرعاية ينير التقدير المتركز على الأشخاص جهود وضع خطة رعاية مشخصنة. وتطبق هذه الخطة نهجًا متكامًلا لتنفيذ التدخلات المعنية بمعالجة أمر الخسائر في شتى ميادين القدرة الأساسية: إذ ينبغي النظر في كل التدخلات وتطبيقها معا. تشتمل مساندة الإدارة الذاتية على تزويد المسنين بالمعلومات، والمهارات، والأدوات اللازمة لهم لإدارة ظروفهم الصحية، والوقاية من المضاعفات، وتعظيم قدرتهم الأساسية، والحفاظ على نوعية حياتهم. ولا يعني ذلك أنه ُينتظر من المسنين «القيام بذلك بمفردهم» أو إلقاء طلبات مفرطة أو غير معقولة على كاهلهم. وعوضًا عن ذلك فإن هذا يقر باستقلالهم الذاتي وبأنهم قادرون على توجيه رعايتهم الذاتية، بالتشاور والشراكة مع العاملين في الرعاية الصحية، وأسرهم، ومقدمي الرعاية الآخرين. ويمكن لمبادرة المنظمة بشأن الخدمات الصحية عبر الهواتف المتنقلة )gniegAm( أن تستكمل تدابير الرعاية الروتينية التي يقوم بها مهنيو الرعاية الصحية من خلال مساندة الرعاية الذاتية والإدارة الذاتية. وبتوفير المعلومات، والنصائح، والتذكيرات الصحية عبر الهواتف المتنقلة فإن هذه المبادرة تحض على السلوكيات الصحية وتساعد المسنين على تحسين قدرتهم الأساسية وصونها. وللاطلاع على المعلومات المتعلقة بإنشاء برنامج لمبادرة gniegAm والرسائل النصية المقترحة، انظر: gniegAm/smetsys-htlaeh/gniega/tni.ohw.www//:sptth. 3 41 ويتسم هذا النهج المتكامل بالأهمية لأن معظم الظروف ذات الأولوية المرتبطة بخسائر القدرة الأساسية تتقاسم المحِددات الفيزيولوجية والسلوكية الدفينة ذاتها. وعلى سبيل المثال فإن تدريبات القوة المكثفة تشكل تدخًلا أساسيًا للحيلولة دون فقد التحرك. وفي الوقت ذاته فإن تدريبات القوة تحمي الدماغ بصورة غير مباشرة من الاكتئاب والتراجع المعرفي وتساعد على الوقاية من السقطات. وتعزز التغذية من تأثيرات التمارين البدنية وتزيد في الوقت ذاته من القوة والكتلة العضلية. وعبر نهج موحد متكامل فقد يكون بالمستطاع تغيير مجموعة العوامل التي تزيد من خطر الاتكال على الرعاية. وتتألف خطة الرعاية المشخصنة من عدد من المكونات التي قد تشمل ما يلي: • حزمة من التدخلات المتعددة المكونات لإدارة الخسائر في القدرة الأساسية. وستشمل معظم خطط الرعاية تدخلات لتحسين التغذية وتشجيع ممارسة التمارين البدنية؛ • إدارة ومعالجة الأمراض المستبطنة، والمراضات المتعددة، وأعراض الشيخوخة. وقد وضعت المنظمة مبادئ توجيهية سريرية للعناية بأمر معظم الأمراض المزمنة ذات الصلة التي يمكن أن تسهم في تراجع القدرة الأساسية )2(. وعلى كل مقدٍم لخدمات الرعاية الصحية أن يطلع على هذه المبادئ. • دعم الرعاية الذاتية والإدارة الذاتية؛ • إدارة أي ظروف مزمنة متقدمة (الرعاية الملطِّ فة، التأهيل) لضمان قدرة المسنين على أن يواصلوا حياة كريمة وذات مغزى. • الرعاية والمساندة الاجتماعية ، بما في ذلك تكييف البيئة، للتعويض عن أي خسائر في القدرة على الأداء؛ و • خطة لتلبية احتياجات الرعاية الاجتماعية بمساعدة أفراد الأسرة، والأصدقاء، والخدمات المجتمعية. وبمقدور العاملين في الرعاية الصحية والاجتماعية مساندة تنفيذ خطة الرعاية في المجتمع المحلي أو في سياق الرعاية الأولية. ويمكن للإدارة الذاتية، المدعومة بالمشورة والتثقيف والتشجيع من مقدمي خدمات الرعاية الصحية في المجتمع المحلي، أن ُتعدِّل بعض العوامل المسؤولة عن تراجع القدرة الأساسية. وستكفل الشراكة بين المسن، والعاملين في الرعاية الصحية، والأسرة، والمجتمع المحلي المحافظة على رفاه الأشخاص أثناء تشيخهم. 3 مسلك الرعاية العامة التقدير المتركز على الأشخاص ومسالك الرعاية الأولية 51 الخطوة 4 ضمان مسلك للإحالة ورصد خطة الرعاية مع صلات برعاية الشيخوخة المتخصصة تعتبر المتابعة المنتظمة والمتواصلة، مع التكامل بين مختلف مستويات وأنواع خدمات الرعاية، ضرورية لتنفيذ التدخلات التي توصي بها هذه الإرشادات. ويؤدي مثل هذا النهج إلى تعزيز الاكتشاف المبكر للمضاعفات أو التغيرات في الوضع الأدائي، بما يكفل تفادي حالات الطوارئ غير الضرورية وتوفير التكاليف من خلال العمل بصورة مبكرة. كما أن المتابعة المنتظمة تتيح الفرصة لرصد التقدم على طريق خطة الرعاية وتوفر الوسيلة اللازمة لترتيب المساندة الإضافية عند الحاجة لها. ويمكن أن تكون المتابعة والمساندة مهمة بشكل خاص بعد حدوث تغييرات بارزة في الوضع الصحي، أو في خطة المعالجة، أو في الدور الاجتماعي أو الحالة الاجتماعية للشخص المعني (تغيير مكان الإقامة، مثًلا، أو وفاة الشريك). وتتسم مسالك الإحالة المتينة بالأهمية لضمان الحصول العاجل على الرعاية الوجيزة عند وقوع أحداث غير منظورة مثل السقطات، أو على الرعاية الملطِّ فة ورعاية نهاية العمر، أو بعد الإخراج من المستشفى. كما ويعتبر إرساء صلة برعاية الشيخوخة المتخصصة بالغ الأهمية. وعلى النظم الصحية أن تكفل حصول الأشخاص في الوقت المناسب على الرعاية المتخصصة والوجيزة عند الحاجة. وثمة بيِّنات جيدة على أن أجنحة الرعاية الوجيزة المتخصصة للشيخوخة تقدم رعاية رفيعة الجودة خلال فترات إقامة أقصر وبتكلفة أقل من رعاية المستشفيات العامة. دور رعاية الشيخوخة المتخصصة يصب أطباء الشيخوخة درايتهم على المسنين ذوي الظروف المعقدة الطويلة الأجل مثل أعراض الشيخوخة (السلس، والسقطات، والهذيان، وما إلى ذلك)، والتعديد الدوائي، وعلى أمراض مثل الخرف، ويوفرون الرعاية لأولئك المعانين من قيود في أنشطة الحياة اليومية. وتزداد المراضات المشتركة مع التقدم في العمر وتسفر عن صور سريرية معقدة، وحينها فإن على أطباء الرعاية الأولية الرجوع إلى أطباء الشيخوخة. وفي نهج الرعاية المتكاملة للمسنين فإن أطباء الشيخوخة يشكلون جزءًا من فريق متعدد الاختصاصات مسؤول عن رعاية المسنين، وهم يساعدون في الإشراف على فرق الرعاية الأولية، ويتدخلون حينما يتطلب الأمر رعاية متخصصة. 3 مسلك الرعاية العامة التقدير المتركز على الأشخاص ومسالك الرعاية الأولية 61 الخطوة 5 إشراك المجتمعات المحلية ومساندة مقدمي الرعاية يمكن أن يكون تقديم الرعاية عملية شاقة، وغالبًا ما ُيصاب مقدمو الرعاية للأشخاص المعانين من خسائر في القدرة بمشاعر العزلة، كما أنهم معرضون بشدة للضيق النفسي والاكتئاب. وينبغي أن تتضمن خطة الرعاية المشخصنة تدخلات مستندة إلى البيِّنات لدعم مقدمي الرعاية. كما أن مقدمي الرعاية يحتاجون إلى معلومات أساسية عن الحالات الصحية للمسنين، واإ لى التدريب لتطوير طائفة من المهارات العملية، مثل كيفية نقل شخص من كرسيه إلى سريره بأمان أو كيفية مساعدته على الاستحمام. وينبغي أن يتلقى المسن ومقدم الرعاية المعلومات عن المصادر المجتمعية المتاحة لهما. ومن الواجب استطلاع فرص إشراك المجتمعات المحلية والأحياء بصورة مباشرة أشد في مساندة الرعاية، ولاسيما من خلال تشجيع التطوع وتمكين المسنين من أفراد المجتمعات المحلية من المساهمة. ويمكن لمثل هذه الأنشطة أن ُتنفذ غالبًا في رابطات ومجموعات تضم شمل المسنين. ويحتوي الفصل 11 على مسلك للرعاية لتقدير أعباء مقدمي الرعاية والعناية بأمر احتياجات مقدمي الرعاية غير المأجورين المتعلقة برعايتهم ومساندتهم هم أنفسهم. ويستند نهج الرعاية المتكاملة للمسنين إلى المجتمع المحلي أو إلى مستوى الرعاية الأولية، حيث يمكن الوصول إلى العدد الأكبر من الأشخاص. وفي الوقت ذاته فإن النهج يدعو إلى إرساء صلات متينة مع مستويات الرعاية المتخصصة والثالثية لمن هم في حاجة إليها مثل الصلات مع خبراء التغذية والصيادلة. تطبيقات كتيب نهج الرعاية المتكاملة للمسنين ستتوافر تطبيقات للأجهزة المتنقلة لإرشاد العاملين في الرعاية الصحية والاجتماعية بشأن كل الخطوات الواجب اتخاذها، وذلك من التحري إلى التقدير وصوًلا إلى تصميم خطة الرعاية المشخصنة. كما أن هذه التطبيقات سُتنتج موجزًا قابًلا للطبع لنتائج التقدير والتدخلات لإدراجه ضمن خطة الرعاية على شكل ملف محمول FDP. 3 مسلك الرعاية العامة التقدير المتركز على الأشخاص ومسالك الرعاية الأولية 71 التعديد الدوائي يوصف التعديد الدوائي عمومًا بأنه استخدام خمسة أدوية أو أكثر في الوقت ذاته، وغالبًا ما يرتبط بتفاعلات دوائية ضارة. ويزيد هذا الاستخدام للأدوية المتعددة من خطر العواقب الصحية السلبية، ويمكن أن يسفر عن خسائر غير ضرورية في القدرة الأساسية وأن يتسبب في عمليات الإدخال الوجيز إلى المستشفيات. والمسنون الذين يزورون عدة عاملين في الرعاية الصحية أو الذين خضعوا للمعالجة في المستشفيات مؤخرًا أكثر تعرضًا لخطر التعديد الدوائي. ومن المرجح أن يكون المسن المعاني من مراضات متعددة أكثر تأثرًا بالتغيرات الفيزيولوجية المرتبطة بالعمر التي يمكن أن تؤدي إلى تغير الحرائك والديناميات الدوائية. وبالنظر إلى أن التعديد الدوائي يمكن أن يسهم في حدوث خسائر في ميادين متعددة من القدرة الأساسية فإن التقديرات المتركزة على الأشخاص ينبغي أن تتضمن استعراضًا للأدوية التي يتعاطاها المسن. وبالمستطاع خفض التعديد الدوائي عبر إلغاء الأدوية غير الضرورية وغير الفاعلة، وكذلك الأدوية ذات الـتأثير المكرر. كيف يمكن إعطاء الوصفات المناسبة وخفض الأخطاء الدوائية: • احصل على التاريخ الدوائي الكامل؛ • انظر ما إذا كانت الأدوية يمكن أن تؤثر على القدرة؛ • تفادى وصف الأدوية قبل إجراء تشخيص إلا في حالات الألم الحاد؛ • استعرض الأدوية بانتظام وقبل وصف أي دواء جديد؛ • اطلع على التدابير، والتأثيرات الضارة، والتفاعلات الدوائية، وارصد المتطلبات وسمِّ ية الأدوية الموصوفة؛ • حاول استخدام دواء واحد لمعالجة ظرفين أو أكثر؛ • أنشئ بطاقة • قم بتثقيف المريض ومقدم الرعاية بشأن كل دواء. إذا ساورتك الشكوك بشأن ما إذا كان من المأمون إيقاف تعاطي دواء ما فإن عليك الرجوع إلى أخصائي مناسب. 3 مسلك الرعاية العامة التقدير المتركز على الأشخاص ومسالك الرعاية الأولية 81 ُيقدم التراجع المعرفي على أنه تزايد النسيان، وفقد الانتباه، وانخفاض القدرة على حل المشكلات. وفي حين أن السبب الدقيق لذلك غير معروف فإن التراجع المعرفي قد يكون مرتبطًا بتشيخ الدماغ، وبالأمراض (مثل الأمراض القلبية الوعائية كفرط الضغط والسكتات، أو داء الزهايمر)، أو حتى بعوامل بيئية مثل الافتقار إلى التمارين البدنية، والعزلة الاجتماعية، وانخفاض مستوى التعليم. ويغدو التراجع المعرفي شاغًلا من الشواغل العظمى حين يبدأ بالتدخل في قدرة الشخص على الأداء بفعالية في بيئته، أي حينما يصاب الشخص بالخرف. وهذا المسلك مزمع للتطبيق على المسنين المصابين بقدر ما من التدهور المعرفي ولكنهم لا يعانون من الخرف. وعلى المهنيين الطبيين أيضًا أن يكونوا قادرين على تقدير الحاجة إلى الرعاية والمساندة الاجتماعية (انظر الفصل 01). النقاط الرئيسية يمكن التقليل من التراجع في القدرة المعرفية بل ودحره أحيانًا باعتماد نهج عام إزاء أسلوب الحياة الصحي، والتنبيه المعرفي، والمشاركة الاجتماعية. قد تؤدي معالجة حالات مثل داء السكري وفرط الضغط إلى الوقاية من تراجع القدرة المعرفية. يمكن للتراجع في الميادين الأخرى للقدرة الأساسية، مثل القدرة السمعية والقدرة التحركية، أن يخل بالمعرفة، وهو ما ينبغي تقديره والعناية بأمره أيضًا. وبالنسبة للمصابين بالخرف فإن الأمر يتطلب رعاية متخصصة لتخطيط وتنفيذ تدخلات معقدة. 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي 91 1i ? اختبار بسيط للذاكرة والتوجه 1. تذكر ثلاث كلمات: اطلب إلى الشخص أن يتذكر ثلاث كلمات ستقولها. استخدم كلمات بسيطة ومحددة مثل «زهرة»، و«باب»، و«أرز» 2. التوجه في الزمان والمكان: ثم اسأل «ما هو التاريخ الكامل لماذا اليوم؟» و«أين أنت الآن؟» (المنزل، العيادة، إلخ...)؟ 3. تذكر ثلاث كلمات: اطلب من الشخص الآن تكرار الكلمات الثلاث التي ذكرتها نجاح أم فشل؟ إذا تعذر على الشخص الإجابة على أحد سؤالي التوجه أو لم يستطع تذكر كل الكلمات الثلاث، فإن التراجع المعرفي محتمل ويتطلب الأمر المزيد من التقدير * عوز فيتامينات، شذوذ في الكهارل، تجفاف وخيم * عوامل الخطر القلبية الوعائية: فرط الضغط، ارتفاع الكوليسترول، داء السكري، التدخين، السمنة، أمراض القلب، سكتة أو نوبة إقفارية سابقة الحد من مخاطر التراجع المعرفي والخرف: المبادئ التوجيهية للمنظمة - 081213/56601/eldnah/siri/tni.ohw.sppa//:sptth تحرَّ عن التراجع المعرفي تعزيز صحة الشيخوخة ومشورة نمط الحياة أو الرعاية المعتادة إسأل تقدير القدرة المعرفية لا نجاح نجاح نعم فشل فشل التراجع المعرفي مستبعد التراجع المعرفي محتملالتراجع المعرفي مستبعد تقدير واإ دارة البيئات الاجتماعية والمادية تقدير الحاجة إلى الرعاية والمساندة الاجتماعية إذا كان التراجع المعرفي يؤثر على الإدارة الذاتية والاستقلال، انظر قسم الخرف في دليل تدخلات برنامج PAGhm 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth توفير الرعاية والمساندة الشخصية في أنشطة الحياة اليومية قدم المشورة للحفاظ على مهارة استخدام المرحاض بشكل مستقل قم بتقدير عبء مقدم الرعاية أو إجهاده (انظر المسلك المتعلق بمقدمي الرعاية) ضع خطة للرعاية والمساندة الاجتماعية بما في ذلك مساندة مقدمي الرعاية توقي المزيد من التراجع في القدرة المعرفية التمارين المتعددة المناويل توفير الحفز المعرفي تقدير واإ دارة الظروف المصاحبة انظر المسلك المتعلق بسوء التغذية - سوء التغذية* حدد السبب (ظروف طبية، تسمم من مواد الإدمان، تعاطي - الهذيان العقاقير) وقم بالمعالجة استعراض الأدوية ووقفها حسب الاقتضاء- التعدد الدوائي - الأمراض الدماغية الوعائية قم بتقدير تاريخ المرض الوعائي في الدماغ (سكتة/نوبة إقفارية عابرة) انظر الأعراض الاكتئابية 9الأعراض الاكتئابية تقدير واإ دارة الأمراض القلبية الوعائية وعوامل الخطر توفير الإدارة المتكاملة للأمراض الحد من عوامل الخطر القلبية الوعائية – اقتراح الإقلاع عن التدخين – معالجة فرط الضغط وداء السكري – توفير المشورة الغذائية لضبط الوزن نعم هل تعاني من مشكلات في التذكر أو التوجه (مثل العجز عن معرفة أين أنت أو ما هو اليوم الحالي)؟ 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي 1 تقدير المعرفة ينبغي أن يستخدم التقدير المعمق للقدرة المعرفية أداة مجازة محليًا إذا أمكن. وترد في الطرف الأيمن أدناه قائمة بخيارات تقدير المعرفة لدى المسنين في سياقات الرعاية الأولية. الافتقار إلى التعليم. تفترض جميع التقديرات المعرفية المعيارية تقريبًا والمستخدمة في تحري الخلل المعرفي أو تشخيصه درجة دنيا من التعليم المدرسي. واإ ذا كان الشخص قد حظي بخمس أو ست سنوات من الدراسة أو ُحرم منها تمامًا فإن التقدير المعرفي قد يكون محدودا. وعوضًا عن ذلك فإن ذلك يجب أن يعتمد على المقابلات وعلى الحكم السريري. وبالنسبة لهؤلاء الأشخاص يوصى بقوة بإدراجهم ضمن برنامج لمحو الأمية عند الكبار (إن توافر)، حيث أن هذا يعزز من الصحة المعرفية. وفي حال عدم توافر أداة تقدير معيارية أو إذا كانت غير مناسبة، فإن بمقدور العاملين الصحيين سؤال المسن، وكذلك شخص وثيق الصلة به، عما يعانيه من مشكلات في الذاكرة، والتوجه، والنطق، واللغة، وأي صعوبات تواجهه لدى أداء الأدوار الأساسية والأنشطة اليومية. ويشير الفشل في التقدير المعرفي، أو الإبلاغ عن مشكلات في الذاكرة والتوجه، إلى الإصابة بخلل معرفي. كما ينبغي إخضاع مثل هذا الشخص لتقدير بشأن المصاعب المتعلقة بأنشطة الحياة اليومية أو الأنشطة المساِعدة للحياة اليومية. وهذه المعلومات هامة لتخطيط الرعاية والمساندة الاجتماعية كجزء من خطة الرعاية المشخصنة. واإ ذا كان التراجع المعرفي يؤثر على قدرة المسن على الأداء الفعال ضمن بيئته، فربما تدعو الحاجة إلى تقدير متخصص لتشخيص الخرف أو مرض الزهايمر (أكثر الأسباب الشائعة وراء الخرف). ويمكن الاطلاع على برتوكولات لتقدير واإ دارة الخرف في دليل المنظمة بشأن تدخلات برنامج PAGhm على العنوان التالي: 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth عندما يتطلب الأمر رعاية متخصصة • تشخيص ومعالجة الخرف • إدارة الظروف المصاحبة المتعددة مثل الهذيان، والأمراض الدماغية الوعائية، والأمراض الدماغية القلبية أمثلة على أدوات التقدير المعرفي للاستخدام في سياقات الرعاية الصحية الأولية الوقتالعيوبالمزاياالأداة/الاختبار وجيز، ضآلة التحيز اللغوي، والتعليمي، والعرقي استخدام قوائم كلمات مختلفة يمكن أن يؤثر على الدرجات 2-4 دقيقة يمكن أن يحدد الخلل المعرفي البسيط؛ متوافر بلغات متعددة تحيز تعليمي وثقافي، قلة البيانات المنشورة 01-51 دقيقة خاضع للتحيز العمري والثقافي، شائع الاستخدام والدراسة تأثيرات الحدود القصوى 7-01 دقائق ضآلة التحيز الثقافي والتعليمي، متوافر بلغات متعددة قد يكون من العسير الحصول على تقارير المخبرين 5-6 دقائق ما هو الخرف؟ إن الخرف هو متلازمة مزمنة ومترقية ناجمة عن تغيرات في الدماغ. ويؤدي الخرف إلى تراجع الأداء المعرفي، ويعيق أنشطة الحياة اليومية مثل الاغتسال، وارتداء الملابس، وتناول الطعام، والنظافة الشخصية، وأنشطة استخدام المرحاض. المزيد من المعلومات: دليل المنظمة بشأن تدخلات برنامج PAGhm )932052/56601/eldnah/siri/tni.ohw.sppa//:sptth( 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي goC-iniM /tnetnoc-pw/moc.goc-inim//:ptth fdp.619110-mroF-goC-iniM-lasrevinU/21/5102/sdaolpu )ACoM( tnemssessa evitingoc laertnoM /gro.tsetacom.www//:sptth )ESMM( noitanimaxe etats latnem iniM 732/yekp/stcudorp/moc.cnirap.www//:sptth fo tnemssessa renoititcarp lareneG )GOCPG( noitingoc sdaolnwod/xedni/ua.moc.gocpg//:ptth 12 هناك خطوة هامة ينبغي اتخاذها قبل إجراء أي عملية لتشخيص التراجع المعرفي وهي تقدير وجود أية ظروف مصاحبة ومعالجتها أوًلا. 1.4 الظروف التي تسبب الأعراض المعرفية تشمل الظروف الشائعة القابلة للإصلاح التي يمكن أن تتسبب في التراجع المعرفي التجفاف، وسوء التغذية، والعداوى، والمشكلات المرتبطة بالأدوية. وبالاعتماد على المعالجة المناسبة لهذه الظروف فإن من المفروض أن تتبدد الأعراض المعرفية للشخص. التجفاف الوخيم. يمكن أن يتسبب التجفاف الوخيم والمشكلات التغذوية الأخرى بالهذيان (الذي يشابه الخرف)، وبالموت في الحالات الوخيمة. الهذيان. إن الهذيان هو الفقد المفاجئ والشديد للقدرة على تركيز الانتباه. كما أن الأشخاص يصابون بالتشوش البالغ بشأن مكان وجودهم وما هو الوقت القائم. ويتطور الهذيان خلال فترة قصيرة وينحو إلى الظهور والاختفاء خلال مجرى اليوم. وقد يكون نتيجة لأسباب عضوية حادة مثل العداوى، والأدوية، والتشوهات الاستقلابية (مثل نقص سكر الدم وفرط صوديوم الدم)، والتسمم الناجم عن تعاطي مواد الإدمان أو الإقلاع عنه. التعديد الدوائي. قد يتفاعل دواءان أو أكثر بما يتسبب في تأثيرات جانبية ضارة (انظر الإطار في الفصل 3، الصفحة 81). وفي غالب الأحيان فإن المهدئات أو المنوِّمات هي المسؤولة عن الاضطرابات المعرفية بين المسنين. تخدير الجراحات الكبرى والتخدير العام. يعتبر تخدير الجراحات الكبرى والتخدير العام من بين المخاطر المعترف بها للتدهور المعرفي. وينبغي على الممارسين الصحيين التساؤل حول ما إذا كان التراجع المعرفي للشخص قد حدث بعد جراحة كبرى. واإ ذا كان الحال كذلك فإن هذا الشخص سيكون عرضة لخطر أشد للإصابة بالتدهور المعرفي في أعقاب أي جراحة كبرى أخرى. ومن الضروري تحديد هذا الخطر المرتفع ومناقشته مع الفريق الجراحي ومع طبيب التخدير قبل أي عملية جراحية أو تخدير في المستقبل. المرض الدماغي الوعائي. يرتبط المرض الوعائي في الدماغ ارتباطًا وثيقًا مع التدهور المعرفي. واإ ذا كان للمريض تاريخ من الإصابة بأحداث السكتة/ السكتة الصغيرة/ النوبة الإقفارية العابرة فإن الوقاية من أي أحداث جديدة هو النهج الرئيسي لوقف المزيد من التراجع في المعرفة. تقدير واإ دارة الأمراض المصاحبة ويشتمل اكتشاف السبب الطبي للتدهور المعرفي القابل للإصلاح فحصًا تشخيصيًا كامًلا. وقد تدعو الحاجة إلى استطلاع عدة تفسيرات محتملة مختلفة للأعراض للوصول إلى النهج الدقيق لخطة الرعاية. 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي 22 • يمكن أن يستفيد المصابون بالتراجع المعرفي من التنبيه المعرفي. • تساهم التدخلات الأخرى لنهج الرعاية المتكاملة للمسنين، مثل التمارين المتعددة المناويل (انظر الفصل 5، محدودية التحرك)، أيضًا في صحة الدماغ. 5 • يمكن أن تؤثر الخسائر في الميادين الأخرى للقدرة الأساسية، ولاسيما السمع، والإبصار، والمزاج على المعرفة. ولتحقيق أفضل الحصائل فإن الأمر قد يتطلب العناية بأمر هذه الخسائر. ويتباين الأفراد المصابين بالتدهور المعرفي في نمط هذا التدهور على امتداد الميادين الأخرى. 2.4 التنبيه المعرفي يمكن أن يؤدي التنبيه المعرفي إلى إبطاء وتيرة التراجع في القدرة المعرفية )7(. ويرمي هذا التنبيه إلى حفز المشاركين عبر الأنشطة المعرفية، والتذكر، وتنبيه الحواس المتعددة، والاحتكاك بالآخرين. ويمكن توفير التنبيه المعرفي لفرد واحد أو ضمن مجموعة. وربما تكون المجموعات أفضل بالنسبة لبعض الأشخاص؛ وقد يكون الاحتكاك الاجتماعي ضمن المجموعة مفيدًا. كما أن المجموعات ربما تكون مناسبة وكفوءة إذا ما كان أفرادها يتقاسمون غاية مشتركة، مثل تحسين الدراية الصحية. ويشتمل نهج المجموعات المعياري على ما يصل إلى 41 جلسة مواضيعية تستغرق كل منها نحو 54 دقيقة، وُتعقد مرتين في الأسبوع. ويتولى ميسِّ ر قيادة هذه الجلسات. وفي العادة فإن الجلسة قد تبدأ ببعض أنشطة الإحماء غير الادراكية ثم تنتقل إلى طائفة متنوعة من المهام المعرفية، بما في ذلك التوجه الواقعي (لوحة تعرض معلومات عن المكان، والتاريخ، والوقت على سبيل المثال). وتركز الجلسات على موضوعات مختلفة، بما في ذلك مثًلا الطفولة، أو استخدام المال، أو الوجوه، أو المناظر. وتتفادى هذه الأنشطة عمومًا تذكر الوقائع وتركز عوضًا عن ذلك على أسئلة مثل «ما السمة المشتركة بين هذه [الكلمات أو الأشياء]؟» من الذي يستطيع القيام بالتنبيه المعرفي؟ يتولى عادة الأطباء النفسيون، في البلدان المرتفعة الدخل، إجراء العلاج بالتنبيه المعرفي. ويمكن أن يقوم بهذا العلاج، بعد المواءمة، غير الأخصائيين من ذوي التدريب والدعم المناسبين. على أن تصميم وتقديم تدخل مشخصن لمصاٍب بأوجه تراجع جسيمة قد يتطلب تقديرًا وتخطيطًا مفصلين، وهي مهام تتطلب مهارات متخصصة. وعلى هذا فإن البروتوكولات المحلية ينبغي أن تتضمن معايير للإحالة إلى إخصائيي الصحة العقلية لتلقي العلاج بالتنبيه المعرفي. يمكن لأفراد الأسرة ومقدمي الرعاية أن يضطلعوا بدور هام في التنبيه المعرفي. من المهم حض أفراد الأسرة ومقدمي الرعاية على تزويد المسنين بمعلومات من قبيل اليوم، والتاريخ، والطقس، والتوقيت، وأسماء الناس، وما إلى ذلك. وتساعد هذه المعلومات المسنين على الحفاظ على الوجهة في الزمان والمكان. كما أن توفير مواد مثل الصحف، والبرامج الإذاعية والتلفزيونية، والألبومات العائلية، والبنود الأسرية، يمكن أن يعزز من التواصل، ويوجه المسنين نحو الأحداث الجارية، وينبه الذاكرة، ويمكِّ ن الشخص من أن يتقاسم ويثمن خبراته. إدارة التدهور المعرفي 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي 32 إذا كان التراجع المعرفي يحد من إدارة الشخص الذاتية واستقلاله، فإن لهذا الشخص على الأرجح احتياجات كبرى للرعاية الاجتماعية. وبمقدور العاملين الصحيين أن يساعدوا مقدمي الرعاية في وضع خطة مخصوصة لأنشطة الحياة اليومية التي تعظِّ م النشاط المستقل، وتعزز الأداء، وتساعد على مواءمة وتطوير المهارات، وتقلل إلى أدنى حد الحاجة إلى الدعم. وبمقدور أفراد الأسرة ومقدمي الرعاية القيام بما يلي: • توفير معلومات التوجه، مثل التاريخ، والأحداث المجتمعية الراهنة، وتحديد هوية الزوار، والطقس، وأنباء أفراد الأسرة؛ • تشجيع وترتيب الاحتكاك مع الأصدقاء وأفراد الأسرة في المنزل وفي المجتمع المحلي؛ • جعل المنزل آمنًا وصونه على هذه الحال للتقليل من خطر السقطات والإصابات؛ • وضع علامات في المنزل، وذلك مثًلا للمرحاض، وغرفة النوم، والباب المفضي إلى الخارج، لمساعدة الشخص على تبين طريقه؛ و • الترتيب لأنشطة مهنية والمشاركة فيها (وفقًا لما هو مناسب لقدرات الشخص). تقدير واإ دارة البيئات الاجتماعية والمادية يواجه مقدمو الرعاية للأشخاص المعانين من تراجع معرفي وخيم مهام جسيمة. ويمكن للإجهاد أن يعرض صحتهم للخطر. انظر الفصل 11 بشأن العناية باحتياجات مقدمي الرعاية. 11 4 القدرة الادراكية مسالك الرعاية لإدارة التراجع الادراكي 42 يمثل التحرك عامًلا محِددًا حاسمًا في التمتع بالصحة في مرحلة الشيخوخة. ومن المهم الحفاظ على الاستقلال الذاتي والحيلولة دون الاتكال على الرعاية. وتسمى القدرة البدنية للشخص للانتقال من مكان إلى آخر بالقدرة التحركية. ويتقبل الكثير من المسنين وأسرهم الخسائر في القدرة التحركية وما يصاحبها من ألم على أنها أمر لا مفر منه. وهذا غير صحيح. وفي الحقيقة فإن هناك استراتيجيات فعالة لتحسين وصون القدرة التحركية في مرحلة الشيخوخة. النقاط الرئيسية تشيع محدودية التحرك في صفوف المسنين ولكنها ليست حتمية. يمكن للعاملين في الرعاية الصحية المجتمعية أن يتحروا عن محدودية التحرك باستخدام اختبارات بسيطة. يتمثل أهم نهج لتحسين أو صون القدرة التحركية في اتباع برنامج للتمارين البدنية المنتظمة. تندرج مواءمة بيئة الشخص واستخدام النبائط المساِعدة في عداد الطرق الجيدة لصون التحرك رغم انخفاض القدرة التحركية. 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 52 1قادر على إتمام وقفات الكرسي الخمس في غضون 41 ثانية دون استخدام الذراعين؟ نعم لا لا للجميع تعزيز صحة الشيخوخة ومشورة نمط الحياة أو الرعاية المعتادة تدعو الحاجة إلى رعاية متخصصة التمارين المتعددة المناويل يشتمل برنامج التمارين المتعددة المناويل الخاص بذوي التحرك المحدود على تمارين وتدريبات متنوعة مع التشديد على مجموعات العضلات الأساسية للظهر، والفخذ، والبطن، وأسفل البدن. وينبغي أن ُيصمم هذا البرنامج بما يتناسب مع القدرات والاحتياجات الفردية. ويوفر مشروع liarfiviV دليًلا عمليًا لوضع برنامج للتمارين متناسب مع القدرات secruoser/moc.liarfiviv.www//:ptth للاطلاع على التوصيات العالمية للمنظمة بشأن النشاط البدني، انظر الإطار، الصفحة 03 توفير التمارين المتعددة المناويل تحت إشراف وثيق النظر في الإحالة إلى التأهيل النظر في زيادة مدخول البروتين دراسة وتوفير نبيطة مساعدة للتحرك التوصية بالتمارين المتعددة المناويل في المنزل مساندة الإدارة الذاتية لزيادة الامتثال تحرك محدود (0-9 درجات لاختبارات BPPS) تحرك طبيعي (01-21 درجات لاختبارات BPPS) تقدير التحرك (اختبارات BPPS أو اختبار آخر للأداء البدني) تحرَّ عن خسائر التحرك اختبار القيام من الكرسي تقدير واإ دارة البيئات الاجتماعية والمادية تقدير البيئة المادية للحد من مخاطر السقطات إدراج تدخلات توقي السقطات مثل تكييف المنزل دراسة وتوفير نبيطة مساعدة للتحرك توفير مساحات آمنة للمشي استعراض الأدوية والسعي للحد منها الإدارة المتكاملة للأمراض النظر في إدارة الألم - التعدد الدوائي - الهشاشة وضمور اللحم - الألم - الفصال العظمي، والتخلخل العظمي، والقيود الأخرى المفصلة العظيمة تقدير واإ دارة الظروف المصاحبة نعم 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 1عندما يتطلب الأمر رعاية متخصصة 2 ينبغي تقدير القدرة التحركية بالإضافة إلى الجوانب الأخرى للقدرة الأساسية، مثل المعرفة، والقدرات الحسية، والحيوية، والنفسية. واإ ذا ما كانت التراجعات الجسيمة في القدرات البدنية أو العقلية أو المراضات المشتركة تجعل من التوصية بالتمارين أمرًا معقدًا فربما يتطلب الأمر معرفة متخصصة لاستنباط برنامج مناسب للتمارين. ويجوز النظر في مسألة الإحالة إلى التأهيل. اختبار القيام من الكرسي بمقدور اختبار بسيط أن يحدد ما إذا كان المسن بحاجة إلى المزيد من عمليات التقدير لمحدودية التحرك. التعليمات: اسأل الشخص، «هل تعتقد أن من المأمون بالنسبة لك أن تحاول الوقوف من الكرسي خمس مرات دون استعمال ذراعيك؟» (قدم له بيانًا عمليًا بذلك) إذا كان الرد بالإيجاب، اطلب إليه ما يلي: - اجلس وسط الكرسي - اعقد ذراعيك على صدرك واتركهما هناك - قم إلى وضع الوقوف الكامل ثم اجلس ثانية - كرر خمس مرات بأسرع ما تستطيع دون توقف احسب الزمن الذي يستغرقه الشخص في الاختبار - تدعو الحاجة إلى مزيد من التقدير إذا عجز عن الوقوف خمس مرات في غضون 41 ثانية. مجموعة الأداء البدني القصير )BPPS( تتوافر تشكيلة واسعة من اختبارات الأداء البدين، إلا أنه يوصى باستخدام مجموعة BPPS لأنها تتمتع بخصائص قياس فائقة ونظرًا لأنها مفيدة على امتداد طائفة من القدرات. وتقيس تدابير المجموعة الأداء زمنيًا في ثلاث مهام، ُتمنح كل منها درجة من أصل أربع درجات، لاستخلاص درجة كلية تتراوح بين الصفر (الأداء الأسوأ) إلى 21 (الأداء الأفضل). صف، أوًلا، كل اختبار واسأل الشخص إذا كان يشعر بأنه قادر على القيام به واإ ذا لم يكن كذلك فضع درجة لذلك وانتقل إلى الخطوة التالية. 1. اختبارات التوازن: الوقوف لمدة 01 ثوان على أن تكون القدمان في أحد الأوضاع التالية. استخدام حاص الدرجات المحققة في الأوضاع الثلاثة. 2. اختبار سرعة المشي - الوقت اللازم لقطع أربعة أمتار مشيًا. الوقت اللازم لقطع أربعة أمتار مشيًا: > 28.4 ثانية 4 نقاط 28.4 – 02.6 ثانية 3 نقاط 12.6 – 07.8 ثانية 2 نقطة < 07.8 ثانية 1 نقطة العجز عن الإكمال 0 نقطة 3. اختبار القيام من الكرسي: الوقت اللازم للقيام من الكرسي خمس مرات > 91.11 ثانية 4 نقاط 2.11 – 96.31 ثانية 3 نقاط 7.31 – 96.61 ثانية 2 نقطة 7.61 – 9.95 ثانية 1 نقطة < 06 ثانية أو العجز عن الإكمال 0 نقطة درجة BPPS النهائية = حاصل الدرجات من الاختبارات الثلاثة أعلاه للاطلاع على المزيد من التفاصيل عن اختبارات BPPS: /stnemucod/hcraeser/asc/ude.notrelluf.scdh//:ptth fdp.teehserocs_snoitcurtsnibpps ألف- الوقوف جنبا إلى جنب البقاء لمدة 01 ثوان 1 نقطة عدم البقاء لمدة 01 ثوان 0 نقطة عدم المحاولة 0 نقطة في حال عدم المحاولة، يجب إيقاف الاختبارات باء- الوقوف شبه الترادفي البقاء لمدة 01 ثوان 1 نقطة عدم البقاء لمدة 01 ثوان 0 نقطة عدم المحاولة 0 نقطة في حال عدم المحاولة، يجب إيقاف الاختبارات جيم- الوقوف الترادفي البقاء لمدة 01 ثوان 2 نقطة البقاء لمدة 3 ثوان إلى 99,9 ثانية 1 نقطة البقاء أقل من 3 ثوان 0 نقطة عدم المحاولة 0 نقطة 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 72 ومن بين هذه الاختبارات اختبار القيام من الكرسي. وينبغي تكرار هذا الاختبار بعد أداء الاختبارين الآخرين وهما: • اختبار التوازن – الوقوف لمدة 01 ثوان في كل وضع من ثلاثة أوضاع للقدمين • اختبار سرعة المشي – ما هو الوقت اللازم لقطع أربعة أمتار مشيًا. وُتجمع الدرجات المحرزة في كل اختبار معًا. وتعني الدرجات المنخفضة المعاناة من محدودية التحرك. ويعرض المسلك طريقين مختلفين للإدارة تبعًا لمجموع الدرجات المحرزة. ويمكن الاطلاع على المزيد من المعلومات عن الاختبارات وكيفية منح الدرجات في الصفحة السابقة. عندما يتطلب الأمر رعاية متخصصة (معلومات إضافية) قد يقتضي الأمر توفير رعاية متخصصة أيضًا لشخص يواجه ما يلي: • ألم متواصل يؤثر على المزاج وعلى مجالات الأداء الأخرى • اختلالات جسيمة في أداء المفاصل • كسر في العظم بعد رضح طفيف • مخاطر سلامة (انظر الإطار في الصفحة المقابلة) • حاجة إلى المعونة في اختيار النبيطة المساِعدة المناسبة للتحرك. يمكن تقدير التحرك بصورة أكمل من خلال منح درجات لأداء الشخص اعتمادًا على ثلاثة اختبارات بسيطة. وُتعرف هذه الاختبارات معًا باسم مجموعة الأداء البدني القصير )BPPS(. تقدير التحرك 82 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 1.5 برنامج التمارين المتعددة المناويل بالنسبة للأشخاص المعانين من محدودية التحرك فإنه ينبغي تصميم برنامج مخصوص للتمارين المتعددة المناويل بما يتناسب مع القدرات والاحتياجات الفردية. ويمكن أن يتضمن البرنامج المتعدد المناويل الخاص بالأشخاص المعانين من محدودية التحرك ما يلي: • تدريبات قوة/ مقاومة، والتي تتطلب عمل العضلات في ظل الأحمال، باستخدام الأوزان، أو شرائط مقاومة، أو تمارين وزن البدن مثل القرفصة، والاندفاع، والجلوس ثم الوقوف؛ • التدريبات الحيوائية/ القلبية الوعائية، مثل المشي السريع أو ركوب الدراجة الذي يزيد من ضربات القلب إلى ـمرحلة انقطاع النفس قليًلا ولكن من الحفاظ على القدرة على تبادل الحديث؛ • تدريبات التوازن، التي تتحدى نظام التوازن، بما في ذلك التمارين السكونية والدينامية؛ ويمكن أن تتقدم بحيث ُتنفذ على سطوح مختلفة مع فتح العيون واإغماضها؛ ومن الأمثلة على ذلك الوقوف على ساق واحدة لبعض الوقت وممارسة مشية العقب ثم الأصابع في خط مستقيم؛ و • تدريبات المرونة، التي تحسن من سحوبية الأنسجة الرقيقة مثل العضلات، ومدى حركة المفاصل؛ ومن الأمثلة على ذلك تمارين الشد، وغيرها من تمارين اليوغا والبيلاتس. التغذية. يمكن لزيادة مدخول البروتين والتدخلات التغذوية الأخرى أن تعزز من فوائد برنامج التمارين البدنية. انظر الفصل 6 عن التغذية. 6 إدارة محدودية التحرك مأمونية التمارين. قبل إعطاء المشورة بشأن التمارين أو تخطيط برنامج لها، ينبغي الاستفسار عن الظروف الصحية التي ستؤثر على توقيت وشدة النشاط. وفي حال إجابة الشخص المعني بنعم على أي من الأسئلة التالية فإن على مهني صحي ماهر أن يضع برنامجًا مخصوصًا للتمارين. • هل عانيت من ألم صدري في وضع الراحة؟ • هل عانيت من نوبة قلبية خلال الأشهر الستة الماضية • هل أُغمي عليك أو فقدت الوعي؟ • هل تعرضت لسقطة خلال الأشهر الاثني عشر الماضية؟ • هل تعرضت لكسر في العظام خلال الشهر الماضي؟ • هل ينقطع نفسك خلال الأنشطة اليومية العادية في المنزل، وذلك عندما ترتدي ملابسك مثًلا؟ • هل تعاني من مرض في المفاصل أو العضلات يحد من القيام بالتمارين؟ • هل طلب منك مقدم للرعاية الصحية الحد من القيام بالتمارين؟ يوفر مشروع liarfiviV دليًلا عمليًا لوضع برنامج مخصوص للتمارين. secruoser/moc.liarfiviv.www//:ptth 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 92 إدارة القيود. حينما يحد الألم من التحرك، فإن تنظيم النشاط البدني وفقًا لشرائح زمنية ميسورة الإدارة وزيادة المهام البدنية بوتيرة بطيئة يساعدان على بناء قدرة البدن على الصمود واإ دارة الألم. وبالنسبة للأشخاص المعانين من انخفاض حاد في التحرك فإن إجراء التدريبات البدنية في الفراش أو في وضع الجلوس على كرسي يمكن أن يشكل نقطة للبداية. أما بالنسبة للأشخاص المعانين من قيود في المعرفة، مثل الخرف، فإن برنامجًا بسيطًا للتمارين أقل انتظامًا قد يكون أكثر ملاءمة. 2.5 مساندة الإدارة الذاتية تزيد مساندة الإدارة الذاتية من الامتثال إلى برنامج للتمارين المتعددة المناويل ومن الفوائد المستخلصة منه. وبمقدور الأشخاص الذين تتراوح درجاتهم في مجموعة الأداء البدني القصير بين 01 درجات و 21 درجة أن يمارسوا التمارين في المنزل وفي المجتمع المحلي. أما الأشخاص المعانين من قيود وخيمة أشد على التحرك فإنهم قد يحتاجون إلى الإشراف والإرشاد خلال التمارين. ويشرح كتيب التمتع بالصحة في مرحلة الشيخوخة المستند إلى الأجهزة المتنقلة )gniegAm( كيف يمكن لتطبيق من تطبيقات الهواتف المتنقلة أن يستكمل الرعاية الروتينية لمهنيي الرعاية الصحية من خلال مساندة الرعاية الذاتية والإدارة الذاتية. للمزيد من المعلومات انظر: gniegAm/smetsys-htlaeh/gniega/tni.ohw.www//:ptth توصيات المنظمة الشاملة بشأن النشاط البدني بمقدور كل المسنين الاستفادة من المشورة بشأن النشاط البدني الموصى به لعمرهم، مع مراعاة ظروفهم الصحية. ويوجز هذا الإطار توصيات المنظمة العامة عن النشاط البدني لمن هم من عمر 56 سنة فأكثر. عليك خلال كل أسبوع ممارسة النشاط البدني الحيوائي ذي الشدة المعتدلة لمدة لا تقل عن 051 دقيقة أو النشاط الحيوائي الشديد لمدة 57 دقيقة على الأقل، أو توليفة مكافئة من هذين. مارس التمارين لمدة لا تقل عن 01 دقائق في كل مرة. للحصول على المزيد من الفائدة عليك كل أسبوع ممارسة النشاط البدني الحيوائي ذي الشدة المعتدلة لمدة لا تقل عن 003 دقيقة أو النشاط الحيوائي الشديد لمدة 051 دقيقة على الأقل، أو توليفة مكافئة من هذين. قم بأنشطة لتقوية العضلات يومين في الأسبوع أو أكثر. إذا كان مستوى التحرك ضعيفًا قم بنشاط بدني يعزز من التوازن في ثلاثة أيام من الأسبوع أو أكثر. إذا ما تعذر عليك ممارسة التمارين كما هو موصى به، فكن نشيطًا بدنيًا قدر استطاعتك. للاطلاع على مزيد من المعلومات انظر: lmth.xedni/ne/ap/ytivitcalacisyhpteid/tni.ohw.www//:ptth 03 5 القدرة التحركية مسالك الرعاية لتحسين التحرك 3.5 التعديد الدوائي يمكن أن تؤدي بعض الأدوية إلى الإخلال بالتحرك أو عرقلة التوازن رغم أنها ليست ضرورية أو غير فعالة أحيانًا بالنسبة لشخص معين )8(. وتشمل هذه الأدوية، على سبيل المثال لا الحصر، ما يلي: • مضادات الاختلاج • مركبات البنزوديازيبين • المنومات من غير مركبات البنزوديازيبين • مضادات الاكتئاب الثلاثية الحلقات • مضادات الاكتئاب المركبة من مثبطات امتصاص السيروتونين الانتقائية (IRSS) • مضادات الذهان • الأفيونات. ويخفف إلغاء الأدوية غير الضرورية وغير الفعالة وكذلك الأدوية ذات التأثير المكرر من التعديد الدوائي. واإ ذا ما ساورتك الشكوك بشأن ما إذا كان من المأمون إيقاف تعاطي دواء ما فإن عليك الرجوع إلى أخصائي مناسب. 4.5 الألم تقدير الألم. يمكن أن يحد الألم الشديد المترافق مع الحركة من التمارين البدنية أو يحول دونها تماما. ومن المفيد تصنيف شدة الألم المتعلقة بالتحرك، وذلك للمساعدة في تصميم برنامج للتمارين ولإدارة الألم في الوقت ذاته. وللاطلاع على قائمة مختصرة بشأن الألم يمكن لك استخدامها انظر: /019212/5100/elfi_fdp/stessa/atad__/ua.vog.wsn.htlaeh.ica.www//:sptth fdp.laniF_yrotnevnI_niaP_feirB إدارة الألم )9(. تشتمل الظروف العضلية الهيكلية التي تخل بالتحرك في غالب الأحيان ألمًا متواصلا. وقلما يمكن اكتشاف سبب بيولوجي نوعي للألم المتواصل. ولذلك فإن نهج الممارسة المثلى إزاء إدارة الألم يتمثل في العناية بأمر عوامل متعددة قد تكون مرتبطة بالألم وهي: العوامل البدنية (مثل القوة العضلية، ومدى الحركة، والتحمل)، والعافية النفسية، والتغذية، والنوم. وحينما يشكل الألم عائقًا بالغًا أمام الحركة والنشاط فإن على مهني صحي ذي معرفة متخصصة بإدارة الألم أن يضع خطة لإدارة هذا الألم. وتشمل التدخلات المتعلقة بالألم ما يلي: • الإدارة الذاتية • التمارين والأنشطة البدنية الأخرى • الأدوية التي تتراوح بين الباراسيتامول والعقاقير اللاسترويدية المضادة للالتهاب إلى الغابابنتين والأفيونات • العلاج اليدوي مثل التدليك، وتقويم المفاصل، وتحريك المفاصل • العلاج النفسي والعلاج المعرفي السلوكي (انظر الفصل 9 عن الأعراض الاكتئابية) 9 • الوخز بالإبر • الحقن النخاعية/ الحقن فوق الجافية • إزالة التعصيب بالترددات الراديوية تقدير واإ دارة الظروف المصاحبة ويمكن إتاحة بعض هذه التدخلات في المجتمع المحلي. وستتطلب التدخلات الأخرى على الأرجح الإحالة إلى مرفق مركزي. 13 5 القدرة التحركية مسالك الرعاية لتحسين التحرك تقدير واإ دارة البيئات الاجتماعية والمادية قد يحتاج الشخص المعاني من محدودية التحرك إلى المساعدة في التعامل مع الأنشطة اليومية. وتتمثل الخطوة الأولى في تقدير احتياجات الرعاية الاجتماعية (انظر الفصل 01). وقد تشمل الاحتياجات المخصوصة للرعاية الاجتماعية للمسنين المصابين بخسائر في التحرك تلك الاحتياجات التي يكشف عنها تقدير لبيئتهم المادية أو الحاجة إلى نبائط مساِعدة. ويمكن لبرنامج للتمارين البدنية أن يسهم في الوقاية من السقطات. 5.5 تقدير البيئة المادية للحد من مخاطر السقطات يتضمن تقدير البيئة المادية استطلاع المنزل للكشف عن الأخطار المحتملة وطرح الاقتراحات. وقد تشمل الأمثلة خفض الضجيج، واإ زالة الُبسط السائبة، وتسوية التحدبات في الأرضيات والدرجات، ونقل الأثاث لإنشاء مسالك طليقة واسعة، وتحسين الإضاءة، وتيسير الوصول إلى المرحاض، ولاسيما أثناء الليل (من خلال إضافة قبضات مثبتة على الجدران مثلا). وسيكفل إنشاء ممر منحدر نحو المدخل الرئيسي تسهيل الأمور بالنسبة لمستخدمي الكراسي المتحركة وغيرهم ممن يعانون من صعوبة في استعمال الأدراج. وستتحدد أهم تدابير المواءمة البيئية في ضوء قيود التحرك المخصوصة للشخص المعني. وعبر التدريب النوعي فإن باستطاعة مقدم خدمات الرعاية الأولية المجتمعية أو المرفقية أن يقدر وضع منزل الشخص. واإ ذا تعذر القيام بزيارة فإن بإمكان العاملين الصحيين في الرعاية الأولية إعطاء توجيهات عامة عوضًا عن ذلك إلى الشخص أو إلى مقدم الرعاية حول سبل إنشاء بيئة منزلية مأمونة. ويتطلب التقدير الكامل والإدارة الشاملة لمخاطر سقوط الشخص معارف متخصصة. 6.5 النظر في النبائط المساِعدة وتوفيرها قد يحتاج الأشخاص المعانين من قيود في التحرك إلى نبائط مساِعدة للتنقل. والنبائط المساِعدة هي تلك التي تتمثل الغاية الرئيسية منها في صون أو تحسين القدرة الأدائية للشخص واستقلاله تيسيرًا للمشاركة وتعزيزًا للعافية الكلية )01(. ويشمل ذلك العصي، والعكاكيز الإبطية، والمشَّ ايات، والكراسي المتحركة، والنبائط التعويضية أو التقويمية. وقد تكون الخيارات محدودة بسبب التكلفة أو قلة التوافر، غير أن بمقدور المهني الصحي العارف بالعلاج الفيزيائي، إن كان موجودًا، أن يقدم النصيحة الفضلى بشأن اختيار النبيطة المناسبة وتقديم الإرشادات حول كيفية استخدامها بأمان. ويمكن أن يزيد التراجع في أي من القدرات الأساسية من مخاطر السقطات. كما أن البيئة المادية وطريقة أداء المهام أو الأنشطة يمكن أن تكون من بين العوامل المعنية. وفضًلا عن تقدير البيئة المادية فإن التقدير الكامل لمخاطر السقطات يشمل ما يلي: • تدوين تاريخ السقطات، بما في ذلك الأنشطة الجاري تنفيذها؛ • تقدير المشية، والتحرك، وأداء العضلات والمفاصل، والمرونة؛ • تقدير الخوف من السقوط، والإبصار، والمعرفة، والوضع القلبي الوعائي، والوضع العصبي، والإلحاح البولي أو البوال الليلي (المشي ليًلا بغرض التبول)؛ و • استعراض الأدوية للتحري عن التعديد الدوائي (انظر الفصل 3 بشأن تقدير ووضع خطة). وسيحتاج بعض الأشخاص إلى المزيد من التقدير والإدارة بشأن مشكلات مثل الَغشي (الإغماءات)، والصرع، والاضطرابات التنكسية العصبية مثل مرض باركينسون. 23 5 القدرة التحركية مسالك الرعاية لتحسين التحرك تستخدم المنظمة مصطلح الحيوية لوصف العوامل الفيزيولوجية التي تسهم في القدرة الأساسية للفرد. وقد تشمل هذه العوامل توازن الطاقة والاستقلاب. ويركز هذا الكتيب على عامل رئيسي واحد من عوامل تراجع الحيوية في مرحلة الشيخوخة ألا وهو التغذية. النقاط الرئيسية يمكن للعاملين الصحيين للرعاية الأولية أن يقوموا بسهولة بتقدير أولى للوضع التغذوي. وينبغي أن يكون ذلك جزءًا من أي تقدير لصحة المسن. ويتطلب التقدير الكامل للوضع التغذوي معارف متخصصة وكذلك إجراء فحوص للدم أحيانًا. وتؤدي التغذية غير الكافية وانخفاض النشاط البدني على حد سواء إلى فقد الكتلة العضلية والقوة. وفي العادة فإن النظام الغذائي المتوازن ذا الكميات الكافية يوفر الفيتامينات والمعادن الضرورية للمسنين، غير إن الإصابة شائعة بعوز فيتامين دال وفيتامين باء21. وغالبًا ما يؤدي سوء التغذية إلى فقد الوزن، ولكن ذلك لا يحدث دائمًا. إذ تستطيع الكتلة الدهنية أن تحل محل الكتلة العضلية بحيث يظل الوزن على حاله. وتعد السمنة جانبًا آخر من جوانب سوء التغذية، غير أن هذا الكتيب لا يتناولها بالبحث. 6 الحيوية مسالك الرعاية لإدارة التغذية 33 ?? i تحرَّ عن سوء التغذية في المجتمع المحلي هل فقدت أكثر من 3 كغ من وزنك دون أن تتعمد ذلك خلال الأشهر الثلاثة الماضية؟ هل عانيت من فقد الشهية؟ (لأي من السؤالين) تعزيز صحة الشيخوخة ومشورة نمط الحياة أو الرعاية المعتادة تقدير الوضع التغذوي مثل التقدير التغذوي الوجيز )ANM( )8( اسأل لالا نعم مصاب بسوء التغذية (درجة NAM: > 71 نقطة) معرض لخطر سوء التغذية (درجة NAM: 71-5.32 نقطة) وضع تغذوي طبيعي (درجة NAM: 42-03 نقطة) تقدير واإ دارة البيئات الاجتماعية والمادية تذليل الحواجز أمام الصحة التغذوية للأشخاص تشجيع الولائم الأسرية والاجتماعية ترتيب المساعدة في إعداد الطعام وتوفيره الإدارة المتكاملة للأمراض انظر في القيام بالتأهيل لتحسين الأداء العضلي تقدير واإ دارة الظروف المصاحبة والمادية - الهشاشة - ضمور اللحم تدعو الحاجة إلى رعاية متخصصة التغذية التكميلية الفموية توفر التغذية التكميلية الفموية مقادير إضافية من البروتينات، والسعرات الحرارية ذات الجودة الرفيعة، وكميات كافية من الفيتامينات والمعادن تتناسب مع الاحتياجات، والأذواق، والقيود البدنية المخصوصة للشخص المعني. التدخل التغذوي ضروري وفرِّ التغذية التكميلية الفموية مع زيادة مدخول البروتين 004-006 سعرة حرارية/يوم قدم المشورة الغذائية ارصد الوزن بدقة تقديم المشورة الغذائية انظر في تقديم التغذية التكميلية الفموية إذا تعذر تحسين المدخول الغذائي ارصد الوزن بدقة انظر في توفير التمارين المتعددة المناويل تعزيز صحة الشيخوخة ومشورة نمط الحياة أو الرعاية المعتادة إعادة التقدير... - بعد حدث أو مرض شديد - مرة في السنة للمسنين المقيمين في المجتمع المحلي - مرة كل ثلاثة أشهر للمسنين ذوي احتياجات الرعاية الاجتماعية 6 الحيوية مسالك الرعاية لإدارة التغذية 12 المشورة المقدمة بشأن التغذية • بمقدور العاملين الصحيين للرعاية الأولية توفير المشورة للمسنين وتشجيعهم على اعتماد نظام غذائي صحي. ويستطيع المسنون الاستفادة من هذه المشورة، بمن فيهم أولئك المعرضون لخطر نقص التغذية أو المصابون به، سواء أكانوا بحاجة إلى رعاية متخصصة أم لا. ومن السهل على الأشخاص الذين يدونون في سجل ما يتناوله خلال الوجبات وفيما بينها اتباع نظام غذائي جيد. وتوفير ما ً • مساعدة الأشخاص على تحديد أغذية مخصوصة متاحة محليا يكفي من الطاقة (كربوهيدرات)، والبروتينات، والمغذيات الزهيدة المقدار مثل الفيتامينات والمعادن. ويتعين تقديم المشورة بشأن المقادير الكافية من هذه الأغذية. • وبالنظر إلى أن امتصاص البروتينات يتناقص مع التقدم في العمر، فينبغي توفير المشورة للمسنين لتناول الكثير منها. ويوصى بأن يبلغ مدخول البروتين 2,1-0,1 غ لكل كيلوغرام من وزن البدن بالنسبة للمسنين الأصحاء. وقد يحتاج شخص يتعافى من فقد الوزن أو من مرض حاد أو إصابة إلى ما يصل إلى 5,1 غ لكل كيلوغرام من وزن البدن. وتدعو الحاجة إلى رصد الأداء الكلوي حيث أن مدخول البروتين العالي قد يؤدي إلى زيادة الضغط الُكبيبي وفرط الترشيح الكبيبي. • تقديم المشورة بشأن النشاط البدني الذي يتيح إدماج البروتينات في العضلات ويبني الشهية. • تشجيع التعرض لأشعة الشمس كي ينتج الجلد فيتامين دال. إذ أن مقادير هذا الفيتامين الموجودة في الأغذية غير كافية للمسنين للحفاظ على المستويات المثلى. وتدعو الحاجة إلى تحليل للدم لقياس ما إذا كان مستوى فيتامين دال عند الشخص المعني كافيا. ما لا يتناول المسنون ما يكفي من غذاء. ولمساعدتهم على تناول ً • غالبا المزيد فينبغي اقتراح وجبات ذات نمط أسري وتناول الطعام في سياق اجتماعي، ولاسيما بالنسبة للمسنين الذين يعيشون بمفردهم أو يعانون من العزلة الاجتماعية. تذكر! على العاملين في الرعاية الصحية تزويد أفراد الأسرة ومقدمي الرعاية الآخرين وكذلك المسنين بالمعلومات. عندما يتطلب الأمر معارف متخصصة يمكن للعاملين في الرعاية الصحية الأولية في المرافق والمجتمعات المحلية أن يقدموا المشورة والمساندة لمساعدة كل المسنين على الحفاظ على نظام غذائي صحي. ويحتاج المصابون بسوء التغذية أو المعرضون بشدة لخطره إلى جهة لتقديم الرعاية ذات معارف متخصصة لدراسة الأسباب وعوامل الخطر والتوصية بخطة تغذية مشخصنة. وعند التنبيه إلى الإصابة بسوء التغذية فإنه ينبغي إجراء أو الحصول على تقدير آخر للظروف المحتملة التي قد تكمن وراء هذه الظاهرة أو تفضي إليها – حتى لو كان الوضع التغذوي الراهن يبدو كافيا. وتشمل علامات مثل هذه الظروف الهزال، وفقد الوزن السريع، والألم الفموي، وألم أو صعوبة البلع، والإسهال أو التقيؤ المزمن، والألم البطني. تقدير الوضع التغذوي تتوافر أدوات جيدة للمساعدة في تقدير الوضع التغذوي )11( منها مثًلا: يستخدم مسلك الرعاية المدرج في الصفحة المقابلة التقدير التغذوي الوجيز )ANM(. )8( )ANM( tnemssessa lanoitirtun iniM tnemssessa ksir noitirtun ENIMRETED /smroF/AAA/sredivorp/su.xt.etats.sdad.www//:sptth( )fdp.ARN/dezidradnats loot gnineercs lasrevinu noitirtunlaM )fdp.lluf_tsum/tsum/sfdp/ku.gro.nepab.www//:sptth( gnitae rof noitaulave ksir ytinummoc eht ni sroineS eriannoitseuq noitirtun dna )/0572/tcejorp/cilbup/moc.xobtnifl.www//:sptth( +56 eriannoitseuq tnemssessa lanoitirtun trohS /stikloot/ue.noitirtunlamthgfi.www//:ptth( )+56QANS( .)sloot-gnineercs-yrammus 53 6 الحيوية مسالك الرعاية لإدارة التغذية تستفسر معظم أدوات تقدير التغذية عن الجوانب التالية: • مدخول الأغذية والسوائل • فقد الوزن مؤخرًا (سؤال اكتشاف الحالات ذاته) • التحرك • الإجهاد النفسي أو المرض الشديد في الفترة الأخيرة • المشكلات النفسية • الوضع المعيشي. كما أن هذه الأدوات تقوم بتدوين ما يلي: • الوزن • الطول • مؤشر كتلة الجسم (IMB – الوزن بالكغ/ مربع الطول بالمتر) • كفاف الذراع والرَّبلة. تقدير الوضع التغذوي تركيب كتلة الجسم والتشيخ بعد انقضاء 07 سنة من العمر فإن الكتلة العضلية قد تنخفض عادة بما يمكن أن يسفر عن تأثيرات مؤذية على الحيوية. وتؤدي التغذية غير الكافية وقلة التمارين البدنية على حد سواء إلى فقد الكتلة العضلية والقوة. وفي الوقت ذاته فإن الكتلة الدهنية قد تزداد. ويمكن أن ينخفض وزن البدن، أو قد يظل على حاله، بما يخفي التغيرات المؤذية المحتملة. ولذلك فإن ناقص التغذية قد يفقد النسيج البدني الغث الحاسم ويظل محافظًا على مؤشر كتلة الجسم ضمن المدى المقبول بل وضمن مدى فرط الوزن. وبمقدور شخص مدرب من غير المختصين أن يقدر بصورة موثوقة أداء العضلات، وبالتالي سوء التغذية البروتيني، باستخدام أداة مثل المقياس اليدوي لقوة التقلص العضلي لقياس قوة القبضة. وتقيس هذه الأداة مقدار القوة التي يمكن فيها للشخص أن يضغط الأداة بيد واحدة. ويشير ضعف قوة القبضة إلى الحاجة إلى التمرين البدين واإ لى نظام غذائي يشتمل على المزيد من البروتينات. 63 6 الحيوية مسالك الرعاية لإدارة التغذية 2.6 بالنسبة للمسنين المصابين بسوء التغذية عند تحديد إصابة الشخص بسوء التغذية (تقل درجته في التقدير التغذوي الوجيز عن 71) فإن ينبغي البدء بتدخل تغذوي على الفور. وبمقدور العاملين الصحيين للرعاية الأولية أن يقدموا فورًا المشورة التغذوية المعيارية (انظر الإطار في الصفحة 53). كما أن على العاملين الصحيين ذوي المعارف المتخصصة أن يوفروا المشورة التغذوية، وأن يصفوا، حسب الاقتضاء، تغذية تكميلية فموية (انظر أدناه). وينبغي أن يكون التدخل جزءًا من خطة رعاية شاملة تتصدي للعوامل الدفينة المساهمة في رداءة التغذية، إلى جانب تدخلات أخرى ُتعنى بالميادين الأخرى للقدرة الأساسية، مثل محدودية التحرك. وعلى وجه الخصوص فإن المدخول الكافي من الطاقة والبروتين سيعزز من فعالية برامج التمارين البدنية المتعددة المناويل (انظر الفصل 5 بشأن محدودية التحرك). 5 التغذية التكميلية الفموية توفر التغذية التكميلية الفموية مقادير إضافية من البروتينات، والسعرات الحرارية ذات الجودة الرفيعة، وكميات كافية من الفيتامينات والمعادن. ويتطلب الأمر معارف متخصصة لوضع خطة لهذه التغذية تتناسب مع الاحتياجات، والأذواق، والقيود البدنية المخصوصة للشخص المعني. ويتيح التقدير اختيار الطريقة الفضلى للتكميل سواء كان ذلك عبر الأغذية الغنية بالمغذيات، أو بحبات التكميل بالفيتامينات أو المعادن، أو من خلال المنتجات التجارية المتخصصة، أو تؤدي الاختلالات الحسية (انخفاض الإحساس بالطعم والرائحة)، وسوء الصحة الفموية مثل مشكلات المضغ وصعوبات البلغ، والعزلة، والشعور بالوحدة، وانخفاض الدخل، والظروف المزمنة المعقدة والطويلة الأجل، جميعًا إلى زيادة خطر الإصابة بسوء التغذية في مرحلة الشيخوخة. 1.6 بالنسبة للمسنين المعرضين لخطر سوء التغذية يمكن أن يستفيد المسن المعرض لخطر سوء التغذية (تبلغ درجته في التقدير التغذوي الوجيز 5.32 -71 مثًلا) من المشورة بشأن التغذية (انظر الإطار في الصفحة 53). كما أن من المفضل أن ُيعرض على مثل هذا الشخص تدخل غذائي للوقاية من الإصابة بسوء التغذية. إدارة سوء التغذية في مرحلة الشيخوخة 73 6 الحيوية مسالك الرعاية لإدارة التغذية ينبغي أن توصف التغذية التكميلية الفموية عندما يعجز الشخص فحسب عن استهلاك أغذية منتظمة كافية غنية بالسعرات الحرارية والمغذيات أو حينما تكون هذه التغذية استراتيجية مؤقتة بالإضافة إلى الاستراتيجيات الغذائية المنتظمة لزيادة مدخول السعرات الحرارية. المستحضرات التغذوية غير التجارية. وبمقدور العاملين الصحيين في المجتمع المحلي أن يساندوا الأشخاص المتلقين للتغذية التكميلية الفموية ويرصدوا أوضاعهم (انظر الإطار). فحص الدم ينير فحص الدم جهود وضع الخطة التغذوية المشخصنة. وبمقدور هذا الفحص أن يحدد حالات العوز المخصوصة من الفيتامينات والمعادن. ويمكن للحقن أو المكملات التغذوية الفموية النوعية معالجة هذه الحالات. وعلى سبيل المثال فإن الحاجة تدعو إلى أقراص أو حقن لمعالجة الحالات الشائعة للعوز بفيتامين دال وفيتامين باء21. النقاط الرئيسية عن التغذية التكميلية الفموية للأغذية موقع الصدارة. وما لم تكن الحاجة ملحة إلى التغذية التكميلية الفموية فإن من الواجب أوًلا تجربة إدخال تحسينات على النظام الغذائي، إن أمكن، وزيادة وتيرة الوجبات. تشكل التغذية التكميلية الفموية عنصرًا مضافًا إلى الأغذية. وينبغي أن يفهم الشخص المتلقي لهذه التغذية الحاجة إلى أن يواصل تناول الطعام أيضًا قدر المستطاع. يحتاج الناس إلى توجيهات بشأن كيفية مزج التغذية التكميلية الفموية، والمقادير الواجب تناولها في كل مرة، ومواعيد ذلك. ينبغي تناول التغذية التكميلية الفموية بين الوجبات، لا في أوقات الوجبات. يحتاج الناس عادة إلى المساندة والتشجيع باستمرار (من أفراد الأسرة، ومقدمي الرعاية، والعاملين الصحيين) لمواصلة تناول التغذية التكميلية الفموية ولمتابعة تناول الطعام أيضًا قدر المستطاع. بعد مضي بعض الوقت قد يمل الشخص من طعم وقوام نوع واحد من التغذية التكميلية الفموية. وربما يساعد في هذا الشأن تقديم طائفة متنوعة من النكهات واإ جراء تغيير من حين إلى آخر. ينبغي رصد الوزن وتسجيله بانتظام. ينبغي أن يكون الهدف في الوضع المثالي إيقاف التغذية التكميلية حال زوال خطر سوء التغذية وتوفير النظام الغذائي لتغذية كافية. 83 6 الحيوية مسالك الرعاية لإدارة التغذية تقدير واإ دارة الظروف المصاحبة 3.6 الضمور العضلي والضعف البدني يندرج الضمور العضلي والضعف البدني ضمن الحالات التي يمكن ربطها برداءة التغذية. وبمقدور تدخلات نمط الحياة، بما في ذلك تحسين النهوض بالتغذية وبالتمارين البدنية، أن تساعد على معالجة هذين الأمرين. الضمور العضلي. يصف هذا المصطلح الفقد العام والمتزايد للكتلة العضلية، والقوة، والأداء. ويمكن أن يجئ ذلك نتيجة المرض، أو رداءة التغذية، أو الافتقار إلى النشاط البدني (الاستلقاء في الفراش لفترات طويلة مثًلا)، أو ربما لا يكون لذلك سبب ظاهر وقد يرتبط بعملية التشيخ. الضعف البدني. يمكن أن يشتمل الضعف البدني فقد الوزن، وضعف العضلات، وانخفاض مستويات النشاط البدني، والإرهاق، والبطء (المشي البطيء مثُلا). وقد بنجم الضعف البدني عن الإجهاد البدني أو النفسي، مثل الرضح، أو المرض، أو فقد الأحبة. ويمكن أن يفقد الشخص المصاب الضعف البدني قدراته على الأداء ويغدو متكًلا على الرعاية. تقدير واإ دارة البيئات الاجتماعية والمادية يمكن أن يساعد مقدمو الرعاية والمجتمعات المحلية في تذليل العوائق القائمة أمام الصحة التغذوية للمسنين. وعلى سبيل المثال فإن المنظمات المجتمعية يمكن أن تنظم حفلات عشاء اجتماعية لهم. وبالنسبة للعاملين الصحيين المجتمعيين فإنهم قد يكونون قادرين على تيسير الوصول إلى دكاكين البقالة، واإ لى مصادر المساعدة في إدارة الشؤون المالية، واإ لى مصادر دعم الدخول، وقد ييسرون العون في إعداد الطعام، أو تلقي الأغذية المحضرة وذلك مثًلا عن طريق الخدمات المجتمعية لتقديم الطعام. 93 6 الحيوية مسالك الرعاية لإدارة التغذية 40 يعد الإبصار مكونًا بالغ الأهمية في القدرة الأساسية، وهو يتيح للأشخاص التنقل والتفاعل بأمان مع أقرانهم ومع البيئة. وثمة أسباب للخلل البصري تغدو أكثر شيوعًا مع التشيخ وهي: حسر البصر، ومد البصر، والساد، والّزرق، والتنكس البقعي. ويمكن أن يسبب الخلل البصري صعوبات في الحفاظ على العلاقات الأسرية وغيرها من العلاقات الاجتماعية، وفي الوصول إلى المعلومات، وفي التنقل بأمان (ولاسيما في سياق التوازن وخطر السقطات)، وفي أداء المهام اليدوية. وقد تقود مثل هذه المصاعب إلى القلق والاكتئاب. ويشكل تقدير الإبصار مكونًا حاسمًا من مكونات التقدير المتركز على الأشخاص. النقاط الرئيسية باستخدام مخطط عين بسيط فإن بمقدور العاملين في الصحة الأولية والمجتمعية إجراء اختبار للكشف عن فقد الإبصار الجسيم. بالمستطاع معالجة حالات الكثير من الأشخاص المصابين بخسارة بصرية. ومن المهم الاستفسار عن وجود مرض عيني مؤكد، أو تقديره، أو التحقق منه. يمكن للنظارات في غالب الأحيان أن تصحح الخسارة المتعلقة بحسر أو مد البصر. يمكن للنبائط المساِعدة (عدسات التكبير، التلسكوبات) أن تدعم المعانين من خسارة بصرية يتعذر تصحيحها بالنظارات. بمقدور إجراءات بسيطة، في المنزل والمجتمع المحلي، مثل الإضاءة المحسنة أن تنهض بقدرة الأداء عند المسنين المعانين من خسارة بصرية. 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري 14 iتدعو الحاجة إلى رعاية متخصصة اسأل هل واجهتك أية مشكلات تتعلق بعينيك: صعوبة الرؤية على مسافة بعيدة، أو في القراءة، أو من أمراض عيون، أو هل تخضع للمعالجة الطبية حاليًا (من حالات مثل داء السكري، وفرط ارتفاع ضغط الدم)؟ نعم نعم نعم فشلفشل لا اختبر حدة البصر باستخدام مخطط العين البسيط الصادر عن المنظمة – اختبر على الدوام الرؤية البعيدة قبل الرؤية القريبة – اختبر بدون نظارات إذا كان من المعتاد وضعها – اختبر عينا واحدة في كل مرة، ثم اختبر العينين معا الرؤية البعيدة الرؤية القريبة هل تحل نظارات القراءة البسيطة الجاهزة المشكلة؟ تعزيز الرعاية العينية ومشورة نمط الحياة توفير النظافة الشخصية العينية تقديم المشورة عن الشخص والبيئة إعادة التقدير... تكرار الاختبار سنويًا حتى لو لم يكن هناك خلل بصري توفير نظارات قراءة قدِّر الخلل البصري وأمراض العيون معالجة أمراض العيون إدارة الخلل البصري استعراض وتحديث وصفة النظارات، أو توفير نظارات جديدة النظر في تأهيل العيون، بما في ذلك توفير النبائط البصرية المساِعدة، مثل المكبرات المكتبية والمتنقلة إدارة عوامل الخطر القلبية الوعائية الإحالة إلى الرعاية العينية كل سنة لفحص الشبكية استعراض الأدوية لتفادي التفاعلات الدوائية الضارة على العيون تقدير واإ دارة الظروف المصاحبة – فرط الضغط – داء السكري – استخدام الستيرويد تقدير واإ دارة البيئات الاجتماعية والمادية تقديم المشورة عن الحياة اليومية في ظل ضعف الرؤية القيام بتكييف المنزل (إضاءة، ألوان متنافرة) لتفادي السقطات إزالة المخاطر من طريق المشي المعتاد يتطلب الفشل في الرؤية البعيدة على الدوام الإحالة إلى الرعاية الشاملة الخلل البصري )41( خلل الرؤية البعيدة: • طفيف- حدة البصر أسوأ من 21/6 • معتدل- حدة البصر أسوأ من 81/6 • وخيم- حدة البصر أسوأ من 06/6 • عمى- حدة البصر أسوأ من 06/3 خلل الرؤية القريبة: • حدة البصر أسوأ من 6N أو 80.M مع التصحيح الحالي 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري 21 3 4 حينما يتطلب الأمر رعاية متخصصة إذا كان الشخص يعاني من مرض عيني مثبت أو إذا ما تم تحديده على أنه يعاني من مرض عيني فإن مهمة البت في وتيرة الفحص ونوعه تقع على عاتق أخصائي الرعاية العينية. اختبار حدة البصر في الرعاية الأولية • ينبغي إجراء تحر بسيط لفقد الرؤية مرة في العام على الأقل لمن هم في سن الخمسين فأكثر. • يمكن إجراء التحري باستخدام مخطط العين البسيط الصادر عن المنظمة لاختبار الرؤية البعيدة والرؤية القريبة على حد سواء. وقد أدرجت التعليمات في الطرف الأيمن. • بمقدور مقدم للرعاية الصحية الأولية أن يقوم بعملية التحري. فهي لا تتطلب تدريبًا نظاميًا على تقدير الرعاية العينية )31(. • إذا تمكنت نظرات القراءة الجاهزة من حل مشكلة الشخص العينية، فقد لا يتطلب الأمر إجراء فحص شامل. البعيدة اختبار الرؤية باستخدام مخطط العين البسيط للمنظمة أوضح على مسافة قريبة من الشخص كيفية إجراء اختبار الرمز E من خلال تبيان اتجاه نقطة هذا الرمز. اختبر الرؤية البعيدة والقريبة لتحديد أصغر رمز يمكن للشخص رؤيته. 1. اختبر بأربعة رموز صغيرة على مسافة 3 أمتار الرؤية طبيعية (81/6 أو أكثر) إذا كان بمقدور الشخص رؤية اتجاه ثلاثة على الأقل من أصل أربعة رموز صغيرة. عند تعذر رؤية ثلاثة رموز كبيرة على الأقل... 2. اختبر بالرموز الكبيرة على مسافة 3 أمتار عند التمكن من رؤية الرموز فإن حدة البصر هي 06/6. عند تعذر رؤية ثلاثة رموز كبيرة على الأقل... 3. اختبر بالرموز الكبيرة على مسافة 5.1 أمتار عند التمكن من رؤية ثلاثة على الأقل من الرموز الأربعة فإن حدة البصر هي 06/3. النظافة الشخصية العينية تشمل النظافة الشخصية العينية البيئة والشخص على حد سواء. ويمكن للعوامل البيئية والسلوكيات أن تيسر أداء الرؤية (مثل الإنارة، والتنافر اللوني، واستخدام الألوان (أو قد تكون مضرة) مثل المشاهدة المطولة لوسائل الإعلام الإلكترونية، واإ نفاق وقت طويل في الرؤية القريبة). وتتضمن النظافة الشخصية العينية المجموعة الكاملة من سلوكيات هذه النظافة مثل غسل الأيدي بصورة متكررة، وعدم فرك العيون، واستخدام الصابون اللطيف فقط للجفون والامتناع عن استخدام مواد تجميل العيون. اختبار الرؤية القريبة باستخدام مخطط الرؤية البسيط لمنظمة الصحة العالمية اطلب من الشخص أن يمسك ببطاقة اختبار الرؤية القريبة على أقرب مسافة يريدها. اختبر الرؤية من الرمز )E( الأكبر إلى الأصغر. إذا حّدد الشخص الاتجاهات بالشكل الصحيح لثلاثة رموز من أربعة، فإنه يكون قد اجتاز بنجاح اختبار فحص الرؤية القريبة. إذا لم يستطع تحديدها بنجاح، تحقق مما إذا كان بوسع نظارات القراءة الجاهزة مساعدته. إذا لم يكن باستطاعته تمييز ثلاثة من الرموز الأكبر (أخفق في اجتياز فحص الرؤية القريبة) بواسطة نظارات القراءة، فاطلب تقييمًا لضعف البصر واعتلالات العين. وتعادل الرموز المتوسطة حجم الحروف العادية في الكتب، بينما تعادل الرموز الأصغر حجم الحروف الدقيقة في الكتب والمجلات (ليس من المطلوب رؤيتها). 34 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري MP 90:70:5 01/9/6 fdp.AF_hsilgnE_edistuo 1.7 مخطط العين البسيط الصادر عن المنظمة (أربعة رموز E صغيرة للرؤية البعيدة) • أربعة رموز E صغيرة من قياس 3,1 سم X 3,1 سم على بعد 3,1 سم من بعضها بعضا • رمز E باللون الأسود الخالص على ورقة بيضاء ناصعة. 44 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري MP 90:70:5 01/9/6 fdp.AF_hsilgnE_edistuo 2.7 مخطط العين البسيط الصادر عن المنظمة (أربعة رموز E كبيرة للرؤية البعيدة) • رموز E كبيرة من قياس 2,4 سم X 2,4 سم على بعد 5,4 سم من بعضها بعضا • رمز E باللون الأسود الخالص على ورقة بيضاء ناصعة. 54 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري MP 60:80:5 01/9/6 fdp.AF_edisnI hsilgne 3.7 مخطط العين البسيط الصادر عن المنظمة (الرؤية القريبة) 64 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري • وتساعد نظارات القراءة الكثير من المسنين على رؤية الأشياء. على أن هذه النظارات بالنسبة للبعض منهم ليست الحل المنشود. وعلى سبيل المثال فإن المعانين من مد البصر والمصابين باللابؤرية المكتسبة يحتاجون إلى نظرات يصفها مهني للرعاية العينية بعد إخضاعهم للفحص. • ويشمل الفحص التشخيصي المعياري استخدام المهني المدرب لمصباح ذي فلعة لفحص العين بصورة مفصلة. وبالمستطاع استخدام هذه الأداة، مثًلا، للكشف عن مرض الساد ويمكن أن تساعد في تحديد ما إذا كانت هناك حاجة لإجراء عملية جراحية. ويتطلب فحص الشبكية والعصب البصري استعمال أدوات أخرى والتقاط الصور أحيانًا للكشف عن التغيرات المبكرة واإ رشاد المعالجة التي يمكن أن تحول دون فقد الإبصار. ويتسم فحص الشبكية على فترات منتظمة بأهمية خاصة بالنسبة للمصابين بداء السكري. 4.7 تقدير الخلل البصري وأمراض العين • يتطلب الفقد المفاجئ أو المترقي بسرعة في عين واحدة أو في كلتا العينين فحصًا أساسيًا للعين وللإبصار واإ حالة إلى الرعاية العينية المتخصصة. • بمقدور مهني للرعاية الأولية أن يفحص عيون الشخص. واإ ذا كانت هناك من تغيرات مثل العيون المحمرة، والإفرازات، والندبات، والألم المتواصل، وعدم تحمل أشعة الشمس، ومرض الساد فإنه ينبغي أن يتولى مهني للرعاية العينية (طبيب عيون، مصحح بصر) فحص الشخص المعني. • يمكن لمهني للرعاية الأولية فحص العيون للكشف عن علامات أمراض العين الشائعة. وهذا الفحص ليس شامًلا عمومًا ويتطلب فحصًا آخر يقوم به اختصاصي. وفي حال استمرار الحالات العينية المذكورة أعلاه فإنه يوصى بتوفير الرعاية العينية المتخصصة. تقدير الخلل البصري وأمراض العين مرض الساد إن مرض الساد هو إعتام عدسة العين الذي يحول دون الرؤية الواضحة، وغالبًا ما يرتبط بعملية التشيخ. ويظل الساد السبب الرئيسي في العمى. ويمكن للتقليل من التدخين ومن التعرض للأشعة فوق البنفسجية أن يحول دون الإصابة بالساد أو يؤخرها. ويندرج داء السكري والسمنة في عداد عوامل الخطر الإضافية. ويمكن توقي الخلل البصري والعمى الناجمين عن مرض الساد لأن جراحة الساد مأمونة وبمقدورها استرداد البصر. 74 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري 6.7 ضعف الرؤية غير القابل للتصحيح يعاني الكثير من الناس من ضعف الرؤية الذي تعجز النظارات الموصوفة عن تصحيحه بشكل كاف. وبالنسبة لهؤلاء فإن نبائط الرؤية المساِعدة، أي المكبرات المكتبية أو المتنقلة، توفر درجة تكبير أعظم من النظارات. وبإمكان هذه النبائط أن تمكِّ ن من أداء مهام تتضمن الرؤية القريبة، مثل قراءة كتاب أو صحيفة، وتحديد النقود، وقراءات الملصقات، وتفحص الأشياء الصغيرة أو أجزاء الأشياء الكبيرة. ويمكن للعاملين المجتمعيين في ميدان الصحة أو التأهيل مساعدة الأشخاص على الحصول على النبائط المذكورة. التأهيل البصري. يمكن أن يستفيد الشخص المصاب بضعف في الرؤية غير قابل للتصحيح من الخدمات الشاملة للتأهيل البصري التي تشمل الدعم النفسي وكذلك التوجه، والتحرك، والتدريب على أنشطة الحياة اليومية. وبمقدور المختصين في التأهيل والرعاية العينية تدريب الأشخاص المصابين بضعف الرؤية على مهارات تعزز من الأداء البصري، مثل مهارات الوعي، والتثبيت، والتفرس، والاقتفاء. وتدعو الحاجة إلى هذه المهارات عادة من أجل الاستخدام الفعال للمكبِّرات، إلا أنها قد تكون نافعة أيضًا في ظروف أخرى. 5.7 نظارات القراءة يعاني الكثير من الناس ممن هم في سن الخمسين فأكثر من صعوبة في الرؤية أو القراءة على مسافات قصيرة. وفي غالب الأحيان فإنهم يمكن أن يستفيدوا من استخدام نظارات القراءة (التي تسمى أيضًا «القارئات»). وتتوافر نظارات القراءة البسيطة بتكلفة زهيدة. وغالبًا ما تتوافر بدرجات متنوعة من قوة التكبير. وهذه النظارات تقوم ببساطة بجعل الأشياء القريبة تبدو أكبر. وعندما لا تحل نظارات القراءة البسيطة المشكلة، فإن من المستصوب إجراء فحص شامل للعين والرؤية. وينبغي، إذا أمكن، إخضاع جميع من هم في سن الخمسين أو أكثر للفحص من قبل مهني للرعاية العينية على فترات منتظمة. ولا تعتبر الاختبارات البسيطة للرؤية والقراءة بديًلا عن الفحص الشامل الذي يجريه مهني للرعاية العينية. إدارة الخلل البصري 84 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري تقدير واإ دارة الأمراض المصاحبة 9.7 استخدام الستيرويد يمكن للعلاج الطويل الأجل بمركبات الستيرويد أن يزيد عند بعض الأشخاص من الضغط على الُمقلة (ضغط باطن العين) أو يؤدي إلى الإصابة بمرض الساد. وهذا الضغط الزائد قد يسفر عن فقد الرؤية، وهو ما يشتمل على الإضرار بالعصب البصري، وقد يفضي إلى العمى إذا لم يخضع للمعالجة. وينبغي أن يخضع أي شخص يتلقى علاجًا طويل الأجل بالستيرويد إلى فحوص منتظمة للعين ولعمليات تحقق من ضغط العين. 7.7 فرط الضغط يمثل فرط الضغط عامل خطر مهم في أمراض الشبكية ومرض الَزرق. 8.7 داء السكري ينبغي أن يخضع المصاب بداء السكري للفحص العيني من ِقبل اختصاصي في الرعاية العينية كل سنة للتحري عن اعتلال الشبكية السكري. 94 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري تقدير واإ دارة البيئات الاجتماعية والمادية خلق التنافر اللوني. إن التنافر اللوني الجيد ضمن الأشياء وفيما بينها ييسر رؤيتها، أو العثور عليها، أو تفاديها. ومن الأمثلة على ذلك الوسوم العالية التنافر على حوافي الأدراج (ولاسيما للأشخاص القادرين على الرؤية بعين واحدة فحسب)، والصحاف الملونة بحيث تتنافر مع الطعام المقدم فيها، واستخدام قلم أسود للكتابة. وبمقدور المصابين بضعف الرؤية، وأفراد الأسرة، ومقدمي الرعاية تلوين قبضات الأدوات المنزلية والمطبخية لجعلها أكثر وضوحًا وأمانًا، وذلك مثًلا بتغليف مقابض السكاكين بأشرطة لاصقة ذات ألوان زاهية أو تلوينها. استخدام الخطوط الأيسر للقراءة. بالنسبة للمواد المطبوعة وشاشات العرض الإلكترونية في الحواسيب والهواتف، فإن الخطوط الضخمة الخالية من الزوائد (مثل الخط المستخدم في هذا الكتيب) التي تبرز بوضوح من لون خلفي متسق هي الخطوط الأسهل للقراءة. اختيار الأشياء المنزلية ذات الخطوط الضخمة والتنافر اللوني الجيد. هناك في الغالب منتجات متوافرة في المتاجر تستخدم حروفًا وأرقامًا ضخمة أو تنافرًا لونيًا جيدًا. ومن الأمثلة على ذلك ساعات الحائط، والساعات اليدوية، والكتب ذات الحروف الضخمة. وبالنسبة لأنشطة التسلية فإن بالمستطاع، مثًلا، شراء أو صناعة ألواح وقطع ألعاب كبيرة ذات حروف ورموز ضخمة. استخدام الأدوات المساِعدة السمعية والبصرية أيضًا. تعرض المتاجر العديد من السلع المجهزة بقدرة نطقية مثل الساعات، ومقاييس الحرارة، والموازين الناطقة. كما أن الكثير من الهواتف المتنقلة والبرامج الحاسوبية مزودة بوظائف لتحويل النصوص إلى كلام. ثمة طرق عديدة لمساعدة المصابين بضعف الرؤية على التمتع بأداء أفضل. وبمقدور أفراد الأسرة ومقدمي الرعاية مد يد العون. وتدعو الحاجة إلى تدابير لتكييف هذه الإرشادات محليًا من أجل تحديد أماكن الحصول على نبائط بصرية مساِعدة وسبل الحصول على الخدمات تبعًا للسياقات. 01.7 تدابير التكيف مع ضعف الرؤية إلى جانب توفير النبائط البصرية المساِعدة فإن إدخال تغييرات بسيطة يمكن أن يتيح للمصابين بضعف الرؤية مواصلة أنشطتهم، ومن ثم الحفاظ على نوعية حياتهم. وبالمستطاع إجراء تغييرات على المنزل وفي مجالات الحركة المعتادة للشخص المعني بحيث تغدو المهام المعتادة وأنشطة الاستجمام أكثر أمانًا ويسرا. وفيما يلي بعض الأمثلة على ذلك. تحسين الإضاءة. تعتبر الإضاءة الجيدة هامة على وجه الخصوص للمصابين بضعف الرؤية. ومن الأفضل أن يجيء الضوء من جانب الشخص (دون أن يخلِّف ظلالا). تخفيف الوهج. إن الضوء الأكثر سطوعًا أفضل في العادة. غير أن بعض الأشخاص يتضايقون من وهج الشمس أو الأضواء الساطعة. إزاحة العوائق. يمكن إزاحة الأخطار مثل قطع الأثاث والأشياء الصلبة الأخرى عن طريق المشي المعتاد للشخص المعني، إما إذا كانت الحاجة تدعو إلى إبقائها فإنها ينبغي أن تظل في مكانها المعتاد. 05 7 القدرة البصرية مسالك الرعاية لإدارة الخلل البصري لعل فقد السمع المرتبط بالتشيخ هو أشد الاختلالات الحسية الشائعة في صفوف المسنين. ويعرقل فقد السمع غير الخاضع للمعالجة التواصل وقد يؤدي إلى العزلة الاجتماعية. ويمكن أن تؤدي القيود على القدرات الأخرى مثل التراجع المعرفي إلى تفاقم هذه العواقب الاجتماعية. ويرتبط فقد السمع بالعديد من المسائل الصحية الأخرى، بما في ذلك التراجع المعرفي وخطر الخرف، والاكتئاب والقلق، وضعف التوازن، والسقطات، وعمليات الإدخال إلى المستشفيات، والوفاة المبكرة. وعلى هذا فإن تقدير السمع يشكل جانبًا بالغ الأهمية من رصد القدرة الأساسية للمسنين على مستوى المجتمع المحلي. كما أن تقدير السمع بتعمق أكبر هو جزء حاسم من التقدير الكامل لصحة المسنين واحتياجاتهم من الرعاية الاجتماعية. النقاط الرئيسية بمقدور العاملين في الرعاية الأولية على مستوى المرافق والمجتمعات المحلية التحري عن فقد السمع بمعدات بسيطة أو باختبار الصوت الهامس. يمكن لتدابير بسيطة على مستوى المنزل والمجتمع المحلي أن تحد من تأثير فقد السمع. وتشمل استراتيجيات التواصل الهادفة إلى تيسير السمع التكلم بوضوح، ومواجهة الشخص المعاني من فقد السمع عند الحديث، وتخفيف ضوضاء الخلفية. يشتمل تحسين السمع ذاته على استخدام نبائط سمعية مثل مساِعدات السمع والطعوم القوقعية. ويتطلب توفير هذه النبائط معارف ومعدات متخصصة. 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع 15 1- اختبار الصوت الهامس: القدرة على سماع الهمسات أو - قياس السمع الفحصي: 53 ديسي بل أو أقل للنجاح - أو - الاختبار المؤتمت للأرقام في الضجيج المعتمد على تطبيقات الأجهزة المتنقلة اختِبر السمع نجاح نجاح فشل لا تعزيز المشورة العامة بشأن رعاية الأذن أو الرعاية المعتادة صمم (قياس السمع: ≤ 18 ديسي بل) – عوامل الخطر (مثل التعرض للضجيج والأدوية السامة للأذن) – ألم في الأذن – تاريخ من النزح النشط للسوائل من الأذن (الأذنين)، فقد السمع المفاجئ أو المترقي بسرعة – الدوخة – التهاب الأذن الوسطى المزمن – فقد السمع الوحيد الجانب فقد سمع معتدل إلى وخيم (قياس السمع: 63-08 ديسي بل) قدرة سمع طبيعية (قياس السمع: ≥ 53 ديسي بل) تقدير القدرة السمعية (قياس السمع التشخيصي) – التقييم وتوفير نبيطة سمعية (مساِعدات سمعية أو طعوم قوقعية) اسأل عن: تقدير واإ دارة البيئات الاجتماعية والمادية تعزيز المشورة العامة بشأن رعاية الأذن أو الرعاية المعتادة إعادة التقييم مرة كل سنة (للكل) (لأي منها) توفير المساِعدات السمعية في حال عدم توافر مساِعدات سمعية، وفر المعلومات عن قراءة الشفاه ولغة الإشارة واستراتيجيات التواصل الأخرى توفير المساندة العاطفية والمساعدة في إدارة الإجهاد العاطفي توفير المساِعدات الصوتية في مختلف أرجاء المنزل (أجراس الباب والهاتف) تزويد الشخص المصاب بفقد السمع وأفراد أسرته ومقدمي الرعاية باستراتيجيات للبقاء على تواصل وصون العلاقات تدعو الحاجة إلى رعاية متخصصة الإحالة إلى الرعاية المتخصصة 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع 12 3 حينما يقتضي الأمر رعاية متخصصة • تقييم المصاب بفقد السمع الوخيم/الصمم. • تثبيت نبيطة سمعية مساِعدة. • إدارة المشكلة المستبطنة التي تسبب أو تسهم في فقد السمع. اختبار السمع يستخدم التقدير الأولي أحد الاختبارات الثلاثة التالية. اختبار الصوت الهامس إن اختبار الصوت الهامس هو أداة فحص للمساعدة في تحديد ما إذا كان الشخص يتمتع بسمع طبيعي أو يحتاج إلى قياس سمع تشخيصي. قياس السمع الفحصي )51( استخدم قياس السمع الفحص إذا كانت لديك المعدات اللازمة. يقدم قياس السمع الفحصي نغمات على امتداد طيف الكلام (005 إلى 0004 هيرتز) عند الحدود العليا للسمع العادي. وتسجل النتائج كنجاح أو فشل. وتشير درجة 53 ديسي بل أو أقل إلى سمع طبيعي. وعبر تدريب نوعي بسيط، يمكن لغير المختص أن يختبر بدقة السمع باستخدام هذه المعدات. الاختبار المؤتمت للأرقام في الضجيج المعتمد على تطبيقات الأجهزة المتنقلة يمكن أيضًا استخدام الاختبار المؤتمت للأرقام في الضجيج المعتمد على تطبيقات الأجهزة المتنقلة لتحديد ما إذا كانت هناك حاجة إلى قياس سمع تشخيصي. متاح كتطبيق للهواتف المتنقلة – مثل: OHWraeh/ssenfaed/tni.ohw.www//:sptth :OHWraeh (مجاني، باللغة الإنكليزية) /az.oc.azraeh.www//:sptth :AZraeh (مجاني، باللغة الإنكليزية) /lanoisseforp/ne/zn/nortinu/tnetnoc/moc.nortinu//:ptth :raeHu lmth.raehu/troppus-ecitcarp (مجاني لمستخدمي آيفون، باللغات الإنكليزية، والفرنسية، والألمانية، والإسبانية). متاح كخدمة على شبكة الإنترنت – مثل: متاح كخدمة على شبكة الإنترنت - مثل: /ssoLgniraeHgnisongaiD/forp/ue.mocraeh//:ptth :moCraeH lmth.ne_tseTtigiDeerhT/stseTneercSfleS (مجاني لمستخدمي آيفون، باللغات الهولندية، والإنكليزية، والألمانية، والبولندية، والسويدية). مشورة عامة بشأن العناية بالأذنين • لا تضع الأصابع القذرة في الأذنين ولا تنس أن تغسل يديك قبل تناول الطعام، ولا تأكل باستخدام يدين قذرتين. • اغسل يديك دائمًا بعد استخدام المرحاض. • لا تسبح أو تغتسل بالماء القذر. • لا تضع أي شيء في أذنيك: – زيت ساخن أو بارد – علاجات عشبية – سوائل مثل الكيروسين اختبار الصوت الهامس قف على بعد ذراع خلف الشخص واإ لى أحد جانبيه. اسأل الشخص أو مساعد لك بأن يسد الأذن المقابلة بالضغط على الزََنمة (الزنمة هي النتوء أمام فتحة الأذن والذي يغطيها جزئيا). ازفر ثم اهمس بنعومة أربع كلمات. استخدم أي كلمات شائعة وغير مترابطة. اطلب إلى الشخص أن يكرر كلماتك. ينبغي أن ُتنطق الكلمات واحدة واحدة، وانتظار الإجابة على كل منها في كل مرة. إذا ما كرر الشخص أكثر من ثلاث كلمات وأنت واثق من أنه يسمعك بوضوح، فإن ذلك يعني أن سمعك طبيعي في هذه الأذن. انتقل إلى الجانب الآخر للشخص واختبر الأذن الأخرى. استخدم كلمات مختلفة. اهمس بكلمات مألوفة للشخص على سبيل المثال: - مصنع - سمك - سماء - دراجة - نار - حديقة - رقم - أصفر 35 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع قياس سماع الكلام. يستفيد المسنون من الخضوع لاختبار إضافي هو قياس سماع الكلام. وفي هذا الاختبار تطلق كلمات بسيطة مسبقة التسجيل بدرجات صوتية متزايدة، وُيطلب من الشخص تكرار الكلمات عند سماعها. ويعمل هذا الاختبار على التحقق من نتائج قياس سماع النغمات. ويساعد الاختبار على البت فيما إذا كان التعرف على الكلام متسقًا مع نتائج قياس سماع النغمات، أو ما إذا كان هناك عدم تناظر في تمييز الكلام لم يتوقعه قياس سماع النغمات، أو أنه يحدد الأذن التي يجب تثبيت الجهاز المساِعد للسمع عليها إذا ما كان من المزمع تثبيت جهاز واحد فحسب. قياس الشق الطبلي الخشائي. يختبر هذا القياس امتثال (أو تحرك) طبلة الأذن. ويمكن لهذا الاختبار أن يساند نتائج قياس سماع النغمات وسماع الكلام لتحديد نوع المشكلة السمعية. 1.8 ثلاثة اختبارات للتقدير الشامل يمكن أن يشتمل تقدير السمع على ثلاثة اختبارات بمعدات متخصصة وهي: مقياس سماع النغمات النقية، ومقياس سماع الكلام، ومقياس الشق الطبلي الُخشائي لتقدير الأذن الوسطى. ويمكن أن تساعد هذه الاختبارات في تحديد مدى الحاجة إلى التأهيل. وتحتاج هذه الاختبارات إلى تدريب متخصص. قياس سماع النغمات. تختبر عملية قياس سماع النغمات قدرة الشخص على سماع الأصوات بترددات مختلفة للنغمات النقية (الدرجات). وتتألف العملية من إطلاق أصوات مسبقة التسجيل بمستوى عال فأعلى وأعلى إلى أن يستطيع الشخص سماعها وهو ما يمثل عتبة السمع. وتختبر العملية توصيل الهواء وتوصيل العظام للأصوات لتقدير عتبات السمع عند ترددات تتراوح من 521 هيرتز (منخفضة جدًا) إلى 0008 هيرتز (مرتفعة جدًا). ويساعد هذا الاختبار على تحديد درجة فقد السمع ونوعه. تقدير القدرة السمعية 45 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع ينبغي النظر على حد سواء في استراتيجيات للتواصل ونبائط سمعية لمعالجة فقد السمع. ويتعين تحديد النهج الأفضل في إدارة فقد السمع في ضوء التقدير الكامل للقدرة الأساسية للشخص. ويقتضي الأمر أن يؤخذ في الحسبان أي تراجع معرفي، وأي فقد للقدرة التحركية، أو أي فقد للمهارة في الأذرع أو الأيدي، إلى جانب الدعم المتوافر من الأسرة والمجتمع المحلي. 2.8 للمسنين المعانين من فقد وخيم في السمع • الإيضاح للمعانين من فقد السمع ولأسرهم فائدة النبائط السمعية مثل مساِعدات السمع، وأين يمكن الحصول عليها، وكيفية استخدامها. وحال حصول الشخص المعني على جهاز مساِعد للسمع فإن بإمكان العاملين الصحيين مساندة وتشجيع استخدامه. • ينبغي ألا تحدد عملية قياس السمع وحدها ما إذا كان الشخص بحاجة إلى جهاز مساِعد للسمع. فمعظم المعانين من فقد السمع يشتكون من أن من الصعب عليهم التواصل حينما تكون هناك ضوضاء في الخلفية. ومن الواجب إخضاع الشخص للتقدير لتحديد حاجته الكلية قبل اقتراح استخدام مساِعدات السمع. • إعطاء إرشادات واضحة إلى المعانين من فقد السمع واإ لى أسرهم ومقدمي الرعاية لهم بشأن استراتيجيات التواصل التي يمكن أن تحسن من القدرة على الأداء. 5.8 • يمكن أن تلحق بعض الأدوية الضرر بالأذن الداخلية، مما يؤدي إلى فقد السمع و/ أو فقد التوازن. وتشمل هذه الأدوية المضادات الحيوية مثل الستربتومايسين وجنتامايسين، ومضادات الملاريا مثل الكينين والكلوروكين. كما أن هناك أدوية أخرى يمكن أن تؤثر على السمع. وقد يؤدي الحد من هذه الأدوية، إن أمكن، إلى الوقاية من المزيد من فقد السمع. 3.8 للمسنين المصابين بالصمم سيحتاج الشخص المصاب بدرجة عالية من فقد السمع (الوخيم أو العميق) والذي لا يستفيد من التدخلات الآنفة الذكر إلى رعاية سمعية متخصصة مثل تثبيت جهاز سمعي مساِعد. ويتطلب توفير النبائط السمعية مهارات متخصصة للاختبار، واإ عطاء الوصفات، والتثبيت. إدارة فقد السمع ُنذر خطر أخرى تتطلب رعاية سمعية متخصصة تحتاج الظروف التي قد تكمن وراء فقد السمع إلى تشخيص واإ دارة متخصصين. ويشمل ذلك ما يلي: • ألم في الأذن • التهاب الأذن الوسطى المزمن (عدوى الأذن الوسطى) • فقد السمع المفاجئ أو المترقي بسرعة • الدوخة مع فقد معتدل أو وخيم للسمع • النزح النشط للسوائل من الأذن (الأذنين) • وجود عوامل خطر مثل التعرض للضوضاء وتناول الأدوية التي يمكن أن تضر بالسمع. 55 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع 4.8 النبائط السمعية المساِعدات السمعية. إن المساِعدات السمعية هي في العادة التكنولوجيا الفضلى للمسنين المعانين من فقد السمع. وتزيد هذه الأجهزة من ارتفاع درجة الأصوات. ويمكن أن تكون الأجهزة فعالة لمعظم الأشخاص، وهي تعتبر ملائمة لأنها تثبت داخل الأذن أو فوقها. ومن المهم الإيضاح للأشخاص المعنيين أن هذه الأجهزة لا تؤدي إلى الشفاء من فقد السمع أو معالجته. الطعوم القوقعية. يمكن أن تعود الطعوم القوقعية بالفائدة على الأشخاص المعانين من درجة عالية من فقد السمع والذين لا يستفيدون من استخدام المساِعدات السمعية. وُيثبت الطعم القوقعي جراحيًا في الأذن. ويقوم هذا الطعم بتحويل الأصوات إلى نبضات كهرباء ويرسلها إلى أعصاب الأذن. ومن الواجب إخضاع الشخص لتقييم دقيق للتأكد من أن الطعم سيساعده. واإ ذا لم تكن الطعوم القوقعية متوافرة أو مجدية فإنه ينبغي إبلاغ المسن أو أسرته بذلك وتوفير التدريب لهم على قراءة الشفاه وعلى لغة الإشارات. دارات الحث السمعي والمضخِّ مات الصوتية الشخصية. تعتبر دارات الحث السمعي والمضخِّ مات الصوتية الشخصية فعالة أيضًا. ودارة الحث السمعي، أو دارة السمع، هي سلك أو أسلاك توضع حول المكان (مثل قاعة الاجتماعات أو مكتب الخدمات). وترسل الأسلاك إشارات من الميكروفون أو المضخِّ م إلى أنواع معينة من المساِعدات السمعية. توفر «مبادئ المنظمة التوجيهية بشأن المساِعدات والخدمات السمعية للبلدان النامية» المزيد من الإرشادات: 66034/56601/eldnah/siri/tni.ohw.sppa//:ptth 65 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع تقدير واإ دارة البيئات الاجتماعية والمادية يمكن أن يساعد التقليل من أثر فقد السمع على الحفاظ على الاستقلال والحد من حاجة المسنين إلى الاتكال على الخدمات المجتمعية لتلبية الاحتياجات المعيشية اليومية. وبمقدور أفراد الأسرة، ومقدمي الرعاية الآخرين والمجتمع المحلي جميعًا المساعدة في ذلك. ويقود فقد السمع في غالب الأحيان إلى ضيق نفسي وعزلة اجتماعية. ولهذا السبب فإن التأهيل الأذني يمنح اهتمامًا أكبر الآن إلى الاعتبارات النفسية، وُيصمم على نحو يتناسب مع أهداف المسنين ومقدمي الرعاية لهم. • يمكن أن يقلل التفاعل الاجتماعي المنتظم من الحد من خطر التراجع المعرفي، والاكتئاب، والعواقب العاطفية والسلوكية الأخرى لفقد السمع. وفي لحظات الضيق البالغ فإن بمقدور شبكات الدعم الاجتماعي تقديم العون. • يستطيع الشركاء وأفراد الأسرة الحيلولة دون الشعور بالوحدة والعزلة. وقد يحتاج هؤلاء إلى المشورة حول سبل القيام بذلك. وعلى سبيل المثال فإن عليهم متابعة التواصل مع الشخص المعاني من فقد السمع وتنظيم أنشطة لإبقائه منخرطًا في شبكة اجتماعية. انظر الإطار المدرج على اليمين للاطلاع على مشورة بشأن التحدث إلى شخص يعاني من فقد السمع. 5.8 • قد تتضمن الحلول البيئية في المنزل وضع أجراس الأبواب والهواتف في مواقع تتيح سماع رنينها في كل المنزل. 5.8 استراتيجيات التواصل لأفراد الأسرة ومقدمي الرعاية يمكن أن يوفر العاملون في الرعاية الصحية المشورة لأفراد الأسرة ومقدمي الرعاية بشأن اتباع ممارسات بسيطة معينة عند التحدث إلى شخص يعاني من فقد السمع )41(. دع الشخص يرى وجهك عندما تتكلم. تأكد من سقوط ضوء كاف على وجهك لمساعدة المستمع على رؤية شفاهك. قم بلفت انتباه الشخص قبل أن تتحدث. حاول تفادي عوامل تشتيت الانتباه مثل الأصوات العالية وضوضاء الخلفية. تحدث بوضوح وببطء أشد. لا تصرخ. لا تقلع عن الحديث إلى المعانين من صعوبة في السمع. فذلك سيؤدي إلى عزلهم وقد يقود إلى الاكتئاب. وهذه الاستراتيجيات مفيدة سواء أكان الشخص مجهزًا بنبيطة سمعية مساِعدة أم لا. 75 8 القدرة السمعية مسالك الرعاية لإدارة فقد السمع 58 ينطبق مصطلح «الأعراض الاكتئابية» (أو سوء المزاج) على المسنين المصابين باثنين أو أكثر من الأعراض الاكتئابية معظم الوقت أو كله خلال أسبوعين على الأقل، والذين لا يلبون في الوقت ذاته معايير تشخيص اكتئاب بالغ. وتشيع الأعراض الاكتئابية بدرجة أشد في صفوف المسنين المعانين من ظروف إعاقة طويلة الأجل، أو من العزلة الاجتماعية، أو من مقدمي الرعاية الاجتماعية الذين يضطلعون بمسؤوليات رعاية شاقة. وينبغي النظر في هذه المسائل كجزء من نهج شامل لإدارة الأعراض الاكتئابية. وتشكل الأعراض الاكتئابية جانبًا هامًا من جوانب القدرة النفسية، ولكنها تمثل بعدًا واحدًا فحسب. فهناك جوانب أخرى مثل القلق، وخصائص الشخصية، والتكيف، والسيطرة، وهو ما يحتاج إلى إجراءات معقدة. ويوفر هذا الفصل إرشادات بشأن الوقاية من الأعراض الاكتئابية واإ دارتها لدى المسنين. ويمكن الاطلاع على مزيد من الإرشادات في «دليل تدخلات برنامج المنظمة المعني بسد الفجوات في مجال الصحة النفسية )PAGhm(» في العنوان التالي: 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth. النقاط الرئيسية من خلال توجيه سلسلة من الأسئلة يمكن للعاملين في الرعاية الأولية في المجتمع المحلي تحديد المصابين بأعراض الاكتئاب وتمييز هذه الأعراض عن الاكتئاب ذاته. يمكن لمهنيي الرعاية الصحية من غير المختصين والمدربين والخاضعين للإشراف استخدام تدخلات نفسية منظمة وجيزة أن يساعدوا الأشخاص المصابين بالأعراض الاكتئابية في المجتمع المحلي وفي سياقات الرعاية الأولية الأخرى. تتطلب معالجة الاكتئاب نهجًا شامًلا وكذلك متخصصًا في العادة. قد يؤدي التراجع في الميادين الأخرى للقدرة الأساسية، مثل السمع أو التحرك، إلى الإخلال بقدرات الأداء، والحد من المشاركة الاجتماعية، والإسهام في الأعراض الاكتئابية. 9 مسالك الرعاية لإدارة الأعراض الاكتئابية القدرة النفسية 95 ?? اسأل هل تضايقت خلال الأسبوعين الماضيين بسبب: لالا تعزيز الصحة العامة والمشورة بشأن نمط الحياة أو الرعاية المعتادة تحرَّ عن الأعراض الاكتئابية شعورك بالإحباط أو الاكتئاب، أو اليأس؟* قلة الاهتمام أو المتعة بالقيام بالأعمال؟ (لأي من السؤالين أعلاه) نعم تقدير أعراض اكتئابية المزاج (0-2 أعراض إضافية) اكتئاب (≤ 3 أعراض إضافية) قدم تدخلات نفسية منظمة وجيزة: – العلاج المعرفي السلوكي – مشورة أو علاج حل المشكلات – التفعيل السلوكي – علاج استعراض الحياة التمارين المتعددة المناويل تمارين التأمل الواعي عالج الاكتئاب يحتاج المسنون الذين ُتشخص إصابتهم باكتئاب جسيم عمومًا إلى رعاية متخصصة. وينبغي تزويدهم بالمشورة والعلاج حسب ما يوصي به دليل تدخلات برنامج PAGhm الصادر عن المنظمة. 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth تقدير واإ دارة الظروف المصاحبة تقدير واإ دارة البيئات الاجتماعية والمادية – خسارة كبرى في الأشهر الستة الأخيرة – تاريخ من الإصابة بالهوس – الخلل المعرفي – فقد السمع – الخلل البصري – إعاقة ناجمة عن مرض أو إصابة الحد من الكرب وتعزيز المساندة الاجتماعية حفز المسنين على مواصلة التحرك والتواصل اجتماعيًا تشجيع الأداء في الأنشطة اليومية تشجيع المشاركة في برامج التمارين المجتمعية وتطوير المهارات تحديد ومعالجة الشعور بالوحدة والعزلة الاجتماعية (انظر في القيام بتدخلات بمساعدة التكنولوجيا) – التعديد الدوائي – فقر الدم، سوء التغذية، قصور الدرقية – الألم استعراض الأدوية مثل مضادات الاكتئاب، ومضادات الهيستامين، ومضادات الذهان الإدارة المتكاملة للظروف تقدير واإ دارة الألم تدعو الحاجة إلى رعاية متخصصة * يستخدم المسنون مجموعة متنوعة واسعة من المصطلحات للإشارة إلى سوء المزاج، مثل الحزن، والاكتئاب، والإحباط، إلخ. لا (للكل) 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 12 قدِّر المزاج إذا أبلغ الشخص عن عَر ض واحد على الأقل من الأعراض الأساسية، وهي الشعور بالإحباط، أو الاكتئاب، أو اليأس وعن قلة الاهتمام أو المتعة بالقيام بالأعمال، فإن عليك أن تقوم بتقدير آخر للمزاج. ويمكن استخدام كلمات بديلة إذا كان الشخص غير معتاد على تلك الواردة في سؤالي التحري. اسأل: «هل تضايقت خلال الأسبوعين الماضيين بسبب أي من المشكلات التالية؟»* • صعوبة الإغفاء أو البقاء نائمًا، أو الإفراط في النوم. • الشعور بالتعب أو ضعف الطاقة. • ضعف الشهية أو الإفراط في تناول الطعام. • الشعور بالاستياء من نفسك أو بأنك فاشل أو بأنك خذلت عائلتك. • صعوبة التركيز على أمور مثل قراءة الصحيفة أو مشاهدة التلفزيون • التحرك أو التكلم ببطء على نحو يمكن أن يكون الآخرون قد لاحظوه. • الإحساس بالتململ أو الضجر بما يدفعك إلى الحركة أكثر بكثير من المعتاد. • الشعور بأن من الأفضل لك أن تموت أو التفكير بإيذاء نفسك بطريقة ما. الأعراض الاكتئابية • إذا كان الشخص يعاني من َعرض واحد على الأقل أو من عرض إضافي أو عرضين فإنه ربما كان مصابًا بالأعراض الاكتئابية. واإ ذا كان لدى الشخص أكثر من عرضين، فقد يكون مؤهًلا للخضوع لتشخيص بشأن اضطراب اكتئابي. ومن المهم تمييز الأعراض الاكتئابية عن الاضطراب الاكتئابي لاختلاف طريقة المعالجة. • وقد يصاحب التراجع المعرفي والخرف أعراض اكتئابية ومن الواجب إخضاعهما للتقدير أيضا. وفي غالب الأحيان يلجأ المصابون بالخرف إلى العاملين الصحيين للشكوى من مشكلات مزاجية أو سلوكية، مثل الخمول، وفقد السيطرة العاطفية، أو صعوبات في القيام بالعمل المعتاد، أو الأنشطة المنزلية أو الاجتماعية. • وفي الوقت ذاته في التراجع في الميادين الأخرى للقدرة الأساسية، مثل القدرة الحسية أو التحرك، قد يحد من القدرة على الأداء والمشاركة الاجتماعية، ومن ثم يسهم في الأعراض الاكتئابية. • وربما تكون التدخلات المتعلقة بتراجع في المكونات الأخرى للقدرة الأساسية، مثل المعرفة أو السمع، أكثر فعالية إذا عولجت الأعراض الاكتئابية في الوقت ذاته. وينبغي النظر في ذلك عند إعداد خطة رعاية مشخصنة. حينما يتطلب الأمر رعاية متخصصة • تحتاج إدارة الاكتئاب إلى نهج شامل ومتخصص في العادة لوضع خطة رعاية مشخصنة. • ولإدارة الأعراض الاكتئابية فإن العاملين الصحيين بحاجة إلى تدريب نوعي في التدخلات النفسية المنظمة الوجيزة. • قد تحتاج بعض الظروف المصاحبة مثل قصور الدرقية إلى تشخيص واإ دارة متخصصين. * يمكن الاطلاع على هذه الأسئلة في استبيان صحة المرضى )9-QHP( )fdp.9qhp_loot/fdp/gro.hmiaqc.www//:ptth(، الذي يعتبر أداة من أدوات تقدير الأعراض الاكتئابية. أو أنظر قسم الاكتئاب في دليل تدخلات برنامج PAGhm في العنوان التالي: 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth. 16 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية العلاج المعرفي السلوكي يستند العلاج المعرفي السلوكي إلى الفكرة القائلة بأن المشاعر تتأثر بالمعتقدات والسلوك على حد سواء. وقد تكون للمصابين بالأعراض الاكتئابية (أو الذين تم تشخيص إصابتهم باضطرابات عقلية) أفكار سلبية مشوهة غير واقعية قد تقود، إن لم ُتكبح، إلى سلوك مؤذ. وهكذا فإن العلاج المعرفي السلوكي يتضمن عادة مكونًا معرفيًا يساعد الشخص على تطوير القدرة على تحديد ومجابهة الأفكار السلبية غير الواقعية لتعزيز السلوكيات الإيجابية والحد من السلوكيات السلبية. وتشمل الخطوات ما يلي: )1( تحديد المشكلات القائمة في حياة الشخص، )2( اكتساب الوعي بالأفكار، والمشاعر، والمعتقدات المتعلقة بهذه المشكلات، )3( تحديد التفكير السلبي أو غير الدقيق، )4( إعادة صياغة هذا التفكير ليغدو أكثر واقعية. المشورة أو العلاج لحل المشكلات يمكن النظر في اعتماد نهج حل المشكلات للأشخاص ذوي الأعراض الاكتئابية المعانين من الضيق أو المصابين بدرجة ما من خلل الأداء الاجتماعي (عندما لا يتم تشخيص نوبة اكتئابية أو اضطراب). ويتيح علاج حل المشكلات الدعم المباشر والعملي للشخص المعني. ويعمل المهني الصحي القائم بدور المعالج بالتعاون مع المسن لتحديد وعزل مجالات المشكلات الرئيسية التي قد تكون مساهمة في الأعراض الاكتئابية. وبمقدورهما معًا تجزئة هذه المجالات إلى مهام محددة قابلة للإدارة عبر حل المشكلات وبتطوير استراتيجيات للتكيف مع المشكلات النوعية. إدارة الأعراض الاكتئابية 1.9 التدخلات النفسية المنظمة الوجيزة يمكن أن تؤدي التدخلات النفسية المنظمة الوجيزة، مثل العلاج المعرفي السلوكي، وُنهج حل المشكلات، والتفعيل السلوكي، وعلاج استعراض الحياة، أن تقلل كثيرًا من الأعراض الاكتئابية لدى المسنين. كما أن بمقدور التمارين المتعددة المناويل وتمارين التأمل الواعي أن تحد بدورها من هذه الأعراض. وبالمستطاع استخدام العديد من التدخلات النفسية، برضا وموافقة المسنين، وعلى أن ُتراعى شواغلهم، مثل صعوبات حل المشكلات. وينبغي النظر في اعتماد التمارين البدنية، إلى جانب المعالجات النفسية المنظمة، بالنظر إلى التأثير الإيجابي لهذه التمارين على تحسين المزاج (انظر الفصل 5 بشأن محدودية التحرك). 5 ولا يوصى بأن يقوم أطباء الرعاية الأولية بإعطاء وصفات مضادات الاكتئاب دون توافر معارف متخصصة في الصحة النفسية. يتولى المهنيون الصحيون المدربون في مجال الصحة النفسية في العادة أمر إدارة هذه التدخلات. كما أن بمقدور العاملين الصحيين المجتمعيين الاضطلاع بها إذا ما كانت لديهم المهارة اللازمة لذلك وكانوا مدربين على مسائل الصحة النفسية للمسنين. ولم يتم الربط بين هذه التدخلات وحدوث أي أذى. 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 26 2.9 التمارين البدنية المتعددة المناويل بمقدور برنامج للتمارين البدنية المتعددة المناول المصمم ليتناسب مع القدرات البدنية للشخص المعني وأفضلياته أن يحد من الأعراض الاكتئابية في الأجل القصير وربما في الأجل الطويل أيضًا. انظر الفصل 5 بشأن محدودية التحرك. 5 3.9 ممارسة التأمل الواعي يتألف التأمل الواعي من إيلاء الانتباه إلى ما يحدث في اللحظة الحالية عوضًا عن الانسياق مع تيار الأفكار عن الماضي، والمستقبل، والرغبات، والمسؤوليات، ومشاعر الأسف. ويمكن أن تتحول الأفكار الأخيرة إلى دوامة هابطة للشخص المصاب بالأعراض الاكتئابية. وثمة أنواع عديدة لممارسة التأمل الواعي. وهناك نهج شائع الاستخدام وهو الجلوس أو الاستلقاء بهدوء وتركيز الانتباه على أحاسيس التنفس. كما أن التأمل الواعي للحركة البدنية، أثناء ممارسة اليوغا أو المشي مثًلا، مفيد أيضًا لبعض الأشخاص. التفعيل السلوكي يشتمل التفعيل السلوكي على تشجيع الشخص المعني على المشاركة في الأنشطة المثمرة كوسيلة لتقليل الأعراض الاكتئابية. ويمكن تعلم هذا النهج بسرعة أكبر من معظم المعالجات النفسية الأخرى المستندة إلى البيِّنات. وبمقدور غير المختصين تعلمه بما يتيح تيسير الحصول على الرعاية المتعلقة بالأعراض الاكتئابية. وقد ُدرس هذا التدخل أساسًا كتدخل متعدد الجلسات يقوم به المختصون. على أن بالإمكان تعديله ليغدو تدخًلا وجيزًا يقوم به مهنيون صحيون مدربون كمعالجة ُمساعدة أو كجزء من خطوة أولى في نهج رعاية شامل في الرعاية الأولية. علاج استعراض الحياة يتضمن علاج استعراض الحياة قيام الُمعالج بتوجيه الشخص ليتذكر ويقيِّم ماضيه بغية الوصول إلى إحساس بالسلام أو القبول بحياته. ويمكن لهذا النوع من العلاج أن يساعد في النظر إلى الحياة من منظور واقعي بل واستعادة بعض الذكريات الهامة عن الأصدقاء والأحباء. وبمقدور علاج استعراض الحياة أن يساعد في معالجة الاكتئاب لدى المسنين وُيعين أولئك الذين يواجهون مسائل نهاية العمر. ويركز الُمعالجون علاج استعراض الحياة على موضوعات حياتية أو على استرجاع بعض الفترات الزمنية، مثل مرحلة الطفولة، أو الأبوة، أو على الفترة التي أصبح فيها الشخص جدًا، أو على سنوات عمله. 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 36 تقدير واإ دارة الظروف المصاحبة • فقد السمع. قد ُيبلغ المسنون المعانون من فقد السمع على الأرجح عن إحساسهم بالحرج، والقلق، وفقد التقدير الذاتي، كما وتقل احتمالات مشاركتهم في الأنشطة الاجتماعية والنشاط البدني، مما يؤدي إلى العزلة الاجتماعية والشعور بالوحدة، ومن ثم الاكتئاب )51(. • يرتبط الخلل البصري ووجود أمراض عينية كبرى ترجع إلى العمر مثل تنكس البقعة والَزرق بخطر متزايد من الإصابة بالاكتئاب )61(. وغالبًا ما ُيبلغ الأشخاص المعانين من ضعف الأداء البصري عن أنهم يشعرون بالتعاسة، والوحدة، بل واليأس. • رد الفعل على الإعاقة الناجمة عن المرض أو الإصابة. يعتبر الاكتئاب ظرفًا ثانويًا شائعًا لدى ذوي الإعاقة. ويعاني الأشخاص المعوقون، بسبب المرض أو الإصابة، من الإجهاد؛ كما أن عليهم التكيف مع التحولات الحياتية. وتشمل مراحل التأقلم مع نوع جديد من الإعاقة الصدمة، والإنكار، والغضب/ الاكتئاب والتأقلم/ القبول. ويواجه المسنون المصابون بإعاقات جديدة خطر الإصابة بالقلق والاكتئاب. يشير وجود الظروف المصاحبة التالية إلى الحاجة إلى نهج مختلف لمعالجة الاكتئاب. • التعرض لخسارة كبرى في الأشهر الستة الماضية. • تاريخ من الإصابة بالهوس. إن الهوس هو نوبة من الارتفاع المزاجي والزيادة في الطاقة والنشاط. وُيصنف الأشخاص الذين يصابون بنوبات الهوس على أنهم يعانون من اضطراب ثنائي القطب. ويمكن تحديد تاريخ الهوس من خلال التحقق من أعراض متعددة تحدث في وقت واحد، وتستغرق أسبوعًا واحدًا على الأقل، وتكون وخيمة إلى درجة العرقلة الجسيمة للعمل والأنشطة الاجتماعية أو تتطلب الإدخال إلى المستشفى أو الاحتجاز. (انظر «دليل تدخلات برنامج المنظمة المعني بسد الفجوات في مجال الصحة النفسية )PAGhm(: lmth.trahcwofl_ralopib/ne/paghm/gro.ohap.www//:sptth). • التراجع المعرفي. تتسم العلاقة بين الاكتئاب والتراجع المعرفي بالتعقيد. وقد ربطت الدراسات الوبائية منذ وقت طويل بين الاكتئاب والإصابة بداء الزهايمر. والوظائف المعرفية التي تتأثر بالاكتئاب هي الانتباه، والتعلم، والذاكرة البصرية، وكذلك الوظائف التنفيذية. ويمكن أن يكون الاكتئاب استجابة نفسية للإدراك الذاتي للفرد لتراجع معرفي خفيف لم يبدأ بالتأثير بعد على الأداء اليومي. 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 46 6.9 قصور الدرقية يندرج قصور الدرقية في عداد الاضطرابات الشائعة لدى المسنين، ولاسيما النساء. وقد تكون أعراض قصور الدرقية غير نوعية وتتباين من شخص إلى آخر، إلا أنها يمكن أن تتضمن أعراضًا اكتئابية. وينبغي أن يقوم العاملون الصحيون من ذوي المعارف المتخصصة بتقدير قصور الدرقية واإ دارته. 7.9 الألم يصاب الأفراد الُمبلغون عن ألم مزمن بالأعراض الاكتئابية في غالب الأحيان. ومن المهم تقدير الألم واإ دارته (انظر الفصل 5 بشأن محدودية التحرك). 5 4.9 التعديد الدوائي يمكن أن يؤدي التعديد الدوائي إلى الإصابة بأعراض اكتئابية، وقد تفضي هذه الأعراض إلى التعديد الدوائي. ومن المهم العناية بأمر التعديد الدوائي وكذلك الأعراض الاكتئابية لكسر الحلقة المفرغة. واإ لى جانب العقاقير التي تؤثر أساسًا على الجهاز العصبي، فإن العقاقير ذات الخصائص النفسية التأثير، مثل مضادات الهستامين، ومضادات الُذهان، ومرخيات العضلات، والعقاقير الأخرى عديمة التأثير النفسي وذات الخصائص المضادة للكولين، يمكن أن تربط بالأعراض الاكتئابية. ويؤدي إلغاء الأدوية غير الضرورية، وغير الفعالة، وكذلك الأدوية ذات التأثير المكرر إلى الحد من التعديد الدوائي. 5.9 فقر الدم وسوء التغذية يمكن أن يؤدي فقر الدم وسوء التغذية إلى أعراض اكتئابية بسبب حالات عوز الحديد، وعوز فيتامينات مثل الفولات، وفيتامين باء6، وفيتامين باء21. كما أن الأعراض الاكتئابية تضطلع بدور في الإصابة بفقر الدم. ويمكن لفقد الشهية والافتقار إلى الاهتمام بأداء الأنشطة اليومية (مثل التسوق والطهي) أن يقلل من نوعية وكمية تغذية المسنين، مما يسهل الإصابة بفقر الدم وسوء التغذية. ولإدارة الأعراض الاكتئابية فإن من المهم للغاية إدارة فقر الدم وتحسين الوضع التغذوي (انظر الفصل 6 بشأن التغذية). 6 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 56 تقدير واإ دارة البيئات الاجتماعية والمادية وفي حال تعرض المسن لفقد في القدرات، مثل فقد السمع أو قيود القدرة التحركية، فإن باستطاعة أفراد الأسرة ومقدمي الرعاية إيلاء اهتمام خاص إلى مسألة تفادي العزلة الاجتماعية. ويمكن لهذه العزلة أن تؤدي إلى الإصابة بالأعراض الاكتئابية. وينبغي النظر في القيام بتدخلات تدعمها التكنولوجيا باستخدام الهاتف أو شبكة الإنترنت لمعالجة أمر الشعور بالوحدة. يعد فقد الاهتمام بالأنشطة التي كانت ممتعة أو باعثة على السرور سمة معتادة من سمات الاكتئاب. وبمقدور أفراد الأسرة ومقدمي الرعاية توفير التشجيع والمساندة بلطف للقيام بالمزيد من النشاط البدني والانخراط الاجتماعي مثل البرامج المجتمعية للتمارين البدنية وتطوير المهارات. 9 القدرة النفسية مسالك الرعاية لإدارة الأعراض الاكتئابية 66 من المتعذر على المسنين المعانين من خسائر جسيمة في القدرة الأساسية في غالب الأحيان العيش بكرامة دون رعاية الآخرين، ومساندتهم، ومساعدتهم. ويعد توافر الرعاية والمساندة الاجتماعية حاسمًا لضمان حياة كريمة وذات مغزى. ولا تشمل الرعاية والمساندة الاجتماعية أنشطة الحياة اليومية والرعاية الشخصية فحسب، ولكنها تتضمن أيضًا تيسير الوصول إلى المرافق المجتمعية والخدمات العامة، والحد من العزلة والشعور بالوحدة، والمساعدة في مجال الأمن المالي، وتوفير مكان مناسب للمعيشة، والحماية من المضايقة وسوء المعاملة، والمشاركة في الأنشطة التي تمنح معنى للحياة. وتتباين هوية الشخص المناسب لتلقي الأسئلة عن طبيعة احتياجات المسن المتعلقة بالرعاية والمساندة الاجتماعية تبعًا لطبيعة السؤال. فإذا كان الشخص يعاني من تدهور معرفي فقد يكون الشخص الأفضل الذي ينبغي أن توجه إليه الأسئلة عن أنشطة الحياة اليومية والشؤون المالية هو شخص على معرفة وثيقة بالمسن، مثل فرد من الأسرة، أو مقدم للرعاية، أو صديق. النقاط الرئيسية يعتبر انخفاض القدرة على الأداء ظاهرة شائعة بين المسنين، ولاسيما المعانين من تراجع في القدرة الأساسية، ولكن هذه الظاهرة ليست حتمية. بمقدور العاملين الصحيين المجتمعيين التحري عن الخسائر في قدرات الأداء عبر استبيان بسيط. يمكن للتدخلات المصممة لتتناسب مع أولويات المسن أن تنهض بالقدرة على الأداء. تشمل التدخلات الفعالة ما يرمي إلى النهوض بالقدرة الأساسية، والقدرة على الأداء، وتوفير الرعاية والمساندة الاجتماعية 01 مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية الرعاية والمساندة الاجتماعية 76 AB 1 قدِّر احتياجات الرعاية والمساندة الاجتماعية 1. هل تواجه أي صعوبة في التحرك داخل المنزل؟ 2. هل تواجه أي صعوبة في استخدام المرحاض (أو المقعدة)؟ 3. هل تواجه أي صعوبة في ارتداء ملابسك؟ 4. هل تواجه أي صعوبة في استخدام حوض الاستحمام أو المسحاح؟ 5. هل تواجه أي صعوبة في العناية بمظهرك؟ 6. هل تواجه أي صعوبة في تناول الطعام بنفسك؟ 7. هل تواجه أي مشكلات حيث تعيش (مكان إقامتك)؟ 8. هل تواجه أي مشكلات تتعلق بشؤونك المالية؟ 9. هل تحس بالِوحدة؟ 01. هل أنت قادر على متابعة ما لديك من اهتمامات استجمامية، وهوايات، وأنشطة عمل، وتطوع، ومساندة أسرتك، والأنشطة التعليمية أو الروحية المهمة بالنسبة لك؟ 11. قدرِّ المخاطر الماثلة لإساءة معاملة المسنين اسأل نعم نعم نعم نعم نعم لا ينبغي استخدام المعلومات الرصدية المستندة إلى سلوك المسن، وسلوك مقدمي الرعاية أو الأقارب، أو إلى علامات الإساءة البدنية لتحديد الإساءة المحتملة. إذا ما كان هناك أي خطر محدق، قم بالإحالة إلى تقدير مختص عبر نظم العمل الاجتماعي، وحماية الكبار، واإ نفاذ القانون وفرِّ لائحة بالخدمات المجتمعية المتاحة للمسنين، مثل مرافق الاستجمام والنوادي، ومقدمي الخدمات التعليمية للكبار، والخدمات الاستشارية بشأن التطوع والعمل شجِّ ع المسن على الاستفادة من هذه الخدمات لزيادة مشاركته اطرح أسئلة تكميلية لتحديد الحواجز غير قادر على القيام بــ .... بسبب: 1. التكلفة، 2. المسافة، 3. المواصلات، 4. انعدام الفرص، 5. أسباب أخرى؟ استعرض الطرق الكفيلة بتعزيز - الصلات الاجتماعية الوثيقة (الزوج، الأسرة، الأصدقاء، الحيوانات الأليفة) - استخدام موارد المجتمع المحلي (النوادي، المجموعات الدينية، المراكز النهارية، الأنشطة الرياضية، والاستجمامية، والتعليمية) – فرص المساهمة (التطوع، العمالة) - القدرة على الاتصال باستخدام تكنولوجيات الاتصالات اطرح أسئلة تكميلية 1. ما هو حال أوضاعك المالية بشكل عام في نهاية الشهر؟ 2. هل أنت قادر على إدارة نقودك وشؤونك المالية؟ 3. هل ترغب في تلقي المشورة بشأن الإعانات والاستحقاقات المالية؟ اطرح أسئلة تكميلية هل تشعر بالقلق بشأن: 1. سلامتك وأمنك في مكان معيشتك؟ 2. وضع منزلك؟ 3. موقع منزلك؟ 4. تكاليف الإقامة؟ 5. إصلاح وصيانة منزلك؟ 6. القدرة على العيش باستقلال حيث أنت؟ قدم المساعدة في الرعاية الاجتماعية (المساعدة الشخصية) تقدير وتعديل البيئات المادية للتعويض عن فقد القدرة الأساسية، وتحسين التحرك وتفادي السقطات انظر في استخدام التكنولوجيات المساِعدة، والأجهزة المساِعدة، وتدابير التكييف تقدير المساندة المقدمة من الزوج، والأسرة، ومقدمي الرعاية الآخرين غير المأجورين، مع إدراج تقدير لاحتياجات مقدمي الرعاية استعراض الحاجة إلى المساندة من عاملي الرعاية المأجورين إتاحة جهات تقديم الرعاية وخدماتها مثل الرعاية المنزلية، والرعاية النهارية، ودور المسنين انظر في: – القيام بتدابير تكييف منزلية – مكان إقامة بديل – الإحالة إلى برامج الرعاية الاجتماعية أو الإسكان المجتمعي أو شبكات المساندة القائمة انظر في: – الإحالة إلى مشورة مالية متخصصة – تقديم المشورة بشأن تفويض اتخاذ القرارات المالية مع الحماية من سوء التصرف المالي 01 الرعاية والمساندة الاجتماعية مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية AB 1 حينما يتطلب الأمر معارف متخصصة على العاملين الصحيين أن يدركوا أنه ينبغي إحالة المسنين إلى تقدير مختص. وتتباين البروتوكولات وفقًا للتوافر. ويعتبر زعيم القرية، أو مدير المدرسة، أو الكاهن، أو قائد عن العاملين الاجتماعيين ً المجموعة الدينية أمثلة على الأشخاص المناسبين عوضا في بعض السياقات. وعلى هذا فإن الرعاية والمساندة الاجتماعية المتكاملة تتطلب مساندة ذات أبعاد متعددة، واجتماعات منتظمة لإرساء الثقة بين المختصين والخدمات. وفيما يلي أمثلة على مجالات الدراية للمختصين المختلفين المنخرطين في رعاية المسنين. • ظروف المعيشة: خدمات الإسكان، العاملون الاجتماعيون، المعالجون المعنيون بالأداء. • الشؤون المالية: العاملون الاجتماعيون، الخدمات الاستشارية بشأن الاستحقاقات. • الإحساس بالوحدة: العاملون الاجتماعيون، الخدمات الطوعية، أطباء الرعاية الأولية. • المشاركة: العاملون الاجتماعيون، خدمات الاستجمام، والعمل، والخدمات الطوعية. • إساءة المعاملة: العاملون الاجتماعيون، أطباء الرعاية الاجتماعية. • أنشطة الحياة اليومية: معالجو الأداء، العاملون الاجتماعيون، الممرضون أو الفريق المتعدد الاختصاصات المعني بالشيخوخة. • التحرك خارج المنزل: المعالجون الفيزيائيون، العاملون الاجتماعيون، خدمات النقل الطوعية. الأدلة الرصدية على الإساءة المحتملة لمعاملة المسنين سلوك المسن • يبدو خائفًا من القريب أو مقدم الرعاية المهني. • لا يرغب في الإجابة عند سؤاله، أو ينظر بقلق إلى مقدم الرعاية/ القريب قبل الإجابة. • يتغير السلوك عند دخول مقدم الرعاية/القريب إلى الغرفة. • يشير إلى مقدم الرعاية بتعابير مثل «حازم» أو غالبًا «متَعب» أو «سيء الطبع»، أو أنه أصبح انفعاليا/قلقًا للغاية/مجهدًا جدًا/يفقد أعصابه بسهولة. • ُيظهر احترامًا مبالغًا أو مراعاة مفرطة لمقدم الرعاية. سلوك مقدم الرعاية/القريب • يعيق أو يمنع تبادل المهني والمسن للحديث على انفراد، أو يختلق الأسباب لمقاطعة سير مقابلة التقدير (دخول الغرفة بصورة متكررة مثلا). • ُيصر على الرد على الأسئلة الموجهة إلى المسن. • يضع العراقيل أمام توفير المساعدة للمسن في المنزل. • ُيظهر درجة عالية من الامتعاض بشأن تحمل مهمة رعاية المسن. • يسعى إلى إقناع الممارسين بأن المسن «مجنون» أو مصاب بالخرف، أو أنه لا يدرك ماذا يقول بسبب التشوش، حينما لا يكون الأمر كذلك. • يبدي العداء، أو التعب، أو نفاذ الصبر خلال المقابلة، ويكون المسن قلقًا للغاية أو غير مهتم عندما يكون مقدم الرعاية حاضرا. إساءة المعاملة البدنية • جروح، وحروق، وكدمات، وخدوش. • إصابات لا تتطابق مع التفسيرات المقدمة. • إصابات ُيستبعد أن تحدث بالصدفة. • إصابات وجروح في مواقع مخفية. • كدمات على شكل أصابع ناجمة عن التعامل بخشونة (على العضد غالبا) • إصابات في مواقع محمية، مثل تحت الإبطين. • إصابات غير معالجة. • إصابات متعددة في مراحل مختلفة من الشفاء. • نقص أو إفراط في تناول الأدوية. 01 الرعاية والمساندة الاجتماعية مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية 96 تقدير واإ دارة احتياجات المساندة الاجتماعية 1.01 تقدير واإ دارة الحاجة إلى الرعاية الشخصية والمساعدة في الأنشطة اليومية (القسم «أ» من المسلك) ُتستخدم ستة أسئلة لتقدير ما إذا كان المسن قد وصل إلى نقطة غدا فيها غير قادر على أن يرعى نفسه دون مساعدة الآخرين. وسيستفيد المسن المصاب بخسارة جسيمة في القدرة الأساسية من مثل هذا التقدير. ويغطي التنقل داخل المنزل عددًا من الأنشطة مثل الانتقال من السرير إلى كرسي، والمشي، والذهاب إلى المرحاض واستخدامه، واستعمال الأدراج. وتقود محدودية الحركة إلى مخاطر متزايدة واإ لى الحاجة إلى الرعاية الشخصية. ويندرج ارتداء الملابس، وتناول الطعام، والاستحمام، والتزين في عداد أنشطة الحياة اليومية. ويفضي العجز عن أداء هذه الأنشطة إلى الحاجة إلى الرعاية الشخصية. ولا يرغب الكثير من المسنين في الاعتماد على الآخرين لمساعدتهم في أنشطة الحياة اليومية، ويفضلون التمكن من القيام بها بأنفسهم. ويمكن أن يستفيد المسنون الذين يواجهون مصاعب في أداء أنشطة الحياة اليومية و/ أو مشكلات تحرك من برنامج للتأهيل. وقد يركز هذا البرنامج على تحسين القدرات لكنه قد يشتمل أيضًا على تكنولوجيات مساِعدة وتدابير لتكييف البيئة للنهوض الأمثل بالقدرة على الأداء رغم القيود في القدرة الأساسية. وفي حال استمرار الصعوبات فإن يتعين النظر في استعراض المساندة المقدمة من الزوج، والأسرة، وغيرهم من مقدمي الرعاية غير المأجورين، بما في ذلك النظر في الاحتياجات الذاتية لهؤلاء. واإ ذا اقتضى الأمر المزيد من المساندة فإنه ينبغي توفير خدمات الرعاية المنزلية الطوعية الخاصة أو العامة. 2.01 تقدير واإ دارة احتياجات المساندة الاجتماعية (القسم «ب» من المسلك) بغض النظر عن مستوى القدرة الأساسية والقدرة على الأداء فإن تقديرًا لاحتياجات المساندة الاجتماعية سيعود بالنفع على المسن. ويتيح توفير المساندة الاجتماعية للمسن القيام بأشياء مهمة بالنسبة له. ويشمل ذلك تقديم المساندة له فيما يتعلق بظروف المعيشة، والأمن المالي، والشعور بالوحدة، والوصول إلى المرافق المجتمعية والخدمات العامة، والدعم إزاء ظواهر إساءة معاملة المسنين. ب7 ظروف المعيشة يمكن للمكان الذي يعيش فيه المسن أن يؤثر على صحته، واستقلاله، ورفاهه. وقد تتعلق المشكلات بأشياء كثيرة، بما في ذلك حجم المكان، وسهولة الوصول إليه، وسلامته، وأمنه. وبمقدور الأسئلة التكميلية أن تحدد المجالات المعينة التي ينبغي العناية بأمرها. 01 الرعاية والمساندة الاجتماعية مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية 07 ب9 الشعور بالوحدة يشيع الشعور بالوحدة في مرحلة الشيخوخة وهو يرتبط بزيادة احتمالات الإصابة بالاكتئاب والوفاة المبكرة. انظر الفصل 9 للاطلاع على إرشادات عن التحري عن الأعراض الاكتئابية. وثمة فرق بين أن يكون الإنسان وحيدًا وأن يشعر بالوحدة، فالمسن قد يحس بأنه وحيد حتى لو كان محاطًا بأناس آخرين، إذا ما كانت نوعية العلاقات منخفضة. ومن المفيد سؤال المسن المعاني من الوحدة ما إذا كانت زيادة الاحتكاك الاجتماعي بالأسرة والأصدقاء، أو الالتقاء بالآخرين من ذوي الاهتمامات المشتركة، سيساعدان على الحد من الشعور بالوحدة. ولكن عند سؤال المسن ما إذا كانت زيادة الاحتكاك قد تفيد فإن من الواجب التأكيد له إن إجابته ستظل طي الكتمان وذلك للتغلب على أي مخاوف تساوره بشأن الكشف عن طبيعة علاقاته الشخصية. ويخفف اقتناء حيوان أليف من الشعور بالوحدة بالنسبة للكثير من المسنين. وينبغي التشجيع على ارتياد المرافق المجتمعية مثل النوادي، والمجموعات الدينية، والمراكز النهارية، وخدمات الرياضة، أو الاستجمام، أو التثقيف. وقد تتوافر فرص للمساهمة من خلال التطوع أو العمالة المأجورة. ويمكن زيادة الصلات الاجتماعية عبر تكنولوجيا الاتصالات. ويتعين إجراء استعراض عام لهذه الإجراءات لمكافحة الشعور بالوحدة. وعلى القائمين بالتقدير أن يكونوا على علم بالطائفة الواسعة من الأصول المحلية المتوافرة. وبالمستطاع التخفيف من حدة مشكلات الظروف المعيشية باتخاذ إجراءات أمنية جديدة، واعتماد رقم هاتفي للاتصال به عند وقوع حالة طوارئ، واإ جراء تدابير للتكيف للحفاظ على المعيشة المستقلة. وربما ُتتاح استحقاقات مالية للمساعدة في تكاليف الإقامة، ولإجراء عمليات الإصلاح والصيانة. وفي حال فشل كل هذه الإجراءات فإنه يتعين النظر في نقل المسن إلى مكان إقامة أشد ملاءمة. ب8 الشؤون المالية ترتبط الموارد المالية ارتباطًا وثيقًا بالصحة، والاستقلال، والرفاه في مرحلة الشيخوخة. ويمكن أن تتضمن المشكلات الافتقار إلى المال اللازم لتلبية الاحتياجات الأساسية أو المشاركة بشكل كامل في المجتمع، وقد يقلق المسنون من أن أموالهم في سبيلها إلى النفاد أو أنهم سيعجزون عن إدارة شؤونهم المالية. وبمقدور الأسئلة الإضافية أن تحدد المجالات المعينة التي ينبغي العناية بأمرها. وبالمستطاع التخفيف من حدة المشكلات المالية عبر توفير المشورة المستقلة عن التخطيط المالي والإدارة المالية. ويمكن اتخاذ ترتيبات لتفويض الصلاحية إلى طرف ثالث موثوق لإدارة الشؤون المالية شريطة توافر الحماية القانونية للحيلولة دون سوء التصرف المالي. 01 الرعاية والمساندة الاجتماعية مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية 17 ب01 الانخراط والمشاركة في المجتمع يتمثل هدف نهج الرعاية المتكاملة للمسنين في مساعدة المسنين على القيام بالأشياء المهمة بالنسبة لهم. ومن المفيد معرفة ما الذي يهم المسن من خلال فهم حياته، وأولياته، وأفضلياته، وقد يكون بالمستطاع إيجاد سبل لزيادة المشاركة. وتعتبر الأنشطة المتعلقة بالاستجمام، والهوايات، والعمل، والتعلم، والشؤون الروحية أمثلة على المشاركة في المجتمع. ولكل مسن شخصيته الفريدة، وله أولويات مختلفة، غالبًا ما تكون بالغة التحديد، بشأن ما هو مهم بالنسبة له. وينبغي توجيه الأسئلة وتسجيل الإجابات عليها للاستنارة بها عند وضع خطة الرعاية المشخصنة. ويتعين طرح أسئلة إضافية لتحديد الحواجز القائمة مثل التكلفة، ويسر المنال، والفرصة المتاحة. وعلى القائمين بالتقدير معرفة مدى توافر مرافق ونوادي الاستجمام المحلية، ومقدمي الخدمات التعليمية للكبار، والخدمات التطوعية، والخدمات الاستشارية الخاصة بالعمالة، والنظر في ما إذا كان ذلك يهم المسن. وقد تكون وسائط النقل مسألة هامة، وربما تتوافر خدمات لتيسير الوصول. وربما تكون الرسوم المفروضة على بعض هذه الخدمات مدعومة للسماح للمسنين وذوي الدخل المنخفض بالمشاركة. ب11 إساءة معاملة المسنين إن الكثير من المسنين المعتمدين على الرعاية معرضون لسوء المعاملة، ويعاني شخص واحد من بين كل ستة مسنين من شكل ما من أشكال إساءة المعاملة، وهو رقم أعلى مما كان مقدرًا قبًلا )02(. وقد تتخذ إساءة المعاملة أشكاًلا عديدة، بما في ذلك الإهمال، والإساءة النفسية، والإساءة البدنية، والإساءة الجنسية، والإساءة المالية. وينبغي استخدام المعلومات الرصدية المستندة إلى سلوك المسن، وسلوك مقدمي الرعاية أو الأقارب، أو علامات الإساءة البدنية، في تحديد إساءة المعاملة المحتملة . واإ ذا كان هناك أي إيحاء بسوء المعاملة، فسيتطلب الأمر تقديرًا واإ دارة على المستوى التخصصي. ومن الواجب إبلاغ المسن بأن لديك مخاوف بهذا الصدد وأنك ستطلب مساعدة متخصصة. وفي حال تحديدك لأي خطر فوري فإن عليك الإحالة إلى تقدير متخصص عبر ُنظم العمل الاجتماعي، أو حماية البالغين، أو إنفاذ القانون. 01 الرعاية والمساندة الاجتماعية مسالك الرعاية بشأن الرعاية والمساندة الاجتماعية 27 حينما يؤدي التراجع في القدرة الأساسية والقدرة على الأداء إلى جعل الشخص معتمدًا على الآخرين للحصول على الرعاية، فإن مهمة الرعاية تقع في الغالب على كاهل الزوج، أو فرد آخر من أفراد الأسرة، أو أشخاص آخرين من الأسرة المعيشية. ورهنًا باحتياجات المسن فإن عبء توفير الرعاية قد يعرض عافية مقدمها للخطر. وبمقدور العاملين الصحيين أو الاجتماعيين في المجتمع المحلي رصد عافية مقدمي الرعاية والسعي للتأكد من أنهم يلقون الرعاية اللازمة من أجل صحتهم الذاتية ومساعدتهم في مهام تقديم الرعاية. النقاط الرئيسية يمكن لعبء واإ جهاد رعاية المسنين المعانين من خسائر جسيمة في القدرة الأساسية والقدرة على الأداء أن يخل بصحة أفراد الأسرة والأصدقاء الذين يضطلعون بدور مقدمي الرعاية. كما أن ذلك قد يضعهم، ولاسيما النساء منهم، خارج صفوف القوة العاملة المأجورة. يشكل العثور على مقدمي الرعاية المحتاجين هم أنفسهم للرعاية جانبًا مهمًا من تحديد المسنين المعانين من تراجع في القدرات. يمكن لطائفة من التدخلات، مثل الرعاية المؤقتة، والمشورة، والتثقيف، والدعم المالي، والتدخلات النفسية، أن تساند مقدم الرعاية للحفاظ على علاقة رعاية مقبولة وصحية. وفي بعض الأحيان تغدو علاقات الرعاية مسيئة. وقد يشاهد العاملون المجتمعيون علامات الإساءة خلال عملية تقدير المسن أو مقدم الرعاية. وفي هذه النقطة فإن الأمر يتطلب الإحالة إلى المستوى التخصصي. 11 مسالك الرعاية لمساندة مقدمي الرعاية مساندة مقدمي الرعاية 37 ?? اسأل هل يختلف دورك كمقدم رعاية إلى (...) أثرًا سلبيًا على حياتك؟ هل تشعر بأنك لا تتلقى المساعدة للقيام بدورك كمقدم للرعاية؟ استطِلع المساندة لمقدمي الرعاية مثل التدريب، والمشورة، والتوجيه، والرعاية المؤقتة كمراكز الرعاية النهارية، والانخراط المجتمعي مع تقديم الرعاية، وشبكات المساندة (يقدم برنامج troppuSi أفكارًا بهذا الصدد على العنوان التالي: gro.aitnemedroftroppusi.www//:sptth) (على أي من السؤالين) (على أي من السؤالين) (على كلا السؤالين) نعم نعم نعم نعم لا لا لا لا قدِّر مزاج مقدم الرعاية اسأل هل تضايقت خلال الأسبوعين الماضيين بسبب: – شعورك بالإحباط، أو الاكتئاب، أو اليأس؟ – قلة الاهتمام أو المتعة بالقيام بالأعمال؟ قم بالعناية بالإجهاد مع مساندة التثقيف النفسي قدم المشورة في حل المشكلات قم بتوفير العلاج المعرفي السلوكي اسأل هل تواجه خسارة في الدخل و/أو نفقات إضافية بسبب احتياجات الرعاية؟ استطلع خيارات المساندة المالية المحلية تعزيز الصلة مع نظام الرعاية الرسمي والطويل الأجل والمساندة المجتمعية مثل رابطات المتطوعين إعادة التقييم كل 6 أشهر قم بإدارة الاكتئاب: انظر دليل تدخلات برنامج PAGhm 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth تدعو الحاجة إلى رعاية متخصصة 11 مساندة مقدمي الرعاية مسالك الرعاية لمساندة مقدمي الرعاية 1قدِّر مزاج مقدم الرعاية إذا أبلغ ا لشخص عن عَرض واحد على الأقل من الأعراض الأساسية، وهي الشعور بالإحباط، أو الاكتئاب، أو اليأس وعن قلة الاهتمام أو المتعة بالقيام بالأعمال، فإن عليك أن تقوم بتقدير آخر للمزاج. ويمكن استخدام كلمات بديلة إذا كان الشخص غير معتاد على تلك الواردة في سؤالي التحري. اسأل: «هل تضايقت خلال الأسبوعين الماضيين بسبب أي من المشكلات التالية؟» • صعوبة الإغفاء أو البقاء نائمًا، أو الإفراط في النوم. • الشعور بالتعب أو ضعف الطاقة. • الشعور بالاستياء من نفسك أو بأنك فاشل أو بأنك خذلت عائلتك. • صعوبة التركيز على أمور مثل قراءة الصحيفة أو مشاهدة التلفزيون • التحرك أو التكلم ببطء على نحو يمكن أن يكون الآخرون قد لاحظوه. • الإحساس بالتململ أو الضجر بما يدفعك إلى الحركة أكثر بكثير من المعتاد. • الشعور بأن من الأفضل لك أن تموت أو التفكير بإيذاء نفسك بطريقة ما. خطر إساءة المعاملة قد تكون العلاقة المتبادلة بين متلقي الرعاية ومقدمها معقدة. وبمقدور مقدمي الرعاية الأصحاء والسعداء أن يوفروا مساندة استثنائية، غير أن علاقة الرعاية قد تكون مكروهة من جانب أحد الطرفين أو من كليهما. وقد يؤدي ذلك إلى إثارة النزاع الذي يمكن أن يعرض المسن لإساءة المعاملة. وربما تتخذ إساءة المعاملة شكل الإهمال، أو الاستغلال المادي (المالي، مثًلا) أو إساءة المعاملة البدنية، أو العاطفية، أو الجنسية. وقد يحدث الإهمال أيضًا بسبب الجهل، أو افتقار مقدم الرعاية إلى الدعم أو الإشراف الخارجيين. وربما لا يُب لغ المسن ولا مقدم الرعاية العاملين الصحيين بإساءة المعاملة. وينبغي استخدام المعلومات الرصدية المستندة إلى سلوك المسن، أو سلوك مقدمي الرعاية أو الأقارب، أو علامات إساءة المعاملة البدنية لتحديد إساءة المعاملة المحتملة (انظر الفصل 01 بشأن الرعاية والمساندة الاجتماعية). العوامل التي تزيد من احتمال قيام العلاقة المسيئة: • العلاقة الرديئة الطويلة الأجل؛ • تاريخ من العنف الأسري؛ • صعوبة توفير مقدم الرعاية باستمرار لمستوى أو نوع الرعاية اللازمة؛ و • مشكلات الصحة البدنية أو النفسية لمقدم الرعاية، ولاسيما الاكتئاب، وكذلك إساءة استعمال الكحول والعقاقير، وخاصة لدى الرجال. ولا يتعلق احتمال إساءة المعاملة فقط بطبيعة الرعاية المقدمة أو حتى بالعوامل المرتبطة غالبًا بإجهاد مقدم الرعاية، مثل التحديات التي يطرحها سلوك المصاب بالخرف. وفي حال الاشتباه بعلاقة مسيئة فإن الحاجة تدعو إلى تقدير مختص أكثر تفصيًلا باتباع مسالك الإحالة المحلية. * يمكن الاطلاع على هذه الأسئلة في استبيان صحة المرض )QHP-9( )fdp.9qhp_loot/fdp/gro.hmiaqc.www//:ptth(، الذي يعتبر أداة من أدوات تقدير الأعراض الاكتئابية. أو أنظر قسم الاكتئاب في دليل تدخلات برنامج PAGhm في العنوان التالي: 932052/56601/eldnah/siri/tni.ohw.sppa//:sptth. حينما يقتضي الأمر رعاية متخصصة • لمعالجة الاكتئاب • لتقديم المشورة لحل المشكلات أو العلاج المعرفي السلوكي إلى مقدم الرعاية المصاب بأعراض اكتئابية. • عند الاشتباه بعلاقة مسيئة. 11 مساندة مقدمي الرعاية مسالك الرعاية لمساندة مقدمي الرعاية 57 11.1 اسأل مقدم الرعاية يوفر المسلك الوارد في الصفحة 47 الإرشاد بشأن النقاش مع مقدم الرعاية. وفي هذا المسلك ُتطرح أسئلة على كل مقدم للرعاية تشمله المقابلات بشأن ثلاثة مجالات هي: 1. العبء الملقى على عاتق مقدم الرعاية (سؤالان)، بما يمكن أن يقود إلى استراتيجيات عملية تساند مقدمي الرعاية. 2. الَعَرضان الرئيسان من أعراض الاكتئاب، بما قد يحفز على إجراء تقدير كامل للاكتئاب (انظر الفصل 9 بشأن الأعراض الاكتئابية). 3. التكاليف المالية لتقديم الرعاية، بما قد يقود إلى مصادر المساندة المالية المحلية والرعاية الاجتماعية المنظمة، في حال توافرها. وعند الحديث إلى مقدم الرعاية فإن على العاملين استطلاع علامات الإرهاق، أو الغضب، أو الإحباط، أو الازدراء. كما أن بمقدور العاملين الصحيين الاستفسار من مقدمي الرعاية فيما إذا كنوا يرغبون في المزيد من عمليات التقدير أو المساندة من جهات تقديم الرعاية الاجتماعية. ومع مضي الوقت فإن الأعباء الملقاة على عاتق مقدم الرعاية قد تتراكم. ومن المناسب إعادة التقدير كل ستة أشهر. ومن الأفضل القيام بتقدير دور مقدم الرعاية وأثره بعيدًا عن المسن، للتخفيف من إحراج مقدم الرعاية وتردده في الحديث بصراحة وبشكل كامل. وقد تتباين أحاديث المسن ومقدم الرعاية لأسباب متنوعة، بما في ذلك مشكلات التذكر التي يعاني منها المسن. وعلى هذا فإنه ينبغي النظر إلى التقدير في ضوء المعارف المكتسبة من التقدير الكامل للقدرة الأساسية. 11.2 توفير المساندة لمقدمي الرعاية على المهنيين ذوي التدريب المناسب ومقدمي الرعاية المأجورين، والمدعومين والخاضعين للإشراف في إطار خدمات الرعاية الصحية والاجتماعية، أن يساندوا مقدمي الرعاية غير المأجورين. وفي المجتمع المحلي فإن بمقدور العاملين في الرعاية الصحية والاجتماعية، من المهنيين والمتطوعين على حد سواء، أن ينشئوا شبكة لتقاسم الموارد المتاحة لمساندة مقدمي الرعاية غير المأجورين. وهناك برنامج تدريبي للمنظمة على شبكة الإنترنت يدعى »troppuSi« يمكن أن يساعد مقدمي الرعاية للمصابين بالخرف لتوفير الرعاية الجيدة وللعناية بأنفسهم - انظر: gro.aitnemedroftroppusi.www//:sptth. وتركز المساندة على مقدم الرعاية الأسري الأول. ولفهم احتياجات مقدم الرعاية فإن بمقدور الجهة المقدمة لخدمات الرعاية أن تستفسر عن طبيعة المهام المنفذة، وكيفية ووتيرة ذلك، والبحث عن جوانب الرعاية التي يمكن أن تنتفع من المشورة، أو المساندة العملية، أو التكنولوجيات المساِندة المبتكرة (انظر الإطار في الصفحة 77). وينبغي أن تراعي المساندة خيارات مقدم الرعاية وأن تشدد على النهوض الأمثل برفاه مقدم الرعاية. 11 مساندة مقدمي الرعاية مسالك الرعاية لمساندة مقدمي الرعاية 67 وبمقدور العاملين الصحيين والاجتماعيين القيام بما يلي: • تزويد مقدم الرعاية بالتدريب والمساندة فيما يتعلق بمهام الرعاية المخصوصة، مثل إدارة السلوك العسير؛ • النظر في توفير أو ترتيب مساندة عملية، مثل الاستراحة من الرعاية؛ و • استطلاع ما إذا كان الشخص المصاب بخسارة في القدرة على الأداء يتمتع بحق تلقي أية استحقاقات اجتماعية أو مساندة اجتماعية أو مالية أخرى من الحكومة أو من المصادر غير الحكومية. قدِّم المشورة. عليك الإقرار بأن تقديم الرعاية يمكن أن يكون محبطًا ومجهدًا للغاية. كما أن ذلك قد يتفاقم بسبب أحاسيس الفجيعة الناجمة عن فقد العلاقة السابقة التي كانت قائمة بين المسن ومقدم الرعاية، ولاسيما إذا كان مقدم الرعاية هو الزوج. وينبغي تشجيع مقدمي الرعاية على احترام كرامة المسنين من خلال إشراكهم في اتخاذ القرارات المتعلقة بحياتهم ورعايتهم قدر المستطاع. رتِّب الرعاية المؤقتة. عندما تغدو الرعاية مفرطة الأعباء أو مرهقة، فهل يمكن لشخص آخر أن يتولى مؤقتًا أمر الإشراف على المسن ورعايته؟ ويمكن أن يكون هذا الشخص فرد آخر من أفراد العائلة أو الأسرة المعيشية، أو أحد العاملين المدربين للرعاية الاجتماعية، سواء أكان مهنيًا أم متطوعا. وبمقدور هذه الرعاية المؤقتة، مثل الرعاية النهارية، أن تحرر مقدم الرعاية الرئيسي بحيث يستطيع أن يستريح أو يقوم بأنشطة أخرى. وتعتبر الرعاية النهارية أحد أنواع خدمات المساندة المجتمعية، وهي توفر الرعاية الشخصية (الاستحمام، الإطعام، الحلاقة، استخدام المرحاض)، والتأهيل، وبرامج الأنشطة الاستجمامية والاجتماعية. توفير المساندة النفسية. ينبغي السعي للعناية بأمر الإجهاد النفسي لمقدم الرعاية من خلال المساندة وتقديم المشورة لحل المشكلات، ولاسيما حينما تكون الرعاية معقدة وواسعة، ويكون الضغط على مقدم المشورة بالغا. التكنولوجيات المساِعدة المبتكرة تعتبر التكنولوجيات الصحية المساِعدة المبتكرة، مثل الرصد من ُبعد والروبوتات المساِعدة، وسائل واعدة لتعزيز قدرات الأداء لدى المسنين، ولتحسين نوعية حياتهم وحياة مقدمي الرعاية لهم، ولزيادة الخيارات، والسلامة، والاستقلال، والإحساس بالتحكم، ولتمكين المسنين من قضاء شيخوختهم في أماكن إقامتهم. وينبغي أن يستند استخدام هذه التكنولوجيات إلى احتياجات وأفضليات المسنين أو مقدمي الرعاية لهم، وهو يحتاج إلى توفير التدريب المناسب للمستخدمين النهائيين. ويتعين إيلاء الاهتمام البالغ إلى تطوير آلية لتمويل البحث والتطوير ولضمان التنفيذ المنصف. ومن الأمثلة على التكنولوجيات المبتكرة ما يلي: • روبوت ORAP للمساعدة الاجتماعية. وهو روبوت على شكل فقمة أليفة يوفر الصحبة )22(. moc.stobororap.www//:ptth. • الأطراف المساِعدة الهجينة – نوع القرص القطني. تمنح هذه الأطراف مقدمي الرعاية عضلات روبوتية يحتاجونها لرفع المرضى وتحريكهم من الفراش إلى السرير واإ لى الحمام. /stcudorp/hsilgne/pj.enydrebyc.www//:sptth lmth.troppuSeraC_rabmuL 11 مساندة مقدمي الرعاية مسالك الرعاية لمساندة مقدمي الرعاية 77 النقاط الرئيسية إن الرعاية المتركزة على الأشخاص هي رعاية شاملة ومصممة حسب كل حالة على حدة ومدعومة بالعلاقات التعاونية بين العاملين الصحيين والمسنين، ومن يساندهم من أسر وأصدقاء. بمقدور الفرق المتعددة الاختصاصات أن تساعد المسنين على تحديد أهدافهم. ينبغي الاتفاق على التدخلات المساندة للمسن في ضوء احتياجاته وأهدافه ذات الأولوية. تعد المتابعة المتواصلة والمنتظمة عنصرًا أساسيًا في تحقيق الأهداف. وضع خطة الرعاية المشخصنة ويعتبر تخطيط الرعاية المشخصنة نهجًا ذا طابع إنساني يبتعد عن الطرق التقليدية الموجهة نحو الأمراض ويركز عوضًا عن ذلك على احتياجات المسنين، وقيمهم، وأفضلياتهم. وحال اعتماد خطة الرعاية المشخصنة فإنها توفر الإرشاد لكل جوانب الرعاية الصحية والاجتماعية وتساند الأهداف الواقعية المتركزة على الأشخاص. خطوات وضع خطة الرعاية المشخصنة 1. استعراض الاستنتاجات ومناقشة الفرص المتاحة للنهوض بالقدرة على الأداء، والصحة، والرفاه تقوم الفرق المتعددة الاختصاصات في هذه الخطوة، بالتعاون مع المسنين وأفراد أسرهم و/ أو مقدمي الرعاية (إن كان ذلك مناسبًا)، باستعراض نتائج التقدير المتركز على الأشخاص والتدخلات المقترحة في مسالك الرعاية. وسيولِّد التقدير المتركز على الأشخاص قائمة بالتدخلات المقترحة التي يمكن إدراجها في خطة الرعاية ومناقشتها مع المسن. ويمكن أن توفر تطبيقات الأجهزة المتنقلة لنهج الرعاية المتكاملة للمسنين المساعدة للعاملين الصحيين في هذا الصدد. وقد تشتمل الفرق المتعددة الاختصاصات على أي شخص منخرط في رعاية المسن، مثل أطباء الرعاية الأولية، والأطباء المختصين، والممرضين، والعاملين في الرعاية المجتمعية، والعاملين في الرعاية الاجتماعية، والمعالجين (العلاج الفيزيائي، الأدائي، الكلامي، النفسي)، ومقدمي الرعاية المأجورين وغير المأجورين، والصيادلة، والمتطوعين. 2. إعداد الأهداف المتركزة على الأشخاص تعتبر عملية إعداد الأهداف المتركزة على الأشخاص الرامية إلى تحديد هذه الأهداف، واعتمادها، وترتيبها من حيث الأولوية عنصرًا أساسيًا في استحداث خطة للرعاية. ومن المهم بالنسبة للفريق المتعدد الاختصاصات أن ُيشرك المسنين في اتخاذ القرارات المتعلقة برعايتهم، وفهم واحترام احتياجاتهم، وقيمهم، وأفضلياتهم، وأولوياتهم. ويمكن أن يشكل ذلك انعطافة تحويلية في طريقة العلاقة بين المهنيين الصحيين ومرضاهم اليوم. ويمكن أن تتجاوز أهداف الرعاية في نطاقها مسألة تقليل الأثر المباشر للظروف الطبية وأن تركز بصورة أشد على الأشياء التي تمكِّ ن المسنين من القيام بالأمور التي يعتبرونها ذات قيمة قصوى بالنسبة لهم، مثل قضاء مرحلة الشيخوخة على نحو يتسم بالاستقلال والسلامة، والحفاظ على تطورهم الشخصي، ودمجهم في مجتمعاتهم المحلية ومشاركتهم فيها مع الحفاظ على استقلالهم الذاتي وصحتهم. واإ لى جانب الأهداف في الأجلين المتوسط والطويل (من ستة أشهر إلى 21 شهرًا)، يوصى بإدراج أهداف قصيرة الأجل (ثلاثة أشهر) لتحقيق المزيد من التحسينات أو المنافع الفورية بما يكفل الحفاظ على حماس المسنين وانخراطهم. 21 87 5. الرصد والمتابعة يعد الرصد مع المتابعة المنتظمة لتنفيذ خطة الرعاية ضروريًا لتحقيق الأهداف المعتمدة. ويتيح ذلك الفرصة لرصد التقدم ويمكِّن من الكشف المبكر عن الصعوبات القائمة في وجه المشاركة في التدخلات، والتأثيرات الضارة لهذه التدخلات، والتغيرات في الوضع الأدائي. كما يساعد على الحفاظ على العلاقة الناجحة بين المسنين ومقدمي الرعاية لهم. وتشمل عملية المتابعة، على سبيل المثال لا الحصر، ما يلي: • ضمان التنفيذ الناجح، خطوة فخطوة، لخطة الرعاية؛ • تكرار التقييم المتركز على الأشخاص وتوثيق أية تغيرات؛ • إيجاز الحصائل، والحواجز، وتعقيدات تنفيذ تدخلات الرعاية الصحية والاجتماعية؛ • تحديد التغيرات والاحتياجات الجديدة؛ • الاتفاق على مواصلة العناية بهذه التغيرات والاحتياجات، بما في ذلك اعتماد تدخلات جديدة عند الحاجة، وتنقيح وتحسين الخطة حسب الاقتضاء؛ و • تكرار الدورة. 3. الاتفاق على التدخلات تتطلب التدخلات المقترحة للإدراج في خطة الرعاية نتيجة التقديرات والمسارات المتركزة على الأشخاص ما يلي: (أ) موافقة المسن (ب) أن تكون متماشية مع أهداف المسن، واحتياجاته، وأفضلياته، وأولوياته (ج) أن تراعي بيئته المادية والاجتماعية. وعلى العاملين في الرعاية الصحية أو الاجتماعية إجراء مناقشة بعد ذلك مع المسن للموافقة على التدخلات، كل على حدة، التي ينبغي أن تظل مدرجة في خطة الرعاية النهائية. 4. إنجاز وتقاسم خطة الرعاية على المهني الصحي الآن أن يوثِّق في خطة الرعاية نتائج المناقشات، وأن يتقاسم الوثيقة مع المسن، وأفراد أسرته، ومقدمي الرعاية، وأي شخص آخر منخرط في رعايته، بعد أخذ الموافقة. ويمكن أن يوفر تطبيق الأجهزة المتنقلة لنهج الرعاية المتكاملة للمسنين المساندة لهذه العملية عبر تزويد كل شخص منخرط فيها بموجز عن خطة الرعاية يتضمن الأهداف ذات الأولوية والظروف المحددة. 21 ميادين القدرة على الأداء 1. تلبية الاحتياجات الأساسية مثل الأمن المالي، والإقامة، والأمن الشخصي. 2. التعلم، واستخلاص واتخاذ القرارات، وهو ما يتضمن بذل الجهود لمواصلة التعلم وتطبيق المعارف، والانخراط في حل المشكلات، والحفاظ على التطور الشخصي، والقدرة على انتقاء الخيارات. 3. التمتع بالقدرة التحركية اللازمة لأداء المهام حول المنزل، والوصول إلى المتاجر، والخدمات، والمرافق في المجتمع المحلي، والمشاركة في الأنشطة الاجتماعية، والاقتصادية، والثقافية. 4. تكوين وصون طائفة واسعة من العلاقات، بما في ذلك مع الأطفال وأفراد الأسرة الآخرين، والعلاقات الاجتماعية غير الرسمية مع الأصدقاء، والجيران، والزملاء، وكذلك علاقات رسمية مع العاملين في الرعاية الاجتماعية. 5. المساهمة، ذات الصلة الوثيقة بالانخراط، في الأنشطة الاجتماعية والثقافية، مثل مساعدة الأصدقاء والجيران، واإ رشاد الأقران والشباب، ورعاية أفراد الأسرة والمجتمع المحلي. 97 21 تحديد الأهداف: حدد الأهداف مع المسن، وأفراد أسرته، ومقدمي الرعاية )32(: • السؤال 1 يرجى إيضاح الأشياء التي تتسم بأهمية بالغة بالنسبة إليك في كل مراحل حياتك. • السؤال 2 اذكر بعض الأهداف المخصوصة لك في حياتك؟ • السؤال 3 اذكر بعض الأهداف المخصوصة لك بالنسبة لصحتك؟ • السؤال 4 بناًء على الأهداف الحياتية والصحية على حد سواء التي ناقشناها، هل يمكن لك اختيار ثلاثة منها تود التركيز عليها خلال الأشهر الثلاثة المقبلة؟ وماذا عن الأشهر الستة أو الاثني عشر القادمة؟ وضع الأهداف: يمكن مواءمة الأهداف مع احتياجات المسن وتعريفه الذاتي للمشكلات. • السؤال 5 ما هو تحديدًا الجانب المخصوص من جوانب الهدف الأول، أو الثاني، أو الثالث الذي تود العمل عليه خلال الأشهر الثلاثة المقبلة؟ وماذا عن الأشهر الستة أو الاثني عشر القادمة؟ • السؤال 6 ما الذي تقوم به حاليًا بشأن [مجال الأهداف]؟ • السؤال 7 ما هي الغاية المثالية والممكنة في الوقت ذاته بالنسبة إليك من تحقيق هذا الهدف؟ ترتيب الأهداف من حيث الأولوية: سيؤدي الاتفاق على الأهداف ذات الأولوية بين المسن وجهات تقديم الرعاية إلى تحقيق حصائل محسنة. • السؤال 8 أي هدف من بين هذه الأهداف أنت على أشد الاستعداد للعمل عليه على مدى الأشهر الثلاثة المقبلة، سواء بمفردك أو بمساندة من [الدكتور XX وفريقه]؟ وماذا عن الأشهر الستة أو الاثني عشر القادمة؟ كيفية إعداد الأهداف المتركزة على الأشخاص المصدر: مقتبس من الأصل من جانب برنامج yrtsepaT htlaeH )ac.yrtsepathtlaeh//:ptth( 08 النقاط الرئيسية يتطلب التنفيذ الفعال لنهج الرعاية المتكاملة للمسنين اعتماد نهج متكامل يربط خدمات الرعاية الصحية والاجتماعية. يبدأ النهوض الأمثل بالقدرات الأساسية وقدرات الأداء للمسنين انطلاقًا من المجتمع المحلي والعاملين المجتمعيين. وعلى نظم القطاعات الصحية والاجتماعية أن تساند الرعاية المتركزة على المستوى المجتمعي. تشكل خطط الرعاية المشخصنة جوهر نهج الرعاية المتكاملة للمسنين. ولتنفيذ هذه الخطط واإ دارتها فقد يحتاج العاملون إلى تدريب مخصوص على إدارة الحالات. يرسم «التقرير العالمي بشأن الشيخوخة والصحة» لمنظمة الصحة العالمية وجهة جديدة للنظم الصحية والطويلة الأجل )1(. ويدعو هذه النظم إلى التركيز على القدرات الأساسية للمسنين بهدف الحفاظ على قدراتهم على الأداء والنهوض بها. وتحوِّل وثيقة «مبادئ توجيهية بشأن التقدير المتركز على الأشخاص ومسالك الرعاية الأولية»، الصادرة عن المنظمة عام 7102 هذه الوجهة الجديدة إلى نهج عملي للتقدير والرعاية على مستوى المجتمع المحلي )2(. وترعى هاتان الوثيقتان معًا الرعاية والمساندة الصحية والاجتماعية المتكاملة والمتركزة على الأشخاص. ويبدأ هذه النهج بتقدير متركز على الأشخاص لاحتياجات الرعاية الصحية والاجتماعية بمقدور العاملين المجتمعيين إجراؤه. ويسلط هذا الفصل الضوء على بعض الاعتبارات الرئيسية المتعلقة بتنفيذ نهج الرعاية المتكاملة للمسنين. وسُتعنى وثيقة المنظمة بشأن الإرشادات الموجهة إلى النظم والخدمات لتنفيذ نهج الرعاية المتكاملة للمسنين بمسائل التنفيذ بشكل مفصل )966523/56601/eldnah/siri/tni.ohw.sppa//:sptth(. كيف يمكن لنظم الرعاية الصحية والطويلة الأجل مساندة تنفيذ نهج المنظمة للرعاية المتكاملة للمسنين 31 18 1.31 المساندة الوطنية للتنفيذ يقتضي الأمر، كخطوة أولى، مواءمة توصيات المنظمة وهذا الكتيب مع السياق، والثقافة، واللغة، على المستوى المحلي بما يتناسب مع العاملين في ميدان الرعاية والصحة، ومقدمي الرعاية، والمسنين أنفسهم. ويمكن أن تبدأ العملية الشاملة للمواءمة بإرساء مساندة واسعة للنهج الجديد. وسيتطلب تنفيذ نهج الرعاية المتكاملة للمسنين تعاونًا متواصًلا في كل الأصعدة والمراحل بين أصحاب المصلحة، بما في ذلك صنَّاع السياسات، والمهنيين الصحيين، والعاملين في الرعاية الاجتماعية، والباحثين، والمجتمعات المحلية، والمسنين. وستدعم المعارف المحلية تحويل الإرشادات العالمية إلى نماذج خدمات مجدية ومقبولة. ويستدعي ترويج التمتع بالصحة في مرحلة الشيخوخة انخراط قطاعي الرعاية الصحية والاجتماعية على حد سواء. وسيكون كلا القطاعين أكثر قدرة على اعتماد وتطبيق نهج الرعاية المتكاملة للمسنين حينما تساند السياسات الوطنية نهجًا متكامًلا إزاء الرعاية الصحية والاجتماعية. وعلى هذا فإن على السياسات أن توضح بشكل محدد كيف ستعمل الصلة بين الرعاية الصحية والرعاية الاجتماعية على الأصعدة الوطنية، والإقليمية، والمجتمعية. ويمكن أن تشجع الحوافز والمكافآت، وآليات التمويل، ورصد الأداء، عملية التحول في الأولويات نحو رعاية المسنين التي تنهض بالقدرة الأساسية والقدرة على الأداء إلى المستوى الأمثل. وينبغي توجيه نظم المعلومات نحو رصد هذا التحول على الأصعدة الوطنية والمحلية. 2.31 متطلبات الميزانية والموارد البشرية ينبغي تحليل تبعات تنفيذ نهج الرعاية المتكاملة للمسنين لتحديد الاستثمارات الإضافية التي ستدعو إليها الحاجة، وذلك، مثًلا، فيما يتعلق بتدريب العاملين الصحيين، واستخدام التكنولوجيات، ومواءمة نظم المعلومات الصحية. وعلى وجه الخصوص فإن العاملين في الرعاية الصحية والاجتماعية وفرق الرعاية الأولية سيحتاجون إلى الدعم لفهم وتطبيق النهج الجديد. وبمقدور الرابطات المهنية الوطنية والمحلية الاضطلاع بدور مهم في هذا الصدد كجزء من العملية التشاركية التي تضم كل أصحاب المصلحة. 31 الاعتبارات الرئيسية للتنفيذ الوطني ينبغي أن يكفل التخطيط لإدماج نهج الرعاية المتكاملة للمسنين ضمن نظم الرعاية الصحية والطويلة الأجل ما يلي: • الجدوى – المالية والتنظيمية • الاستدامة – الكفاءة وقدرة القوة العاملة • الاتساق – الترابط مع السياسات الداعمة للتمتع بالصحة في مرحلة الشيخوخة • التكامل – الصلات بين خدمات الرعاية الصحية والاجتماعية. 28 3.31 تكامل الرعاية والمساندة على امتداد الخدمات الصحية والاجتماعية ينبغي أن تتبع كل تدخلات الرعاية المتكاملة مبادئ ترجمة المعارف التي عرّفتها المنظمة عام 5002 على أنها «توليف أصحاب المصلحة للمعارف وتبادلها وتطبيقها تسريعًا لجني فوائد الابتكار على الصعيدين العالمي والمحلي في مجال تعزيز النظم الصحية وتمتع الناس بصحة أفضل». وقد تم استحداث إطار المنظمة لترجمة المعارف من أجل الشيخوخة والصحة لعام 2102 خصيصًا لتطبيق هذه المبادئ لرعاية المسنين ذوي المراضات و/ أو الصعوبات المتعددة القادرين على الوصول إلى الخدمات الصحية )42(. ويقترح إطار المنظمة لعام 6102 بشأن الخدمات الصحية المتكاملة المتركزة على الأشخاص ُنهجًا رئيسية لضمان الرعاية المتكاملة ذات الجودة الرفيعة )6(. ومن بين العناصر المهمة للرعاية المتكاملة توفير الإدارة القوية للحالات لمساندة تصميم، وتنسيق، ورصد خطط الرعاية، التي ستغطي على الأرجح ميادين متعددة للرعاية الصحية والاجتماعية. وقد يحتاج العاملون في الرعاية الصحية والاجتماعية إلى تدريب خاص على إدارة الحالات وكذلك على الجوانب السريرية لتوصيات نهج الرعاية المتكاملة للمسنين. ويشدد إطار تنفيذ نهج المنظمة للرعاية المتكاملة للمسنين على التدابير الأساسية على مستوى الخدمات والنظم لتنفيذ النهج )52(. وتغطي الإرشادات التدابير (الصفحة 48) التي ينبغي أن يتخذها مدراء الخدمات والنظم لتوفير الرعاية المتكاملة. ويوصي الإطار بالقيام بتدابير محددة رهنًا باتساع الخدمات الصحية والاجتماعية القائمة. 4.31 مواءمة الخدمات المحلية للرعاية الصحية والاجتماعية لمساندة التنفيذ ينبغي تنفيذ تدخلات نهج الرعاية المتكاملة للمسنين على نحو يستهدف مساندة المسنين في أماكن إقامتهم. ويعني ذلك أنه ينبغي تجهيز خدمات الرعاية الصحية والاجتماعية على نحو يتيح للمسنين العيش في منازلهم ومجتمعاتهم المحلية بسلامة، واستقلال، وراحة. وهذه التدخلات مصممة لتنفيذها عبر نماذج من الرعاية تمنح الأولوية للرعاية الأولية والمجتمعية. ويشمل ذلك التركيز على التدخلات المنزلية، والانخراط المجتمعي، وعلى نظام متكامل تمامًا للإحالة. ولا يمكن تحقيق هذا التركيز إلا من خلال الإقرار بالدور الحاسم الذي يضطلع به العاملون المجتمعيون في تيسير الحصول على الرعاية الصحية الأولية والتغطية الصحية الشاملة ومساندة هذا الدور. وتطرح المبادئ التوجيهية للمنظمة المعنية بدعم السياسات والنظم الصحية للنهوض الأمثل ببرامج العاملين الصحيين المجتمعيين اقتراحات وتوصيات مسندة بالبيِّنات بشأن اختيار العاملين الصحيين، وتدريبهم، وكفاءاتهم الأساسية، والإشراف عليهم، ومكافأتهم )62(. 31 دلیل النظم والخدمات إطار التنفیذ الرعاية المتكاملة للمسنین 966523/56601/eldnah/siri/tni.ohw.sppa//:sptth 38 وعند الحاجة إلى الرعاية المتخصصة فإن من الواجب أن تقوم شبكة من العاملين الصحيين على المستويين الثانوي والثالثي بمساندة جهود العاملين الصحيين المجتمعيين. ويجب إرساء معايير ومسالك واضحة للإحالة عبر الاتفاق بين كل الأطراف على المستوى التشغيلي ثم رصدها من أجل ضمان الجودة. ويتعين أن تكون ترتيبات المتابعة جلية لضمان بقاء خطط الرعاية مناسبة وأنشطة الرعاية والمساندة الصحية فعالة. وتتسم المتابعة والمساندة بأهمية خاصة في أعقاب التغيرات الكبرى في الوضع الصحي أو إذا ما واجه المسن حدثًا حياتيًا بالغ الأهمية مثل تغيير مكان الإقامة أو وفاة الزوج أو مقدم الرعاية. 31 ملخص تدابير إطار تنفيذ نهج الرعاية المتكاملة للمسنين التدابير المتعلقة بالنظم تعزيز نظم الحوكمة والمساءلة. إشراك أصحاب المصلحة في تطوير السياسات والخدمات؛ ووضع سياسات ولوائح لمساندة الرعاية والاستجابة المتكاملة لظواهر إساءة معاملة المسنين؛ ومواصلة تحسين الجودة وتدابير ضمانها؛ والاستعراض المنتظم للقدرات بغية تقديم الرعاية بصورة منصفة. التمكين من التعزيز على مستوى النظم. تطوير قدرة القوة العاملة، والتمويل، واإ دارة الموارد البشرية؛ واستخدام التكنولوجيا لتبادل المعلومات بين مقدمي الخدمات؛ وجمع البيانات عن القدرة الأساسية والقدرة على الأداء والإبلاغ عنها؛ واستخدام التكنولوجيات الرقمية لدعم الإدارة الذاتية. التدابير المتعلقة بالخدمات إشراك وتمكين الأشخاص والمجتمعات المحلية. إشراك المسنين، وأسرهم، والمجتمع المدني في تسليم الخدمات؛ ودعم وتدريب مقدمي الرعاية. دعم تنسيق الخدمات التي توفرها الفرق المتعددة الاختصاصات. تحديد المسنين في المجتمع المحلي الذين يحتاجون إلى رعاية، واإ جراء تقديرات كاملة، واستحداث خطط رعاية شاملة؛ واإ نشاء شبكات للعاملين في الرعاية الصحية والاجتماعية. توجيه الخدمات نحو الرعاية المجتمعية. توفير رعاية فعالة ومقبولة تركز على القدرة على الأداء من خلال العاملين والخدمات على المستوى المجتمعي بدعم من بنية تحتية وافية. 48 5.31 انخراط المجتمعات المحلية ومساندة مقدمي الرعاية يحتاج مقدمو الرعاية إلى موارد إضافية من المجتمع المحلي. وقد تتطلب زيادة الانخراط النشط والمباشر للمجتمعات المحلية والأحياء في رعاية ومساندة المسنين تنظيمًا محليًا واإ رادة سياسية على حد سواء، ولاسيما لتشجيع التطوع وتيسير مساهمات أفراد المجتمع المحلي المسنين. وتعتبر نوادي المسنين ورابطاتهم من الحلفاء الطبيعيين في هذه الجهود. وفي الوقت ذاته فإن نظام الرعاية الصحية يتحمل مسؤولية إزاء شركائه في مساندة التمتع بالصحة في مرحلة الشيخوخة وهم: المجتمعات المحلية، والمنظمات المجتمعية، وأفراد الأسر، وغيرهم من مقدمي الرعاية غير المأجورين للمسنين. وتشمل هذه المسؤولية الاهتمام بصحة مقدمي الرعاية للمسنين ورفاههم، على النحو المعروض في الفصل 11، والدعم المتبادل، والتعاون، والتنسيق مع المجتمعات المحلية والمنظمات المجتمعية لإرساء بيئة صحية للتمتع بالصحة في مرحلة الشيخوخة. 58 عجارملا 9. painHEALTH. 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Blindness and vision impairment Global strategy and action plan on ageing and health. Geneva: WHO; 2018 (https://www. who.int/en/news-room/fact-sheets/detail/blindness-and-visual- impairment, accessed 2 April 2019). 15. Acceptability, benefit and costs of early screening for hearing disability: a study of potential screening tests and models. Davis A, Smith P, Ferguson M, Stephens D, Gianopoulos I. Health Technology Assessment, 2007, 11(42). 16. Primary ear and hearing care training resource. Geneva: WHO; 2006 (https://apps.who.int/iris/handle/10665/43333, accessed 2 April 2019). 1. World report on ageing and health. Geneva: World Health Organization (WHO); 2015 (https://apps.who.int/iris/ handle/10665/186463, accessed 2 April 2019). 2. Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity. Geneva: WHO; 2017 (http://apps.who.int/iris/handle/10665/258981, accessed 2 April 2019). 3. 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J Am Geriatr Soc. 2014;62(1):16–24. doi: 10.1111/jgs.12607. 8. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46. doi: 10.1111/jgs.13702. 17. Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in us adults, national health and nutrition examination survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4):293–302. doi: 10.1001/jamaoto.2014.42. 18. Zhang X, Bullard KM, Cotch MF, Wilson MR, Rovner BW, McGwin G Jr, et al. Association between depression and functional vision loss in persons 20 years of age or older in the United States, NHANES 2005–2008. JAMA Ophthalmol. 2013;131(5):573–81. doi: 10.1001/jamaophthalmol.2013.2597. 19. Spotting the signs of harm, abuse and neglect Scotland. Streatham: Action on Elder Abuse; no date (https://www. elderabuse.org.uk/spotting-the-signs-of-harm-abuse-and- neglect, accessed 2 April 2019). 20. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/S2214-109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128(6):3925–36. doi: 10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with dementia living in the community. J Am Med Dir Assoc. 2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. 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老年人综合照护 初级保健中以人为本的评估 和路径指南 手册
老年人综合照护 初级保健中以人为本的评估 和路径指南 手册 老年人综合照护（ICOPE）：初级保健中以人为本的评估和路径指南 [Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care] WHO/FWC/ALC/19.1 © 世界卫生组织 2019 保留部分版权。本作品可根据Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence（CC BY-NC-SA 3.0 IGO； h t t p s : / / c reativecommons. org/licenses/by-nc-sa/3.0/igo ）获得。 根据本许可证的条款，如果按如下所示适当提及本作品，可以复制、 重新排列和改编本作品以用于非商业目的。在对本作品的任何使用中，都不 得暗示世界卫生组织认可任何特定组织、产品或服务。不允许使用世界卫生 组织的徽标。如果对作品进行改编，就必须根据相同或等同的知识共享许可 证注册作品。如果翻译本作品，就应该添加以下免责声明以及建议的出处说 明：“该译文不是由世界卫生组织（WHO）翻译的。世界卫生组织对此译文 的内容或准确性概不负责。英文原版应作为有约束力和作准的版本”。 有关根据许可证发生的争议的任何调解都应按照世界知识产权组织的调 解规则进行。 建议的出处说明。老年人综合照护（ICOPE）：初级保健中以人为本的 评估和路径指南[Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care]。日内瓦：世界 卫生组织；2019（WHO/FWC/ALC/19.1）。许可证：CC BY-NC-SA 3.0 IGO. 在版编目数据（CIP）。CIP数据请参阅http://apps.who.int/iris 。 销售、权利和许可。购买世界卫生组织出版物，请参阅 https://apps.who.int/bookorders 。提交商业用途申请和有关权利和许可证 的查询，请参阅https://www.who.int/publishing/copyright 。 第三方材料。如果希望使用本作品中归属于第三方的材料（如表格、图 形或图像），则有责任确定是否需要得到许可才能使用，并获得版权所有者 的许可。因作品中第三方拥有的任何内容遭到侵权而导致索赔的风险完全由 使用者承担。 一般免责声明。本出版物采用的名称和陈述的材料并不代表世界卫生组 织对任何国家、领地、城巿或地区或其当局的合法地位，或关于边界或分界 线的规定有任何意见。地图上的虛线表示可能尚未完全达成一致的大致边界 线。 凡提及某些公司或某些制造商的产品时，并不意味着它们已为世界卫生 组织所认可或推荐，或比其它未提及的同类公司或产品更好。除差错和疏忽 外，凡专利产品名称均冠以大写字母，以示区别。 世界卫生组织已采取一切合理的预防措施来核实本出版物中包含的信 息。但是，已出版材料的分发无任何明确或含蓄的保证。解释和使用材料的 责任取决于读者。世界卫生组织对于因使用这些材料造成的损失不承担责 任。 Erica Lefstad设计和排版 致谢 iv 缩写 v 1. 老年人综合照护（ICOPE） 1 2. 优化内在能力与功能发挥： 走向人人健康老龄化 5 3. 评估老年人需求并 制定个性化照护计划 9 4. 管理认知减退的照护路径 19 5. 改善行动能力的照护路径 25 6. 管理营养不良的照护路径 33 7. 管理视力受损的照护路径 41 8. 管理听力丧失的照护路径 51 9. 管理抑郁症状的照护路径 59 10. 社会关怀与支持的照护路径 67 11. 支持照护人员的照护路径 75 12. 制定个性化照护计划 78 13. 卫生保健和长期照护系统如何支持 世界卫生组织ICOPE方法的实施 81 参考文献 86 目录 iii 致谢 这本手册借鉴了全世界许多致力于老年人照护和支持的 人士的工作。世界卫生组织老龄化和生命历程部门的Islene Araujo de Carvalho和Yuka Sumi主导编写本手册。负责编写手 册和制定路径的核心小组包括Islene Araujo de Carvalho、John Beard、Yuka Sumi、Andrew Briggs（柯廷大学，澳大利亚） 和Finbarr Martin（伦敦国王学院，英国）。尤拉编辑服务公 司的Sarah Johnson和Ward Rinehart负责撰写最后文本。 许多来自于区域办事处和许多部门的其他世界卫生组织工 作人员对与其工作领域相关的具体部门和照护路径的形成做出 了贡献：Shelly Chadha（世界卫生组织非传染性疾病、残疾、 暴力和伤害预防司），Neerja Chowdhary（世界卫生组织精 神卫生和药物滥用司），Tarun Dua（世界卫生组织精神卫生 和药物滥用司），Maria De Las Nieves Garcia Casal（世界卫 生组织营养促进健康和发展司），Zee A Han（世界卫生组织 非传染性疾病、残疾、暴力和伤害预防司），Dena Javadi（世 界卫生组织卫生政策与系统研究联盟），Silvio Paolo Mariotti （世界卫生组织非传染性疾病、残疾、暴力和伤害预防司）， Alarcos Cieza（世界卫生组织非传染性疾病、残疾、暴力和伤 害预防司），Alana Margaret Officer（世界卫生组织老龄化和 生命历程司），Juan Pablo Peña-Rosas（世界卫生组织营养促 进健康和发展司），Taiwo Adedamola Oyelade（家庭和生殖 健康单位，世界卫生组织非洲区域办事处），Ramez Mahaini （生殖和产妇保健司，世界卫生组织东地中海区域办事处）， Karen Reyes Castro（世界卫生组织非传染性疾病、残疾、暴 力和伤害预防司），Enrique Vega Garcia（健康生命历程司， 美国卫生组织／世界卫生组织）。 该手册得益于一系列专家和学者的大力投入，他们也为具 体章节的编写做出了贡献：Matteo Cesari（格兰达•奥斯佩代 尔•马焦雷•综合性医院IRCCS基金会，意大利），Jill Keeffe （世界卫生组织预防失明合作中心，印度），Elsa Dent（昆 士兰大学，澳大利亚），Naoki Kondo（东京大学，日本）， Arunee Laiteerapong（朱拉隆功大学，泰国），Mikel Izquierdo（纳瓦拉公立大学，西班牙），Peter L loyd- Sherlock（东安格利亚大学，英国），Luis Miguel Gutierrez Robledo（墨西哥国家卫生研究所，墨西哥），Catherine McMahon（麦格理大学，澳大利亚），Serah Ndegwa（内 罗毕大学，肯尼亚），Hiroshi Ogawa（新泻大学，日本）， Hélène Payette（舍布鲁克大学，加拿大），Ian Philp（斯特 林大学，英国），Leocadio Rodriguez-Mañas（赫塔菲大学 医院，西班牙），John Starr（爱丁堡大学，英国），Kelly Tremblay（华盛顿大学，美国），Michael Valenzuela（悉 尼大学，澳大利亚），Bruno Vellas（世界卫生组织衰弱症临 床研究及老年人培训合作中心，老年学，图卢兹大学医院，法 国），Marjolein Visser（阿姆斯特丹大学，荷兰），Kristina Zdanys（康涅狄格大学，美国），和世界卫生组织衰弱症临 床研究及老年人培训合作中心（老年学，图卢兹大学医院，法 国）和肌肉骨骼健康和老龄化的公共卫生方面（列日大学，比 利时）。 澳大利亚国家健康和医学研究委员会、全球肌肉骨骼健康 联盟和泰国朱拉隆功大学通过提供工作人员来制定指南内容和 组织专家会议，支持制定本指南。 我们还受益于2018年12月世界卫生组织健康老龄化临床联 合会年会与会者的投入。 世界卫生组织老龄化和生命历程司对日本政府、德国政府 和日本神奈川县政府的财政支持致以感谢。 Green Ink编辑。 iv 缩写 ADLs 日常生活活动 BMI 体质指数 CBT 认知行为疗法 ICOPE 老年人综合照护 MNA 微型营养评定法 OSN 口服补充营养 PTA 纯音听力检查 SPPB 简易体能状况量表 WHO 世界卫生组织 表示需要专业知识和技能来提供照护服务 v
2015年《老龄化与健康的全球报告》将健康老龄化的目标 定义为帮助人们发展和保持有利于健康的功能发挥。功能发挥 被定义为“使人们能够成为并做他们有理由重视的事情的与健 康相关的属性”。功能发挥由个体的内在能力、个体环境及两 者间的相互作用组成。内在能力是“一个人可以利用的所有身 体和心理能力的总和”(1)。 这一健康老龄化的概念激发了人们对老年保健的新关注， 即随着年龄的增长，注重优化人们的内在能力和功能发挥。 2017年10月，世界卫生组织（WHO）公布了《老年人综 合照护：社区采取干预措施处理老年人内在能力下降问题指 南》(2)。这些指南为卫生和保健工作者提出了13项基于证据 的建议，在社区帮助发展和开展以人为中心的老年人综合照护 （ICOPE）。ICOPE方法体现了对于优化内在能力和功能发挥 的重视，将其作为健康老龄化的关键。这些建议可作为国家指 南的基础。这些建议可用于支持预防护理依赖的服务，特別是 为实现全民健康覆盖的初级保健方案和基本卫生服务。 关键点 • 对于卫生保健系统来说，支持人人健康老龄化的关键是 即使随着老龄化带来的能力逐渐降低内在的情况下，优 化人们的内在能力和功能发挥功能发挥。 • 如果与内在能力下降相关的优先事项得到及时诊断和管 理，就可以预防照护依赖情况。 • 在初级保健层面，社区的卫生和社会保健工作者可以 根据此指南，识别能力丧失的老年人，并提供适当的照 顾，以扭转或减缓这些损失。这种方法简单且成本低。 • 与能力下降有关的事项是相互关联的，因此需要以综合 和以人为本的方法进行评估和管理。 老年人综合照护（ICOPE）1 1 为何需要老年人综合照护（ICOPE）？ 老年人在世界人口中所占的比例比以往任何时候都要 大。2017年，全球60岁及以上人口约9.62亿，占全球人口的 13%(3)。这一比例在未来几十年将迅速上升，特别是在中低收 入国家。到2050年，每5个人中就有一个60岁或以上老年人。 这种趋势始于大约50年前。这反映了世界许多地区生育率迅速 下降和期望寿命迅速增加的综合影响，这些往往伴随着社会经 济的发展。 维持老年人健康是对人力和社会资本的投资，并且支持联 合国可持续发展目标（SDGs）(4)。同时，护理需求日益增长的 老年人给卫生系统带来了挑战。需要在不同年龄组之间重新平 衡卫生保健资源。公共卫生的方向必须从根本上作出改变以回 应社會老龄化。 传统的老年人卫生保健方法侧重于医疗条件，把诊断和管 理放在核心位置。处理这些疾病仍然很重要，但过分关注这些 疾病往往会忽视老龄化带来的听力、视力、记忆、运动方面的 困难以及内在能力方面的其他常见损失。对这些问题的识别和 管理，将使每个人的健康在生命中的某个时候受益。整个卫生 保健系统对老年人内在能力的关注，将对大规模且不断增加的 人口的安全与健康做出大量贡献。 大多数卫生保健专业人员缺乏认识和有效管理内在能力下 降的指导和培训。随着人口老龄化，迫切需要制定以社区为基 础的综合办法，包括预防内在能力下降，促进健康老龄化以及 支持老年人照护者的干预措施。世界卫生组织的ICOPE方法解 决了这一需求。 这个指南是给谁的？ 本手册的主要读者是社区和初级保健机构的卫生和社会保 健工作人员。指南还应告知卫生保健工作人员，根据需要，将 用他们的专业知识为内在能力和功能发挥丧失的人们进行评估 和制定照护计划。 此外，负责开展医学、护理及相关卫生和公共卫生领域培 训的专业人员可借鉴本指南所述的概念和实用方法。其他读者 包括卫生保健管理人员和政策制定者，例如负责规划和组织卫 生保健服务的国家、区域和地区项目管理人员，以及资助和／ 或执行公共卫生保健项目的机构，以及在社区机构中为老年人 服务的非政府组织和慈善机构。 本手册中的指导将有助于社区卫生和保健工作者将ICOPE 推荐付诸实施。指南提供管理与内在能力下降相关的优先事 项⸺丧失行动能力、营养不良、视力受损、听力丧失、认知 减退、抑郁症状的照护路径。这些路径从筛查测试开始，以确 定那些最有可能正在经历内在能力丧失的老年人。卫生和社会 保健工作者可以很容易地在社区开展这种筛查。这是通往对老 年人健康和社会照护需求进行更深入评估的大门。继而，这些 评估可以引出综合了扭转、减缓或预防内在能力进一步衰退、 治疗疾病和满足社会保健需求的战略的个性化照护计划。以人 为本的评估和照护计划的制定通常需要在初级保健机构中受过 培训的卫生专业人员，如初级保健医生和护士。然而，在多学 科小组的支持下，在老年人和照护人员居住的社区中，可以管 理内在能力衰退。 2 指导原则 以下原则是本指南的基础： • 老年人有权获得最可能好的健康。 • 不论社会或经济地位、出生地或居住地或其他社会 因素如何，老年人都应有获得健康老龄化决定因素 的平等机会。 • 在没有歧视，特别是没有性别或年龄的歧视下，向 所有人平等地提供照护。 这个指南提供什么？ 本指南基于世界卫生组织关于社区层面管理内在能力衰退 干预措施的指南(2)，旨在支持社区机构中卫生和社会照护工作 人员发现和管理内在能力丧失，并全面解决老年人的卫生和社 会照护需要。 本指南描述了如何： • 制定以人为本的目标（第2章）； • 支持自我管理（第2章）； • 制定一项包括管理与内在能力丧失有关情况的多项干预措施 在内的照护计划，（第3章）； • 筛查内在能力损伤，评估健康和社会照护需求（第4–10 章）； • 支持照护者（第11章）；�� • 制定个性化照护计划（第12章）。 一定背景下的ICOPE方法 全民健康覆盖是实现SDGs健康目标的基础(4)。要 实现SDG3，老年人的卫生和社会照护需要必须以综合 的方式得到解决，并保持长期照护的连续性。世界卫生 组织老龄与健康战略和行动计划(5)概述了卫生系统通过 优化内在能力在促进健康老龄化方面的作用。ICOPE推 荐(2)和本指南有助于实现该战略的目标。 本指南也是执行世界卫生组织关于综合的以人为本 的卫生服务框架的工具(6)。该框架要求改变管理和提 供卫生服务的方式，转变为综合的、以人为本的综合办 法。在这一框架的背景下，ICOPE建议基于以下方面照 顾老年人： • 对个人需求、偏好和目标的评估； • 制定个性化照护计划； • 协调服务，致力于保持内在能力和功能发挥的单一 目标，并尽可能通过初级保健和社区为基础的照护 来实现。 3 4 世界卫生组织《老龄化与健康的全球报告》将健康 老龄化定义为帮助人们发展和保持有利于健康的功能发 挥(1)。 本指南通过解决以下与内在能力领域下降（图1）、 老年人社会照护需求和照护人员支持等相关的优先事 项，支持健康老龄化。 • 认知减退（第4章） • 行动能力受限（第5章） • 营养不良（第6章） • 视力受损（第7章） • 听力丧失（第8章） • 抑郁症状（第9章） • 社会关怀和支持（第10章） • 照护者支持（第11章） 优化内在能力与功能发挥： 走向人人健康老龄化 心理能力 听力 视觉能力 活力 认知能力 运动能力 图1. 内在能力的关键领域 内在能力在生命历程中是如何变化的？ 图2显示了成人生命历程中内在能力和功能发挥的典型模 式。随着年龄的增长，由于衰老过程和潜在疾病，内在能力和 功能发挥下降。这一典型模式可分为三个共同阶段：能力相对 较高和稳定的阶段，能力下降的阶段和能力严重丧失的阶段， 其特点是依赖照护。 2 5 优化内在能力的干预 识别与内在能力丧失相关的状况，提供了一个减缓、停止 或扭转降低趋势的干预机会（图2）。临床机构和社区的卫生保 健工作者可以检测到与内在能力下降相关的示踪条件。随着时 间推移，重复的评估使得我们可以监测到任何比预期更大的变 化，以便在丧失功能发挥之前提供具体的干预措施。 通过这种方式，在社区背景下提供的干预措施可以防止一 个人变得虚弱或依赖照护。多项干预措施似乎更为有效。 围绕着平均模式有多样化的内在能力。这些差异在同一 国家和不同国家之间都很明显。它们反映在期望寿命的持续差 异上，范围从澳大利亚、日本和瑞士等国的期望寿命为82岁或 以上，到中非共和国、乍得和索马里等国的期望寿命为55岁 以下。 年人内在能力的变化比年轻人要大得多。这种多样性是老 龄化的特点之一。一个人的年龄可能与另一个人相差10岁或10 岁以上，但具有类似的内在能力和／或功能发挥。这就是为什 么时间年龄并不能是反映其健康状况的一个好的指标。 内在能力和功能发挥 世界卫生组织将内在能力定义为个人的身体和心理能力的综合能力，包括心理能力。功能发 挥是人的内在能力与所居住环境的结合和互动。 6 图2. 健康老龄化的公共卫生框架： 贯穿生命历程的公共卫生行动机会 许多决定内在能力的特性可被调整。其中包括与健 康有关的行为和存在的疾病。因此，有充分的理由来引 入有效干预措施以优化内在能力。此理由是ICOPE方法和 本指南的基础。 许多决定内在能力的特性可被调整。其中包括与健 康有关的行为和存在的疾病。因此，有充分的理由来引 入有效干预措施以优化内在能力。此理由是ICOPE方法和 本指南的基础。 资料来源：世界卫生组织，2015(1)。 高且稳定能力 卫生服务： 长期照护： 环境： 能力下降 能力显著丧失 功能发挥 内在能力 预防慢性疾病或确保 早发现、早控制 逆转或减缓能力下降 支持提高能力的 行为 促进能力提供的行动 管理晚期慢性疾病 确保 有尊严的老年生活 移除 参与者障碍，补偿能力损失 ICOPE方法 7 8 以人为本的照护基于这样一种观点，即老年人不仅仅是要 着重关注其反映疾病或健康状况的血管；所有人，无论其年龄 大小，都是具有独特经历、需要和喜好的个体。以人为本的照 护解决个人健康和社会照护需求，而不是由单独的健康状况或 症状所驱动。以人为本的综合办法还包括个人日常生活背景， 包括其健康影响和对身边人和社区的需求。 采用综合照护方法满足老年人的健康和社交需求有五个步 骤，如以下一般路径所示。 评估老年人需求并 制定个性化照护计划 关键点 • 在老年人综合照护（ICOPE）筛查工具的帮助下，可在 社区中识别那些老年人面对内在能力下降的情况识别出 有这些事项的患者将转诊至基层卫生保健诊所进行深入 评估，这有助于制定个性化照护计划。 • 照护计划可包括多项干预措施以管理内在能力的下降和 加强功能发挥的多种干预措施，如通过身体活动、口服 补充营养、提高认知能力和预防跌倒的家居环境改善 等。 3 9 3 一般照护路径 初级照护中以人为本的 评估和路径 社会照护和支持计划 消除社会参与的障碍 环境适应 管理内在能力下降的 社区干预措施 了解老年人的生活、价值观、优先事项 和社会背景 疾病综合管理 康复 姑息性治疗和临终关怀 加强一般健康生活方式 建议或常规照护 内在能力下降相关的健康状况 无内在能力下降 是 是 否 否 否 是 筛查 有内在能力下降 在社区 筛查 步骤1 初级照护中以人为本的评估 步骤2 深入评估 潜在疾病 评估和管理 社会照护服务需求的评估 （家，机构） 社会及物理环境 评估和管理 10 10 3 Person-centered assessment and pathways in primary care 设定以人为本的目标 多学科团队 设计一项照护计划，以包含多项干预措施、管 理潜在疾病、自我照护和自我管理、以及社会 照护和支持 确保转诊路径及照护计划的 监测联 系专业老年照护 步骤4 让社区参与及支持照护者 步骤5 Generic care pathway 制定个性化照护计划 步骤3 3 P rson-centered assessment and pathways in primary care Person-centred goal setting Multidisciplinary team Design a care plan including multi-component interventions, management of underlying diseases, self-care and self-management, and social care and support DEVELOP PERSONALIZED CARE PLAN STEP 3 ENSURE REFERRAL PATHWAY AND MONITORING OF THE CARE PLAN WITH LINKS TO SPECIALIZED GERIATRIC CARE STEP 4 ENGAGE COMMUNITIES AND SUPPORT CAREGIVERS STEP 5 Gen ric care pathway 11 与内在能力下降有关的优先事项 测试 全面评估各方面在圆圈里打勾 认知减退 （第4章） 1. 记住三个字：花、门、米（举例） 2. 时间和空间定位：今天是哪年哪月哪天？ 你现在在哪里（家、诊所，等）？ 3. 还能回忆这三个字吗？ 行动能力受限 （第5章） 椅子起立测试：不使用手臂从椅子起立五次。 是否在14秒内完成了5次椅子起立动作？ 营养不良 （第6章） 1. 体重下降：在过去的三个月里，你是否无意中体重下降了3千克 或以上？ 2. 食欲不振：你是否经历过食欲不振？ 视力受损 （第7章） 你的眼睛有什么问题吗：远视困难、阅读困难、眼疾或目前正在接受治疗 （如糖尿病、高血压）？ 听力丧失 （第8章） 听到耳语（耳语测试）或 筛查测听结果为分贝以下或 通过自动化应用程序数字噪音测试 抑郁 （第9章） 在过去的两周里，你有没有被以下症状困扰 – 感到情绪低落、沮丧或绝望? – 做事情时几乎没有兴趣或乐趣? 任何一个问题回答错误或不知道 不能回忆这三个字 否 是 是 是 是 是 失败 表1. 世界卫生组织ICOPE筛查工具 12 步骤1 筛查内在能力下降 通过本指南中的流程和工具，受过培训的卫生保健工作者 可以开始识别在社区或家中内在能力丧失的人。为了做到这一 点，他们可以使用ICOPE筛查工具（表1）。ICOPE筛查工具是 第4章至第9章中介绍的每个照护路径的第一步，涵盖了内在能 力领域的六个相关事项（第5页图1）。社区外展战略，比如社 区卫生工作者的家访和使用手机技术的自我评估，都可以用来 发现实例。 那些在这第一步中出现能力丧失迹象或报告能力丧失的人 应该进行全面评估。全面评估可能需要受过必要培训的卫生保 健专业人员来完成，通常但不一定由医生来完成。 卫生和保健工作者必须确保由ICOPE筛查工具识别出的任 一能力限制，应常触发更一步的深入评估。筛查结果应为个性 化照护计划的制定提供依据。 对阿尔茨海默病、抑郁症、骨关节炎、骨质疏松症、白内 障、糖尿病和高血压等潜在疾病的诊断是以人为本评估的关 键。此类诊断可能需要复杂的诊断测试，而初级卫生保健诊所 并不总是提供这种测试。根据情况而定，可能需要转诊至二级 或三级专业老年护理。 2D. 评估社会和物质环境以及对社会关怀和支持的需求 对丧失内在能力的人来说，需要对社会和物质环境进行评 估，并了解对社会和支持服务的任何需要。这是初级卫生保健 机构对老年人进行以人为本评估的一个重要部分。通过询问老 年人是否可以在没有他人帮助的情况下完成各种日常工作，可 以确定他们的社会护理需求。第10章中的路径提出了一系列用 于评估和确定总体社会照护需求的问题。此外，第4章至第9章 中的每一个照护路径都指出了特定于优先事项的可能的社会照 护需求。 步骤2 在初级保健机构进行以人为本的评估 在初级卫生保健机构进行以人为本的老年人卫生和社会护 理需求的评估，对于优化内在能力至关重要。 2A. 了解老年人的生活 以人为本的评估不仅要从常规历史记录开始，而且要全面 了解个人的生活、价值观，以及其健康及管理过程的优先事项 和偏好。 2B. 深入评估与内在能力丧失相关的事项 此评估还估计与内在能力丧失相关的更深入的事项。第4章 至第9章介绍了包括内在能力领域的关键事项的护理路径，一般 分为三个部分，第一是在社区中进行筛查，第二是在初级卫生 保健机构进行评估，最后是进行个性化护理计划。 2C. 评估和管理潜在疾病 应调查潜在的慢性病，了解多重用药情况（使用多种药 物）。多重用药和由此产生的任何不利影响都可能导致内在能 力多个方面的损失，因此一贯值得调查（见第18页多重用药方 框）。 13 步骤3 确定照护目标并制定个性化照护计划 3A. 与老年人一起确定照护目标 制定优化内在能力和功能发挥的统一目标有助于确保照 护的整合，并且还提供了监管老年人进步和干预措施影响的机 会。从一开始，老年人和照护者就必须参与决策和目标设定， 并且必须根据该老年人的优先事项、需求和喜好确定目标并确 定优先次序，这一点至关重要。 3B. 制定照护计划 以人为本的评估有助于制定个性化照护计划。该个性化照 护计划采用一种综合方法来实施干预措施，以处理内在能力各 个方面的损失：所有干预措施均应考虑并一起应用。 3 一般照护路径 初级照护中以人为本的 评估和路径 对自我管理的支持涉及为老年人提供他们管 理健康状况、预防并发症、最大化其内在能力和 维持生活质量所需的信息、技能和工具。 这并不意味着期望老年人“独自行动”，也 不会对他们提出不合理或过度的要求。相反，通 过与卫生保健人员、其家人和其他照护者进行协 商和建立伙伴关系，可认识到他们的自主权和指 导自己照顾的能力。 世界卫生组织的移动健康老龄化（mAgeing）策略 通过支持自我照顾和自我管理，可以补充卫生保健专业 人员的日常护理工作。通过手机发送健康信息、建议和 提醒，鼓励健康行为，并帮助老年人改善和维持其内在 能力。 有关如何设置移动健康老龄化程序和建议的短信信 息，请参阅https://www.who.int/ageing/health-systems/ mAgeing 。 14 3 初级照护中以人为本的 评估和路径 一般照护路径这种综合方法非常重要，因为大多数内在能力丧失都跟 相同的生理和行为因素有關。因此，干预措施对各个方面都有 益处。例如，强化力量训练是预防行动能力下降的重要干预措 施。同时，力量训练可间接保护大脑免受抑郁和认知能力衰退 的影响，并有助于预防跌倒。营养可增强运动效果，同时增加 肌肉质量和力量。使用综合统一的方法，可改变一系列增加照 护依赖风险的因素。 个性化照护计划将包括以下几个部分： • 一套管理内在能力丧失的多项干预措施。大多数照护计划将 包括改善营养和鼓励身体活动的干预措施； • 潜在疾病，多发病和老年综合症的管理和治疗。世界卫生组 织已经制定了临床指南以处理大多数可能导致内在能力下 降的慢性疾病(2)。每个卫生保健提供者都应有权使用这些 指南； • 支持自我保健和自我管理； • 任何晚期慢性病（姑息治疗，康复）的管理或确保老年人能 够继续过着有意义和有尊严生活的管理； • 社会照护和支持，包括改变环境以配合任何功能损失所需； 和 • 在家人、朋友和社区服务的帮助下满足社交需求的计划。 卫生和社会照护工作者可以支持在社区或初级保健机构中 的照护计划的实施。在社区卫生保健服务提供者的建议、教育 和鼓励的支持下，自我管理可以改变造成内在能力下降的一些 因素。随着他们年龄的增长，老年人、初级卫生保健工作者、 家庭和社区之间的合作关系将维持人们的健康。 15 3 一般照护路径 初级照护中以人为本的 评估和路径 步骤4 确保转诊路径并监测护理计划与专业老年护理链接 结合不同级别和类型的护理服务给予定期和持续的随访， 对于实施本指南中建议的干预措施至关重要。这种方法有助于 及早发现并发症或功能状态改变，从而避免不必要的紧急情况 并通过及早采取行动节省成本。 定期随访还提供了监测照护计划进展、并在需要时安排额 外支持方法的机会。在健康状况、治疗计划或人的社会角色或 状况（例如居住地变化或伴侣死亡）发生重大变化之后，随访 和支持尤其重要。 强有力的转诊路径对于确保在发生不可预见的事件（例如 跌倒）后迅速获得急诊照护、姑息治疗和临终照护或出院后照 护至关重要。 与专业老年护理的联系也很重要。卫生系统需要确保人们 在需要时能够及时获得专业和紧急照护。有很好的证据表明， 与一般医院照护相比，专业急性照护老年病房提供的照护质量 更高，住院时间更短且成本更低。 专业老年医学科的角色 老年医学科医师的专长集中在患有长期复杂疾 病的老年人身上，如老年综合征（失禁、跌倒、谵妄 等）、多发性疾病和例如认知障碍症等疾病，并为那 些日常生活活动受限的人提供照护。随着年龄的增 长，多发病率上升，导致临床表现复杂，此时初级保 健医生应向老年医学科医师咨询。 在ICOPE方法中，老年医学科医师是多学科老年人 护理团队的一部分，他们协助指導初级保健团队，并 在需要专科治疗时介入。 16 3 一般照护路径 初级照护中以人为本的 评估和路径 3 初级照护中以人为本的 评估和路径 一般照护路径步骤5 社区参与和支持照护者 照护的要求较高，能力丧失者的照护者通常会感到孤独， 并且极有可能有心理困扰和抑郁。个性化照护计划应包括基于 证据的干预措施以支持照护者。照护者还需要有关老年人健康 状况的基本信息，并需要进行培训以掌握一系列实用技能，例 如如何将人从椅子安全地转移到床上或如何协助洗澡。 老年人和照护者了解如何使用社区资源。必须让社区和邻 里更直接地参与支持照护，特别是通过鼓励志愿工作、讓老年 社区成员能够做出贡献。这种活动可在老年人聚集在一起的协 会和团体中进行。 第11章包含了一个用于评估照护者负担并处理无偿照护者 需要的照护路径。 ICOPE方法是基于社区或初级保健机构层面制定的，在这 些机构可被最多的人使用。同时，该方法要求与专业和三级护 理人员（如营养学家和药剂师）建立强有力的联系。 ICOPE手册APP 将提供移动应用程序指导卫生和社会照护工作者 实施从筛查到评估、再到设计个性化照护计划的所有 步骤。该应用程序还生成PDF格式可打印的评估及纳入 照护计划干预措施的结果的总结。 17 3 一般照护路径 初级照护中以人为本的 评估和路径 多重用药 多重用药通常被描述为同时使用5种或更多种药物，并且经常与 药物不良反应相关。这种多种药物使用增加了健康的风险，并可能 导致内在能力的不必要损失，是急性入院的原因。咨询多名卫生保 健人员或最近住院的老年人发生多重用药的风险更大。患有多种疾 病的老年人更容易受到与年龄相关的生理变化的影响，这些变化会 改变药代动力学和药效学。 由于多重用药可能会造成内在能力多个方面的损失，因此，以 人为本的评估应包括对老年人所服用药物的检查。 可以剔除不必要的无效药物以及具有重叠效果的药物来减少多 重用药。 如何合理用药，减少用药失误： • 获得完整的用药史； • 考虑药物是否会影响能力； • 诊断前避免开处方，严重急性疼痛除外； • 在开新药之前常规检查用药情况； • 了解处方药的作用、不良反应、药物相互作用、监测要求和毒 性； • 尝试使用一种药物治疗两种或多种疾病； • 为患者制作药片卡；以及 • 就每种药物对患者和护理人员进行教育。 如果不确定是否可以安全地停药，请咨询适当的专家。 18 4 认知能力 管理认知减退的照护路径 认知减退表现为健忘、注意力损失和解决问题的能力下 降。虽然确切原因尚不清楚，但认知能力衰退可能与大脑老 化、疾病（如高血压和中风等心血管疾病或阿尔茨海默病）、 甚至与环境因素如缺乏身体活动、社交孤立和教育水平低有 关。 当认知能力开始影响到一个人在其环境中生活时，即当一 个人患上认证障碍症时。 该路径旨在应用于具有一定程度的认知能力衰退但没有认 证障碍症的老年人。卫生专业人员还必须能够评估对社会照护 和支持的需求（请参阅第10章）。 关键点 认知能力衰退可以最小化，并且有时可以通过采取更健康的 生活方式、认知刺激和社会参与的方法来逆转。 对糖尿病和高血压等疾病的治疗可以预防认知能力衰退。 内在能力的其他领域（例如听力和运动能力）衰退会损害认 知能力，因此这些问题也应被评估和处理。 对于认知障碍症患者，需要专业照护以制定和实施复杂的干 预措施。 19 https://apps.who.int/iris/handle/10665/250239 加强一般健康和生活方式 建议或一般照护 筛查 认知减退 认知能力下降可能性不大 认知能力下降可能性不大 ‒ 营养不良* ‒ 谵妄 ‒ 多重用药 ‒ 脑血管疾病 ‒ 抑郁症状 参阅营养不良路径 确定原因（疾病、物质中毒、药物使用）和处理 审查用药情况并且酌情撤药 评估脑血管疾病的病史（中风短暂性脑缺血事件） 并预防进一步事件 参阅抑郁症状路径 6 9 通过 多模式运动 提供认知刺激 评估认知能力 1 失败 失败 有可能认知能力下降 通过 相关健康状况评估和管理 i 社会和物理环境 评估和管理 预防 认知能力的进一步减退 评估社会照护和支持的需求 提供保持独立的上厕所技能的建议。 评估照护者负担或压力（参阅照护者 路径） 制定社会照护和支持计划，包括对照 护者的支持 如果认知能力下降影响自主性和独立 性，请参阅mhGAP干预指南中的痴呆 部分内容 在日常活动中提供个人护理和支持 11 10 心血管疾病和危险因素** 评估和管理 简单的记忆和定位测试 1. 记忆三个词： 请其记住你将说的三个词。使用简单、具体的词。 如花、门、米。 2. 时间和空间定向： 然后，问其“今天是哪年哪月哪天？”和“您现在 在哪里？”（家庭，诊所，等）？ 3. 回忆三个字： 现在请其重复你提到的三个词。 通过或失败？ 如果一个人不能回答有关定向的两个问题之一或不能 记住所有三个单词，则认知能力有可能下降，需要进 一步评估。 你在记忆或定位上有问题吗 （如不知道在哪儿或哪年哪月哪天）？ 询问 ? 是 4.1 4.2 5.1 * 维生素缺乏、电解质异常、严重脱水。 ** 心血管危险因素：高血压、高胆固醇、糖尿病、吸烟、肥胖、 心脏病、既往卒中或短暂性脑缺血发作。 降低认知能力下降和痴呆的风险：WHO指南 ‒ https://apps.who.int/iris/handle/10665/312180 提供疾病综合管理 降低心血管疾病危险因素： ‒ 建议戒烟 ‒ 处理高血压和糖尿病 ‒ 提供控制体重的膳食建议 是 否 https://apps.who.int/ ris handle/10665/250239 管理认知减退的照护路径 认知能力 4 4 认知能力 管理认知减退的照护路径 评估认知能力 如果可能的话，使用一个本地验证的工具对认知能力进行更深 入的评估。右下方是在初级保健机构评估老年人认知能力的选 项列表。 缺乏教育。几乎所有用于筛查或诊断认知障碍的认知评估标准 都假定接受了最少的学校教育。如果一个人的受教育年限少于 五年或六年，或者没有受过教育，认知评估可能会受到限制。 认知评估转而必须依靠面谈和临床判断。对于这些人，高度推 荐参加成人扫盲计划（如果有的话），成人扫盲计划促进认知 健康。 如果没有标准的评估工具或评估工具不合适，卫生工作者可以 询问此人，以及熟悉此人的人，关于记忆、方向、言语和语言 方面的问题，以及执行关键角色和日常活动方面存在的任何困 难。 认知评估失败或在记忆或方向上报告有问题则表明存在认知障 碍。此类人员还应接受日常生活活动（ADLs）或工具性日常生 活活动（IADLs）困难的评估。这些信息对于作为个性化照护 计划一部分的社会照护和支持计划非常重要。 如果认知能力下降会影响老年人在其环境中的有效运作能力， 则可能需要进行专门评估，以诊断痴呆或阿尔茨海默病（痴呆 症最常见的原因）。评估和管理痴呆的方案可以在世界卫生组 织 1 更多信息： 世卫组织mhGAP干预指南 (https://apps.who.int/iris/handle/10665/250239) 当需要专业照护时 • 痴呆的诊断和治疗。 • 管理多种相关疾病，如谵妄、脑血管和心血管疾病。 简易智力状态评估 http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf 简短；最少语言、教育和种 族偏见 使用不同的词汇表可能会影 响得分 2–4分钟 工具／测试 优点 缺点 时间 蒙特利尔认知评估（MoCA） https://www.mocatest.org/ 可识别轻度认知障碍；有多 种语言版本 教育和文化偏见；有限的公 开数据 10–15分钟 简易精神状态检查（MMSE） https://www.parinc.com/products/pkey/237 被广泛应用和研究 受年龄和文化偏见的影响， 天花板效应 7–10分钟 全科医生认知评估（GPCOG） http://gpcog.com.au/index/downloads 最少文化和教育偏见；有多 种语言版本 可能很难得到知情者的报告 5–6分钟 初级保健机构中使用的认知能力评估工具示例 什么是痴呆？ 痴呆是一种由大脑变化引起的慢性进行性综合征。痴呆导致认知功能 下降，并干扰日常生活活动，如洗衣、穿衣、饮食、个人卫生和厕所 活动。 mhGAP干预指南中找到，在 https://apps.who.int/iris/handle/10665/250239 21 管理认知减退的照护路径 认知能力 4 在认知减退的任何诊断过程之前，重要的一步是评估是否存 在任何相关的事项并首先治疗这些事项。 4.1 引起认知症状的事项 可以导致认知能力衰退的常见可逆事项包括脱水、营养不 良、感染和药物问题。通过合理治疗这些事项，其认知症状应会 消失。 严重脱水。严重脱水和其他营养问题会导致谵妄（类似于认 知障碍症），严重时还会导致死亡。 谵妄。谵妄是集中注意力的能力突然快速丧失。人们也对 自己所处位置和时间感到非常困惑。谵妄症状在短时间内发展， 并且往往在一天之中出现和消失。这可能是由于急性器质性原因 引起的，例如感染，药物治疗，代谢异常（例如低血糖或低钠血 症），物质中毒或物质戒断。 多重用药。两种或两种以上的药物可能相互作用并引起副作 用（见第3章第18页方框）。镇静剂和催眠药通常是造成老年人 认知减退的药物。 大手术和全身麻醉。从业人员应该询问病人是否在大手术 后有认知能力下降情况。如果是这样的话，在任何进一步大手术 后，这个人将面临更高的认知能力衰退的风险。在任何手术或麻 醉之前，需要与手术团队和麻醉师识别并讨论这种高风险。 脑血管疾病。脑血管疾病与认知能力衰退密切相关。如果患 者有中风／小中风／短暂性缺血事件的病史，那么预防未来事件 是停止认知能力进一步衰退的主要方法。 评估和管理 相关疾病 揭开认知能力衰退的可逆医学原因涉及全面诊 断检查。可能有必要探索症状的几种可能解 释，以为制定照护计划找到准确的方法。 4 认知能力 管理认知减退的照护路径 22 4 认知能力 管理认知减退的照护路径 • 认知能力衰退的人可以从认知刺激中受益。 • 其他ICOPE干预措施，如多项运动（见第5章，行动能力受 限），也有助于大脑健康。 • 内在能力其他领域特别是听觉、视觉和情绪的丧失，会影响认 知能力。为了达到最佳结果，可能需要处理这些问题。认知能 力衰退的个体在其他领域的下降模式不同。 4.2 认知刺激 认知刺激可以减缓认知能力的下降(7)。认知刺激的目的是通 过认知活动和回忆、多种感官的刺激和与他人的接触来刺激参与 者。 认知刺激可以提供给个人或群体。团体对某些人来说可能更 好；团体中的社会接触可能会有帮助。如果群体中的人们有一个 共同的目标，例如提高健康素养，那么群体也可能是合适和有效 的。 标准的小组方法包括多达14个主题会议，每个约45分钟，每 周举行两次。一位主持人主持这些会议。通常，话题可能从一些非 认知的热身活动开始，然后转移到各种认知任务，包括现实定向 （例如，显示诸如地点、日期和时间等信息的板子）。会议关注不 同的主题，包括童年、金钱的使用、面孔或场景。这些活动通常避 免事实回忆而是集中在诸如“这些（词或对象）有什么共同点”之 类的问题上。 谁能进行认知刺激？在高收入国家，通常是心理学家进行认知 刺激治疗。通过调整适应，可以由受过适当培训和支持的非专家进 行。然而，为一个有明显认识衰退的人设计和提供个性化干预可能 需要更详细的评估和规划—需要专门技能的任务。因此，当地方案 应包括转诊给心理健康专家进行认知刺激治疗的标准。 家庭成员和照护者可以在认知刺激中发挥重要作用。鼓励家庭 成员和照护者定期向老年人提供诸如日期、天气、时间、人名等信 息非常重要。这些信息帮助他们保持时间和地点的定向。此外，提 供诸如报纸、广播和电视节目、家庭相册和家庭用品等材料，可以 促进交流，使老年人了解时事，刺激记忆，并使老年人能够分享和 重视他们的经验。 管理 认知减退 5 23 管理认知减退的照护路径 认知能力 4 如果认知能力衰退限制了一个人的自主性和独立性，那么这 个人很可能会有重大的社会照料需求。健康工作者可以帮助照护 者制定最大限度地提高独立活动的能力、增强功能、帮助适应和 发展技能、并最大限度地减少对支持需求的日常生活活动计划。 家庭成员和照护者可以： • 提供定向信息，如日期、当前社区活动、访客身份识别、天气、 家庭成员的信息； • 鼓励和安排与家庭和社区的朋友和家人的联系； • 确保并保持家庭安全，以减少跌倒和受伤的风险； • 在家中张贴标牌，例如厕所、卧室、室外门，以帮助其找到他的 或她的出行路线；以及 • 安排和参加职业活动（视个人能力而定）。 评估和管理 社会和物理环境 患有严重认知减退的人的照护者面临着巨大的需求。压力会危 害他们的健康。请参阅第11章，了解照护者需求。 11 24 改善行动能力的照护路径 5 运动能力 行动能力是健康衰老的关键决定因素。保持自主权并预防 对照护的依赖非常重要。一个人从一个地方走动到另一个地方 的身体能力称为运动能力。 许多老年人和他们的家人认为行动能力的损失和随之而来 的痛苦是不可避免的。但并不是这样。确实，有有效的策略可 以改善并保持老年人的行动能力。 关键点 老年人行动能力受限是常见的，但并不是不可避免的。 社区级卫生保健人员可以通过简单的检查筛查出行动能力受 限的人。 根据个人能力和需要制定的定期运动计划是提高或保持行动 能力的最重要途径。 尽管行动能力下降，适应其环境和使用辅助设备是保持行动 能力的好方法。 25 评估 行动能力 加强一般健康和生活方式 建议或日常照护 （SPPB或其他身体 能力测试） 在14秒内 不用扶手可以完成 5次椅子起立动作 筛查 行动能力丧失 椅子起立测试 否 审查用药情况且 旨在减少用药 疾病综合管理 考虑疼痛 是 ‒ 多重用药 ‒ 骨关节炎、骨质疏松和 其他骨关节限制 ‒ 虚弱和肌肉减少症 ‒ 疼痛 全都不是 是 在严格监督下提供多项运动 考虑转诊康复 考虑增加蛋白质摄入量 考虑并提供辅助设备以辅助行动 推荐在家进行多项运动 支持自我管理以增加依从性 多项运动 一项针对行动能力受限人士的多项运动计划，将 运动和交叉训练结合起来，重点是背部、大腿、 腹部和下半身的核心肌肉群。 制定多项运动计划应适合个人能力和需要。 Vivifrail项目提供了一个用于针对个人能力制定 运动计划的实用指南。 5.3 5.2 5.1 5.4 5.5 5.6 1 2 正常行动能力 （SPPB得分10‒12分） 行动能力受限 （SPPB得分0‒9分） 相关健康状况 评估和管理 社会和物理环境 评估和管理 需要专业照护 运动能力 5 改善行动能力的照护路径 评估物理环境以降低跌倒风险 包括预防跌倒的干预措施，如家庭适应 考虑并提供帮助行动的辅助设备 提供安全的行走空间。 http://www.vivifrail.com/resources 世界卫生组织关于身体活动的全球建议，见第 30页方框。 简易体能状况量表（SPPB） 虽然可获得多种体能测试，但建议使用SPPB，因为它具有 优越的测试性能，并且对一系列能力都有用。SPPB测量三 个任务的时间能力，每一个任务得分在1-4之间，总分范围 在0（最差体能）到12（最佳体能）之间。 首先，描述每项测试，并询问测试人感觉是否有能力完成。 如果不能，则给予相应评分并进入下一步。 1. 平衡测试：在三个原地站立的位置各站立10秒。用三个 位置的得分总和作为此项测试得分。 2. 步行速度测试：步行4米的时间。 步行4米的时间： < 4.82秒 4分 4.82 – 6.20秒 3分 6.21 – 8.70秒 2分 > 8.70秒 1分 不能完成 0分 3. 椅子起立测试：5次椅子起立动作的时间 < 11.19秒 4分 11.2 – 13.69秒 3分 13.7 – 16.69秒 2分 16.7 – 59.9秒 1分 > 60秒或不能完成 0分 1 2当需要专业照护时 运动能力应与内在能力的其他方面一起评估，如认知、感觉、 活力和心理能力。如果身体或心理能力显著下降或存在合并症 会使运动处方更加复杂，则可能需要专业知识来设计合适的运 动方案。可考虑转介康复中心。 A. 并排站立 保持10秒 1分 未保持10秒 0分 不尝试 0分 如果不尝试，结束平衡测试。 B. 半足距站立 保持10秒 1分 未保持10秒 0分 不尝试 0分 如果不尝试，结束平衡测试。 C. 全足距站立 保持10秒 2分 保持3-9.99秒 1分 保持< 3秒 0分 不尝试 0分 一个简单的测试可以决定老年人是否需要进一步的行动能力受 限的评估。 说明：问这个人，“你认为你试着不用手臂从椅子上站起来五 次是安全的吗？”（向此人演示。） 如果是，请让他们： – 坐在椅子中间 – 交叉手臂放在胸前并保持 – 起立，然后再坐下 – 不停地、尽可能快地重复五次。 对这个人完成测试的时间进行计时 ‒ 如果他们在14秒内不能 站立5次，则需要进一步的评估。 椅子起立测试 最终SPPB得分 = 以上三个测试得分的总和 SPPB测试的更多细节： http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf 5 改善行动能力的照护路径 运动能力 27 运动能力 改善行动能力的照护路径 5 椅子起立测试是这些测试之一。应该在另外两个测试之后应 重复进行： • 平衡测试 – 在三个原地站立的位置各站立10秒 • 步行速度测试 – 走四米需要多长时间。 将每个测试的分数相加。总分较低意味着行动能力受限。该 路径根据总分列出了两种不同的管理路径。 有关测试和如何评分的更多信息，请参阅上一页。 当需要专业照护时（更多信息） 有以下情况的人可能需要专业照护： • 影响情绪或其他功能区域的持续疼痛 • 关节功能严重受损 • 轻微创伤后骨折 • 安全风险（见另一页方框） • 需要帮助选择适当的行动辅助设备 通过三个简单的测试中对一个人的表现进行评分，可以更全 面地评估行动能力。所有这些测试一起被称为简易体能状况量表 （SPPB）。 评估 行动能力 28 5 改善行动能力的照护路径 运动能力 对于行动能力受限的人，应制定适应个人能力和需求的多项 运动计划。 行动能力受限的人的多项运动计划可能包括： • 力量／抵抗训练，要求肌肉在负重的情况下工作，使用重 量、阻力带或体重运动，如下蹲、弓步和坐立运动； • 有氧／心血管训练，例如以快走或骑自行车运动来增加心 率，直到人稍微喘不过气来但能保持谈话的状态； • 平衡训练，挑战平衡系统，包括静态和动态运动；可以在睁 开、闭上眼睛下进入不同表面；例如，单腿站立，脚跟与脚 趾成直线行走；以及 • 柔韧型训练，改善软组织（例如肌肉）的延伸性和关节运动 范围；例如伸展运动以及其他瑜伽和普拉提运动。 营养。增加蛋白质摄入量和其他营养干预措施可以提高运动 计划带来的益处。参见第6章营养不良。 管理 行动能力受限 运动安全。在提供运动建议或制定运动计划之前，请先 询问会影响运动时间或强度的事项。 如果此人对以下任何问题的回答是“是”，则熟练的卫 生专业人员应制定针对性的运动计划。 • 你休息时是否有胸痛？ • 最近6个月内您是否有心脏病发作？ • 你是否晕倒或失去意识？ • 你在过去12个月跌倒过吗？ • 上个月你骨折了吗？ • 在家里做日常活动，比如穿衣服，你会喘不过来气吗？ • 你是否患有限制运动的关节或肌肉疾病？ • 是否有提供卫生保健的人员告诉你要限制运动？ Vivifrail项目为制定量身定制的运动计划提供了实用指南。 http://www.vivifrail.com/resources 6 29 运动能力 改善行动能力的照护路径 5 管理局限性。当疼痛限制行动能力时，在可管理的时间内 调整身体活动节奏，并缓慢增加体力任务以帮助增强机体恢复能 力并管理疼痛。对于行动能力严重降低的人来说，刚开始的时候 可以躺在床上或坐在椅子上进行运动训练。对于患有认知减退 （例如认知障碍症）的人，更适合简单且结构化程度较低的运动 计划。 5.2 自我管理支持 对自我管理的支持有助于坚持多项运动计划且增加多项运动 计划的益处。SPPB分数在10–12分之间的人可以在家里和社区运 动。行动能力受限较严重的人在运动中可能需要监督和指导。 世界卫生组织移动健康老龄化（mAgeing）手册解释了移动 电话应用程序如何通过支持自我护理和自我管理来补充卫生保健 专业人员的日常护理。 更多信息： http://www.who.int/ageing/health-systems/mAgeing 世界卫生组织关于身体活动的全球建议 考虑到老年人的健康状况，所有老年人都可以从推荐的适合他们 年龄的身体活动建议中受益。本框总结了世界卫生组织关于65岁及以 上老年人身体活动的全球建议。 • 每周至少进行150分钟中等强度的有氧运动，或至少75分钟的高 强度有氧运动，或等量组合。 • 每次至少运动10分钟。 • 为了获得更多益处，每周进行300分钟中等强度的有氧运动，或 每周进行150分钟的高强度有氧运动，或等量组合。 • 每周进行两天或更多的肌肉力量运动。 • 如果行动能力较差，每周进行3天或更多提高平衡的身体活动。 • 如果你不能按照推荐量运动，那么就尽可能多地运动。 更多信息： http://www.who.int/dietphysicalactivity/pa/en/index.html 30 5 改善行动能力的照护路径 运动能力 5.3 多重用药 有些药物会损害行动能力或干扰平衡能力，但有时对一些特 定的人来说是不必要或无效的(8)。包括但不限于以下： • 抗惊厥药 • 苯二氮卓类 • 非苯二氮卓类安眠药 • 三环类抗抑郁药 • 选择性5-羟色胺再吸收抑制剂（SSRI） 抗抑郁药 • 抗精神病药 • 阿片类药物 剔除不必要、无效的药物以及具有重复作用的药物可减少多 重用药。如果不确定是否可以安全地停药，请咨询合适的专家。 如果不确定是否可以安全地停药，请咨询合适的专家。 5.4 疼痛 评估疼痛。与运动有关的严重疼痛可能会限制甚至阻止 运动。评估与行动能力有关的疼痛的严重程度是有帮助的，这 既有助于设计运动计划，也有助于控制疼痛。你可以使用简明 疼痛量表： https://www.aci.health.nsw.gov.au/__data/assets/pdf_ file/0015/212910/Brief_Pain_Inventory_Final.pdf 管理疼痛(9)。损害行动能力的肌肉骨骼情况往往会有持续 疼痛。然而，很少能找到导致持续性疼痛的特定生物学原因。因 此，疼痛管理的最佳实践方法是处理可能与疼痛相关的多种因素— 身体因素（如肌肉力量、运动范围和耐力）、心理健康、营养和 睡眠。如果疼痛是运动和活动的重要障碍，应由具有疼痛管理专 业知识的卫生专业人员制定疼痛管理计划。 疼痛干预措施包括： • 自我管理 5.2 • 运动和其他身体活动 • 药物范围包括从扑热息痛和非甾体类抗炎药到加巴喷丁和阿片 类药物 • 手法治疗如按摩、关节推拿和关节放松 • 心理治疗和认知行为治疗（见第9章抑郁症状） • 针刺疗法 • 脊髓注射／硬膜外注射 • 射频去神经。 评估和管理 相关事项 其中一些干预措施可以在社区获得。其他人可能 需要转诊到中心机构。 9 31 运动能力 改善行动能力的照护路径 5 管理和评估 社会和物理环境 行动能力受限的人可能需要帮助来应付日常活动。第一步是 评估社会照护需求（见第10章）。对行动能力受限老年人的特定 社会照护需要可能包括通过对其物理环境评估后显示出的需要 或对辅助设备的需要。一个运动计划可以帮助防止跌倒。 5.5 评估物理环境以降低跌倒风险 对物理环境的评估包括在家里仔细找出可能的危险因素并提 供建议。例如，减少杂物、去除松散的地毯、消除地板和台阶上 的凹凸不平、重置家具以建立一条宽阔、畅通的走道、改善照明 和改善上厕所的通道，特别是在晚上（例如在墙上添加把手）。 设置通往主门口的斜坡将使坐轮椅的人和爬台阶有困难的人更容 易。分析一个人特定的行动能力限制因素将指引哪些环境适应是 最重要的。 通过特定的培训，社区或基于设施的初级照护者可以评估一 个人家里的物理环境。如果无法家访，初级照护卫生工作者可以 向患者或照护者提供一般指导，说明如何营造一个更安全的家庭环 境。 需要专业知识来全面评估和管理一个人的跌倒风险。 5.6 考虑并提供辅助设备 行动能力受限的人可能需要辅助设备才能走动。辅助设备是指其 主要目的是维持或提高个人的功能发挥和独立性，以促进其参与和提 高其整体健康的设备(10)。这些设备包括手杖、拐杖、助行器、轮椅 和假肢或矫形器。这些设备的可用性和成本可能会限制对其的选择， 但是如果有具有物理治疗知识的卫生专业人员，可以提供关于选择合 适设备的最佳建议以及有关如何安全使用该设备的说明。 任何内在能力的衰退都会增加跌倒的风险。物理 环境以及任务或活动的执行方式也可能是其影响因素。 除了评估物理环境外，还包括对跌倒风险的全面 评估： • 记录跌倒历史，包括正在进行的活动的详细信息； • 评估步态、平衡、行动能力和肌肉和关节功能和柔 韧性； • 评估对跌倒的恐惧、视力、认知、心血管系统和神 经系统状况、尿急或夜尿症（夜间醒来小便）；以 及 • 多重药物的药物检查（见第3章评估和制定计划）。 有些人需要对晕厥（昏厥）、癫痫和帕金森病等 神经生成障碍进行进一步的评估和管理。 32 6 活力 管理营养不良的照护路径 世界卫生组织使用活力一词来描述有助于个体内在能力的 生理因素。这些因素可能包括能量平衡和新陈代谢。本手册重 点介绍了老年人活力下降的一个关键原因⸺营养不良。 关键点 基层照护卫生工作者可以很容易地进行初步的营养状况评 估。这应该是任何一项老年人健康评估的一部分。全面的营 养状况评估需要专业知识，有时还需要血液检查。 营养不足和身体活动量较低都会导致肌肉质量和力量的损 失。 适量的平衡饮食通常可为老年人提供必需的维生素和矿物 质，但维生素D和B12缺乏较为常见。 营养不良常常导致体重下降，但并非总是如此。肌肉质量可 被脂肪质量代替，而保持体重不变。 营养不良的另一个方面是肥胖，本指南未涉及肥胖的处理。 33 过去3个月，您是否在非 刻意减重情况下体重减少 3kg？ 您是否经历过食欲 不振？ ? ? 正常营养状态 (MNA分数：24‒30分) 有营养不良风险 (MNA分数：17‒23.5分) 营养不良 (MNA分数：< 17分) ‒ 急性事件或疾病后 ‒ 居住在社区的老年人每年进行一次 ‒ 有社会照护需求的老年人每3个月进行一次 评估 营养状况 询问 活力 否 否 (任一问题) 是 提供膳食建议 如不能提高膳食质量，考虑 口服补充营养 密切监测体重考 虑多种运动 必须进行营养干预 给予口服补充营养同时增加蛋白质 摄入（400‒600千卡／天） 提供膳食建议 密切监测体重 重新评估… 例：微型营养评估 (MNA) (8) 管理营养不良的照护路径 口服补充营养 口服补充营养（OSN）可以根据个体需要、口味和 身体状况提供额外的优质蛋白质、能量和足量维生 素及矿物质。 i 加强一般健康和生活方式 建议或日常照护 加强一般健康生活方式 建议或日常照护6 社会和自然环境 评估与管理 克服居民营养健康的障碍 鼓励家庭和社区饮食服务 在准备和提供食物过程中提供帮助 6.2 6.3 6.2 相关条件 评估与管理 ‒ 衰弱 ‒ 肌肉减少症 1 1 2 1 疾病综合管理 考虑复健以改善肌肉功能 筛查 社区营养不良 需要专业照护 6营养方面的建议• 初级保健工作者可以向老年人提供建议并促进其健康饮食。无论 他们是否需要特殊照护，所有老年人都可以从这个建议中受益， 包括那些有营养不良风险或受到营养不良影响的人。对于那些每 天都在图表上记录饮食的人来说，遵循良好的饮食习惯更为容易 —无论是在用餐时还是在两餐之间。 • 帮助人们识别当地可获得的、提供足够能量（碳水化合物）、蛋 白质和微量营养素（如维生素和矿物质）的特殊食品。建议食用 足够量的这些食物。 • 由于蛋白质吸收随年龄增长而减少，建议老年人吃充足蛋白质。 建议健康老年人每公斤体重摄入1.0–1.2克蛋白质。从体重丢失 或急性疾病或损伤中恢复的人每公斤体重可能需要1.5克蛋白质。 需要监测肾功能，因为高蛋白摄入可能导致肾小球内压和肾小球 滤过升高。 • 建议进行体力活动，可以使蛋白质整合到肌肉中并增进食欲。 • 鼓励暴露在阳光下以促使皮肤产生维生素D。食物中的维生素D不 足以使老年人保持最佳水平。需要血液检测以衡量一个人的维生 素D水平是否足够。 • 老年人往往吃得不够。为了帮助老年人多吃些，建议家庭用餐和 社交用餐，特别是对于独居或社交孤立的老年人。 1 以社区和设施为基础的初级保健工作者可以提供帮助所有老 年人保持健康饮食的建议和支持。营养不良或有营养不良高 风险的人需要由具备专门知识的提供者来寻找病因和危险因 素，并制定个性化的营养计划。 即使目前的营养状况似乎合格，必要时，对营养不良的原因 或导致营养不良的可能情况进行或获得进一步评估。这些可 能的症状包括消瘦、快速体重丢失、口腔疼痛、吞咽疼痛或 困难、慢性呕吐或腹泻以及腹痛。 当需要专业知识时 有好的工具可以帮助评估营养状况(11)。 例如： 评估营养状况 2 请记住 ! 保健工作者需要告知家庭成员、其他照料以及老年人。 微型营养评定法（MNA）(8) 确定营养风险评估 (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) 营养不良综合筛查工具 (https://www.bapen.org.uk/pdfs/must/must_full.pdf) 社区老年人饮食营养风险评估问卷 (https://www.flintbox.com/public/project/2750/) 短期营养评估问卷65+（SNAQ65） (http://www.fightmalnutrition.eu/toolkits/ summary-screening-tools) 首页的照护路径使用微型营养评定法（MNA）。 活力 管理营养不良的照护路径 35 6 活力 管理营养不良的照护路径 大多数营养评估工具询问： • 食物和水分摄入 • 近期体重减轻（与病例调查问题相同） • 行动能力 • 最近有心理压力或急性疾病 • 心理问题 • 生活状况 此外，他们记录： • 体重 • 身高 • 体质指数（BMI – 体重kg／身高m2） • 上臂围和小腿围。 评估 营养状况 身体成分组成与衰老 通常在70岁左右，肌肉质量可能会减少，对活力有重要和潜 在的有害影响。营养不足和身体活动不足都会导致肌肉质量和力 量的丢失。 同时，脂肪质量可能增加。体重可能减少，或者保持不变， 掩盖了这些可能的不利变化。因此，营养不良的人可能已经失去 了重要的瘦组织，但体质指数仍然在可接受的范围内，甚至在超 重范围内。 经过培训的非专业人员可以使用诸如握力计之类的工具测量 握力来可靠地评估肌肉功能，从而评估蛋白质营养不良。该工具 可测量人用一只手挤压工具的力度。手握力度低表明需要运动， 并且需要蛋白质含量更高的饮食。 36 6 活力 管理营养不良的照护路径 6 活力 管理营养不良的照护路径 6.2 营养不良的老年人 对于识别为营养不良的人（例如，MNA分数低于17），应立即 开始营养干预。基层照护卫生工作者可以立即提供标准的饮食建议 （请参阅第35页方框）。具有专业知识的卫生专业人员应尽快提供 饮食建议，并在必要时开具口服补充营养处方（见下文）。 这些干预措施应作为处理造成营养不良的根本原因的全面照护 计划的一部分，以及处理其他内在能力领域的干预措施的一部分， 例如行动能力受限。特别是，充足的能量和蛋白质摄入将使多项运 动计划更加有效（请参阅第5章行动能力受限）。 感觉障碍（味觉和嗅觉降低）、口腔卫生健康差例如咀嚼问 题和吞咽困难、孤立、孤独、低收入和复杂的长期慢性病，都增 加老年人营养不良的风险。 6.1 有营养不良风险的老年人 有营养不良风险的老年人（例如，MNA得分为17-23.5）可 以从营养方面的建议中获益（见第35页方框）。有发展中营养不 良风险的人最好也接受营养干预，以防止营养不良的发展。 管理 老年人营养不良 5 37 6 活力 管理营养不良的照护路径 只有当一个人不能摄入足够的能量和营养丰富的普通食物，或 者OSN是除了常规食物策略之外的增加能量摄入的一种临时策略 时，才让采用口服补充营养的处方。 口服补充营养 口服补充营养（OSN）提供额外的优质蛋白质、能量和足够 的维生素和矿物质。需要专业知识来为制定一个适合个人需求、 口味和物理限制的OSN计划。经过评估有助于选择最佳的补充方 法，即是通过营养丰富的食物、维生素或矿物质补充剂，还是通 过专门的商业产品或非商业营养配方来补充。社区卫生工作者可 以支持和监测服用OSN的人（见方框）。 血液检查 血液检查会对个性化营养计划有影响。血液检查可以识别特 定的维生素和矿物质缺乏。特定的口服营养补充剂或注射剂可以 治疗这些缺乏。例如，需要片剂或注射剂来治疗常见的维生素D 和B12缺乏。 OSN的关键点 • 食物第一。除非对OSN的需求是迫切的，否则，如果可能的话，应该首 先尝试改善饮食，并增加进餐次数。 • 食物之外添加OSN。它不应该代替食物。服用OSN的人应了解尽可能好 地保持进食的必要性。 • 人们需要关于如何混合OSN、一次服用多少、何时服用的指导信息。 • OSN应该在两餐之间服用，而不是在用餐时服用。 • 人们经常需要持续支持和鼓励（来自于家庭成员、照护者和卫生工作 者），以保持服用OSN并尽可能好地保持进食。 • 一段时间后，一个人可能会厌倦一种OSN的味道和质地。多种口味和不 时更改口味可能会有所帮助。 • 应定期监测和记录体重。 • 理想情况下，目标应该是一旦营养不良风险已经消除并且饮食提供充足 营养，就应停止OSN。 38 6 活力 管理营养不良的照护路径 6 活力 管理营养不良的照护路径 评估与管理 相关条件 6.3 肌肉减少症和衰弱 肌肉减少症和衰弱可能与营养不良有关。生活方式干预措 施，包括改善营养和体育锻炼，可以对两者都有帮助。 肌肉减少症。指肌肉质量，强度和功能的普遍持续降低。 它可能是由于疾病，营养不良或缺乏运动（例如长期卧床）引起 的，也可能没有明显的原因，可能与衰老过程有关。 衰弱。衰弱可能涉及体重减轻，肌肉无力，身体活动水平低 下，疲惫和行动缓慢（例如，缓慢行走）。身体或心理压力会导 致衰弱，例如创伤，疾病或失去亲人。衰弱的人可能会失能，变 得依赖照护。 评估与管理 社会和自然环境 照护者和社区可以帮助老年人克服营养健康的障碍。例如， 社区组织可以为老年人组织社交餐饮活动。 就社区工作本身而言，社区卫生工作者可以促进食品杂货的 便利获取，提供财务管理帮助或获得收入支持，还可以帮助准备 食物，或通过社区餐饮服务提供准备好的食物。 39 40 7 视觉能力 管理视力受损的照护路径 视力是内在能力的关键组成部分，它使人们可以移动并与 同伴和环境安全地进行交互。随着年龄增长，可能导致视力受 损的一些原因变得更加普遍：近视和远视，白内障，青光眼和 黄斑变性。 视力受损可能会在维持家庭和其他社会关系，获取信息， 安全移动（尤其是在平衡和跌倒的风险中）以及执行手作任务 方面造成困难。这样的困难可能导致焦虑和沮丧。 视力评估是以人为本评估的重要组成部分。 关键点 通过简单的视力表，基层和社区卫生工作者可以测试是否有 明显的视力下降。 许多视力丧失的人可以接受治疗。询问，评估或验证所患的 眼部疾病很重要。 眼镜通常可以矫正近视或远视。 辅助设备（放大镜，望远镜）可以为视力损失而眼镜无法矫 正的人提供支持。 在家庭和社区中，简单的措施（例如更好的照明）可以提高 视力损失老年人的视力能力。 41 需要专业照护 7 远视 视力 近视 视力 评估视力受损和眼部疾病 治疗眼部疾病 管理视力受损 检查和更新配镜度数，或提供新眼镜 考虑眼部康复，包括视力辅助设备书桌和移动放大镜 加强眼部护理和生活 方式建议，为个人和 环境提供视力卫生建 议。 否 是 现成的简单阅读眼镜是否 能解决问题？ 未通过 检测视敏度 使用世界卫生组织简单视力图 1 2 3 4 相关条件 评估与管理 管理心血管风险因素 每年转诊至专业眼科进行视网膜 检查 检查药物以避免药物对眼睛产生 不良反应 是 ‒ 高血压 ‒ 糖尿病 ‒ 类固醇使用 社会和自然环境 评估与管理 提供阅读眼镜 对低视力者的日常生活提出建议 介绍调节低视家庭措施（照明，对比颜色） 以防止跌倒 移除日常路线中的障碍物。 询问 您的眼睛是否有任何问题： 望远、阅读、眼疾、 或目前正在接受医学治疗 （如糖尿病，高血压）? 未通过 是 ‒ 在测试近视前先测试远视 ‒ 有佩戴眼镜习惯者应摘去眼镜测试 ‒ 先测试单侧视力，然后测试双眼视力 远视视力损受总是需要转诊进行综合 护理 视力受损(14) 远视视力受损： • 轻度 ‒ 视敏度低于6/12 • 中度 ‒ 视敏度低于6/18 • 重度 ‒ 视敏度低于6/60 • 失明 ‒ 视敏度低于3/60。 近视视力受损： • 视力纠正下，近视视敏度低于N6或M.08。 i 7.4 7.5 7.9 7.10 管理视力受损的照护路径 视觉能力 即便没有出现视力受 损，也要每年重复测 试 重新评估… 7远视测试使用WHO简单视力表 通过显示Es点的方向，向被测试者演示如何进行E测试。 从小Es到大Es进行测试。 1. 在3米处用4个小Es进行测试。7.1 如果可以看到四个小Es中至少三个的方向（通过远视筛查测试）， 视力是6/18或更好。 如果不能看到大Es中至少三个的方向（未通过远视筛查测试）则 需要评估视力损伤和眼部疾病。下面的附加测试可能有助于评估 视力。 2. 在3米处用大Es进行测试。7.2 如果可以看到Es，视力是6/60。 如果在3米不能看到大Es中至少三个 3. 在1.5米处用大Es进行测试。7.2 如果至少看到四个最大Es中的三个，视力是3/60。 2 1 近视测试 使用WHO简单视力表7.3 让被测试者尽可能近距离地持有近视测试卡。从大到小Es测试。 如果被测试者在四个最大Es中至少辨别了三个方向，则他／她通过了近 视筛查测试。 如果没有，检查一下架子上的阅读眼镜是否有帮助。使用这种眼镜，如 果不能看到至少三个最大的Es（未通过近视筛查测试），则需要评估视 力损伤和眼睛疾病。中等尺寸与书上的印刷字大小接近。最小尺寸类似 于书刊杂志上的最小印刷字（不需要看）。 3 视力卫生 视力卫生涉及环境和个人。环境因素和行为可促进视觉功能 （例如，照明、对比度、颜色的使用）或有害（例如，长时 间的电子媒体观看、长时间使用近视力）。个人卫生包括一 整套的眼部卫生行为，如勤洗手、不揉眼睛、只用温和的肥 皂擦眼睑和避免使用眼部化妆品。 4 当需要专业照护时 如果一个人患有眼病或被诊断，科护理专家决定检查的频率和 类型。 • 对于50岁及以上的人，应至少每年进行一次简单的视力损 伤筛查。 • 使用 WHO简单视力表 侧。 • 初级保健提供者可以进行筛查。它不需要正规的眼部照护 评估培训(13)。 • 如果搁架式阅读眼镜解决人的视力问题，则可能不需要进 行综合检查。 初级保健中的视力测试 视觉能力 管理视力受损的照护路径 进行近视和远视筛查。说明显示在右 43 7 管理视力受损的照护路径 视觉能力 outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO简单视力图（四个小“E”远视） • 小“E”为1.3 cm x 1.3 cm，间隔1.3 cm • E为全黑在纯白纸上显示。 44 7 视觉能力 管理视力受损的照护路径 7 管理视力受损的照护路径 视觉能力 outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO简单视力图（四个大“E”远视） • 大“E”为4.2 cm x 4.2 cm，间隔4.5 cm • E为全黑在纯白纸上显示。 45 7 管理视力受损的照护路径 视觉能力 english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO简单视力图（近视） 46 7 视觉能力 管理视力受损的照护路径 7 管理视力受损的照护路径 视觉能力 • 放大镜可帮助老年人看到附近的物体。但是，对于某些人来 说，老花镜并不能解决问题。例如，有远视或散光的老年人 需在检查后由专家配镜。 • 标准诊断检查包括由训练有素的专业人员使用裂隙灯来详细 检查眼睛。例如，该仪器可用于检测白内障并有助于确定是 否需要手术。视网膜和视神经的检查需要使用其他仪器，有 时需要拍摄图像以检测早期变化并指导进行预防视力下降的 治疗。定期检查视网膜对于糖尿病患者尤其重要。 7.4 评估视力受损和眼部疾病 • 一只或两只眼睛的视力突然或迅速下降，需要进行基本的眼 睛和视力检查，并需要转诊以进行专门的眼部护理。 • 初级保健专业人员可以检查患者眼部。如果出现诸如发红， 异常分泌物，疤痕，持续疼痛，畏光或白内障的变化，则应 由眼保健专业人员（眼科医生，验光师）进行检查。 • 初级保健专业人员可以检查患者眼睛是否有常见眼疾的症 状。该检查通常不全面，需要由专家进行检查。如果上述眼 部症状持续存在，建议进行专门的眼部护理。 评估 视力受损和眼部疾病 白内障 白内障使眼睛的晶状体浑浊，从而妨碍了清晰的 视力，通常与衰老过程有关。白内障仍然是失明的主要 原因。减少吸烟和紫外线照射可预防或延缓白内障的发 展。糖尿病和肥胖也是其危险因素。 白内障导致的视力受损和失明是可以避免的，因 为白内障手术是安全的并且可以恢复视力。 47 7 管理视力受损的照护路径 视觉能力 7.6 不可逆转的视力降低 许多人视力低下，专业配镜无法充分矫正视力。对于这些 人，辅助视觉设备（台式或移动式放大镜）比眼镜提供更大的放 大倍率，可以使近距离视物的任务成为可能，例如阅读书籍或报 纸、识别纸币、阅读标签以及检查小物体或大物体的一部分。 社区一级的卫生或康复工作者可以帮助人们获得这些设备。 视力康复。视力降低无法逆转的人将受益于全面的视力康复 服务，其中包括心理支持以及方向判定，行动能力和日常生活活 动培训。眼保健和康复专家可以训练视力低下人士增强视觉功能 的技能，例如意识、注视、扫描和跟踪等技能。这些技能通常需 要有效使用放大镜，但在其他情况下也可能有用。 7.5 放大镜 许多50岁以上的人在近距离看书或阅读时都有困难。通常可 以通过使用放大镜（也称为“阅读器”）获得帮助。 简单的放大镜价格低廉。它们通常具有各种放大倍率。放大 镜只会使距离近的物体显得更大。当简单的放大镜不能解决问题 时，建议进行全面的视力检查。 如果可能的话，所有50岁或以上的人都应定期接受眼保健专 家的检查。简单的视力和阅读测试不能代替眼保健专业人员进行 的全面检查。 管理 视力受损 48 7 视觉能力 管理视力受损的照护路径 7 管理视力受损的照护路径 视觉能力 评估与管理 相关疾病 7.9 类固醇使用 部分人长期使用类固醇激素治疗可能会增加眼球压力（眼内 压）或导致白内障。这种增加的压力可能会导致视力下降，从而 损害视神经，如果不加以治疗，则会导致失明。任何接受长期类 固醇治疗的人都需要定期进行眼部检查和眼压检查。 7.7 高血压 高血压是视网膜疾病和青光眼的重要危险因素。 7.8 糖尿病 糖尿病患者每年应由眼保健专家进行眼科检查，以检查是否 患有糖尿病性视网膜病变。 49 7 管理视力受损的照护路径 视觉能力 评估与管理 社会和自然环境 建立对比。对象内部和对象之间的良好对比度使它们更易 于查看，寻找或避免。示例包括台阶边缘的高对比度标记（特别 是对于只有一只眼睛有视觉识别能力的人），使用有色的盘子以 使食物在对比中更为显眼，使用黑笔书写等。视力低下的人，家 庭成员和护理人员可以为家用和厨房工具的手柄上色，以使其更 清晰，更安全⸺例如，用色彩鲜艳的胶带将刀柄包裹起来或上 漆。 使用最清晰的字体。对于计算机和电话上的印刷材料和电子 显示屏，统一的背景色中清晰可见的大型无衬线字体（例如本手 册中的字体）最容易阅读。 选择体积较大且对比度较高的家用物品。商店中经常有使用 较大字母和数字或高对比度的产品。以这种方式提供的产品示例 包括钟表，手表和大字本。对于休闲活动，可以购买或制作大型 游戏机板和棋子，以及带有大型符号的扑克牌。 使用听力和视觉辅助工具。现在商店中的许多物品都具有语 音功能，例如具有语音功能的手表、温度计和体重秤。现在，许 多移动电话和计算机程序都具有文本转语音功能。 有很多方法可以帮助视力低下人士享受更好的功能。家庭成 员和照护者可以提供帮助。根据设置，对本指南进行调整以指定 需要在哪里获得辅助视觉设备以及如何获得服务。 7.10 适应低视力 除了提供辅助视觉设备之外，简单的改变就可以使视力低下 者维持其活动，从而维持其生活质量。可以对住处和患者的日常 活动区域进行更改，以使日常任务和休闲活动更安全，更容易。 以下是示例。 改善照明。良好的照明对于近视尤其重要。光最好来自人的 侧面（不产生阴影）。 减少眩光。通常，明亮的光线会更好。但是，阳光或明亮的 灯光会打扰部分人。 移除障碍物。诸如家具和其他硬物之类的危险可以移出低视 力者的日常路线，或者如果需要的话，应始终保持在同一位置。 50 8 听觉能力 管理听力丧失的路径 与年龄有关的听力丧失可能是老年人最常见的感觉障碍。 听力丧失如果不进行治疗会干扰沟通，甚至可能导致社会隔 离。其他能力的限制，如认知减退，会使这些社会后果更加严 重。听力丧失与许多其他健康问题有关，包括认知减退和认知 障碍症的风险增加，抑郁和忧虑，平衡能力变差，跌倒，住院 和早逝。 因此，评估听力是在社区一级监控老年人内在能力的关键 部分。深入评估听力也是全面评估老年人的健康和社会关怀需 求的关键部分。 关键点 社区的初级保健工作者可以使用简单的便携式设备或耳语测 试来筛查听力丧失。 在家庭和社区采取简单的措施可以减少听力丧失的影响。使 听力更轻松的沟通策略包括发音清晰，说话时面对听力丧失 的人以及减少背景噪音。 改善听力本身涉及助听器和人工耳蜗等听力设备。提供它们 需要专门的知识和设备。 51 需要专业照护 中到重度听力丧失 (听力测试：36‒80 dB) 失聪 (听力测试：≥ 81 dB) 正常听觉能力 (听力测试：≤ 35 dB) 8 询问： ‒ 危险因素危 （如噪声暴露或服用耳毒性药物） ‒ 耳朵痛 ‒ 耳部主动引流病史，突发性或快速 进展性听力丧失 ‒ 晕眩 ‒ 慢性中耳炎 ‒ 单侧听力丧失 提供助听器 如果无法获得助听器，应告知读唇和 手语以及其他交流方法 否 通过 加强关于耳部护理的一般 性建议或日常照护 加强关于耳部护理的一般 性建议或日常照护 每年重新评估一次 失败 测试 听力 ‒ 耳语测试：能够听到耳语 或 ‒ 听力测试筛查：35 dB 及以下通过或 ‒ 基于应用程序的自动数字噪声测试 社会和自然环境 评估与管理 评估 听觉能力 （诊断性听力测试） 2 1 3 提供情感支持，帮助管理情绪困扰 在房屋各处提供听力辅助设备（电话，门铃） 为听力丧失者、其家庭成员和照护者提供保持联络和维护关系的方法 （任一问题） 是 转诊至专业听力照护 评估和提供听力设备 （助听器或植入人工耳蜗) 8.1 8.5 8.4 8.4 2 ‒ （所有问题） 管理视力受损的照护路径 视觉能力 1初步评估采用三个可能的测试之一。 耳语测试 耳语测试是一个筛选工具，可以帮助确定受试者是否有正常的听 力以及是否需要诊断测听。 筛查测听(15) 如有设备可使用诊断测听。 筛查测听显示音调跨越语音频谱（500至4,000 Hz）在正常听力 的上限。结果记录为通过或参考。读数在35 dB或以下表示听力 正常。通过简单具体的培训，非专业人员也能够用设备准确测试 试听力。 基于应用程序的自动数字噪声测试 自动数字噪声自我测试也可以用来确定诊断测听是否需要。 可作为手机应用程序 – 例如： 可基于网页服务 – 例如： hearWHO: https://www.who.int/deafness/hearWHO （免费，英语界面） hearZA: https://www.hearza.co.za/ （免费，英语界面） uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html （免费，苹果手机用户，英语， 法语，德语和西班牙语界面）。 来自 HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html （免费，荷兰语，英 语，德语，波兰语和瑞典语界面）。 听力测试 管理听力的一般性建议 切勿把脏手指放入耳朵或忘记在处理食物之前洗手，以及不 要用脏手吃东西 切记如厕后洗手 切勿在脏水里游泳或洗澡 切勿把任何东西放进耳朵： – 热或冷的油 – 草药 – 煤油等液体 2 耳语测试 站立在受试人员一侧的一臂距离之后。 请受试人员或一名助手按下对侧耳耳屏以关闭对侧耳。 （耳屏是耳朵前方的突起物，部分遮盖耳朵的开口。） 呼气然后轻声低语四个词语。 可以使用任何常见，无关的词语。 请受试者重复该词语。词语应逐一说出，并等待每个词 语的反馈。 试者确认她／他能够听清楚， 那么受试者很可能这侧听 如果受试者重复出三个以上的词语，同时测 力是正常的。 移动到受试者另一侧并测试另一侧听力，使用不同的词 语。 3 耳语测试采用的词语应该是受试人 员熟悉的。以下为例子： – 工厂 – 天空 – 火焰 – 数字 – 鱼 – 自行车 – 花园 – 黄色 需要特殊护理时 • 评估严重听力丧失／失聪。 • 安装听力辅助设备。 • 管理造成听力丧失的根本原因。 8 听觉能力 管理听力丧失的路径 53 8 管理视力受损的照护路径 视觉能力 语音听力测试。老年人可以从一项额外的测试中受益⸺语 音测听。在此测试中，一系列预先录制的简单单词会以越来越大 的音量播放，并且要求此人在听到它们时重复这些单词。此测试 会交叉检查PTA的结果。如果存在PTA无法预测的语音感知不对 称性，或者仅安装一个助听器，则可以确定语音识别是否与PTA 结果一致。 鼓室图。最后，鼓室图测试鼓膜的顺应性（或行动能力）。 该测试可以支持纯音和语音测听结果，以确定听力问题的类型。 8.1 三项综合评估 听力评估可能需要使用专门设备进行三项测试⸺用于纯音 的诊断听力计和语音听力计以及用于中耳评估的鼓室计。这些 测试可以帮助确定是否有康复的需要。进行这些测试需要专门的 培训。 纯音听力测试。纯音听力测试（PTA）测试一个人听不同纯 音频率（音高）声音的能力。它包括逐渐增加预先录制的声音的 播放音量，直到该人可以听到为止⸺听力阈值。它测试声音的 空气传导和骨传导，以评估从125 Hz（非常低）到8000 Hz（非 常高）的频率下的听力阈值。该测试有助于确定听力丧失的程度 和类型。 评估 听力能力 54 8 管理视力受损的照护路径 视觉能力 8 听觉能力 管理听力丧失的路径 应同时考虑交流策略和听力设备以应对听力丧失。 确定管理听力丧失的最佳方法是根据对患者内在能力的全面 评估。任何认知减退，行动能力丧失或手臂或手部灵活性丧失， 以及家庭和社区的支持都必须考虑。 8.2 对于中到重度听力丧失的老年人 • 向听力丧失的人及其家人说明听力辅助设备器如助听器的好 处，在何处获得以及如何使用它们。如果已有助听器，卫生 工作者就可以支持并鼓励老年人使用助听器。 • 仅听力测定法不能确定一个人是否需要助听器。大多数听力 丧失的人会抱怨在有背景噪音时沟通困难。在建议使用助听 器之前，必须先评估个体的整体需求。 • 为听力丧失者及其家人和照护者就沟通策略提供明确的指导， 以提高听力丧失者的听力功能。 • 某些药物可能损伤内耳，导致听力丧失和／或失去平衡。这些 包括抗生素，例如链霉素和庆大霉素，以及抗疟药，例如奎宁 和氯喹。其他药物也会影响听力。如果可能，减少服用这些药 物可能会防止进一步的听力丧失。 8.3 对于失聪的老年人 听力高度丧失（严重）或无法从上述干预措施中受益的老年 人将需要专门的听力照护，例如安装听力设备。提供听力设备需 要测试，处方和验配的专业技能。 管理 听力丧失 其他专门听力照护的危险信号 可能导致听力丧失的疾病需要专门的诊断和管 理。这些包括： • 耳朵痛 • 慢性中耳炎（中耳感染） • 突然或迅速地进行性听力丧失 • 头晕，中度至重度听力丧失 • 主动从耳部排出液体 • 存在危险因素，例如噪音暴露和服用会损害听力的 药物。 8.5 55 8 管理视力受损的照护路径 视觉能力 8.4 听力设备 助听器。助听器通常是解决老年人听力丧失的最佳方法。助 听器能够放大声音。它们对大多数人都有效，且佩戴于耳朵上方 或内部，便于佩戴。必须向人们解释助听器不能治愈或治疗听力 丧失。 人工耳蜗。听力高度丧失但使用助听器没有帮助的人，可以 从植入人工耳蜗中受益。将耳蜗植入物通过外科手术放置在耳朵 中。它将声音转换为电脉冲，然后将其发送到耳部神经。必须仔 细评估人工耳蜗是否会有所帮助。如果无法或不适合进行人工耳 蜗植入，应告知老年人及其家人有关读唇和手语的知识并接受相 关培训。 音频感应环路和个人声音放大器。音频感应环路和个人声音 放大器也有效。音频感应回路或听觉回路是围绕空间（例如，会 议室或服务台）放置的一根或多根电线。电线将来自麦克风和放 大器的信号发送到某些类型的助听器。 世界卫生组织关于发展中国家助听器和服务的准则提供了更多 指导： http://apps.who.int/iris/handle/10665/43066 56 8 管理视力受损的照护路径 视觉能力 8 听觉能力 管理听力丧失的路径 评估与管理 社会和自然环境 最小化听力丧失的影响可以帮助保持独立性，并减少老年人 依靠社区服务来满足日常生活的需求。家庭成员、其他照护者和 社区都可以提供帮助。 听力丧失通常会导致心理困扰和社会孤立。因此，听觉康复 现在更加重视针对老年人及其照护者的心理社会因素。 • 定期的社交互动可以降低认知减退，抑郁以及听力丧失的其 他情绪和行为后果的风险。在特别困难的时候，社会支持网 络可以提供帮助。 • 同伴和家人可以帮助防止孤独和孤立。他们可能需要有关如 何执行此操作的建议。例如，他们应该与听力丧失者保持沟 通，并组织使听力丧失者参与社交网络的活动。请参阅右侧 的方框，以获取有关与听力丧失者交谈的建议。 • 家庭的环境解决方案可以包括将门铃和电话放在整个房屋内 都能听到的地方。 8.5 家庭成员和照护者的沟通策略 与听力丧失的人交谈时，医护人员可以建议家庭成员 和照护者遵循某些简单的做法(14)。 • 说话时让对方看到你的脸。 • 确保脸部光线充足，以帮助听众看到您的嘴唇。 • 在讲话之前引起听力丧失者的注意。 • 尽量避免分心，特别是大声的噪音和背景噪音。 • 说话清晰且较慢。不可喊。 • 不要放弃与听力丧失的人说话。这将使他们孤立，并 可能导致抑郁。 无论是否有助听器，这些策略均有帮助。 8.5 57 58 名词“抑郁症状”（或情绪低落）适用于那些老年人，在大 多数情况下或至少在两周内一直有两种或多种抑郁症状同时出现但 不符合诊断为严重抑郁的标准。抑郁症状在长期处于残疾状况的老 年人，社会隔离的老年人或具有苛刻的照护责任的照护者中更为常 见。这种情况应被视为治疗抑郁症状的综合方法的一部分。 抑郁症状是心理能力的重要部分，但只是其中一个方向。还有 其他方面，例如焦虑，人格特征，应对和掌握能力等，均需要采取 复杂的措施。 本章为预防和管理老年人的抑郁症状提供指导。有关抑郁症干 预措施的更多指南，请参见WHO mhGAP干预指南，网址为https:// apps.who.int/iris/handle/10665/250239 关键点 通过提出一系列问题，社区初级保健工作者可以识别出有抑郁症 状的人，并将抑郁症状与抑郁症区分开。 受过训练和被监督的非专科医疗保健专业人员可通过简单而结构 化的心理干预帮助社区和其他保健中心内患有抑郁症状的人。 抑郁症需要全面及专业的治疗方法。 内在能力的其他领域（例如听力或行动能力）的下降可能会损害 功能发挥，减少社会参与并导致抑郁症状。 9 心理能力 缓解抑郁症状的照护路径 59 * 老年人会使用多种的词语来形容低沉情绪，如 悲伤、沮丧、失落等。 感觉失落、抑郁或 绝望?* 做任何事都提不起兴趣或 感受不到愉悦 ? ? 抑郁 （≥ 3额外症状） 抑郁症状 （0‒2额外症状） 9 否 否 （以上任一问题） （所有问题） 是 https://apps.who.int/iris/handle/10665/250239 加强关于生活方式的一般 性建议或日常照顾 在过去两周内，您是否有 以下情绪？ ‒ 最近6个月有重大损失 ‒ 躁狂史 ‒ 认知减退 ‒ 听力丧失 ‒ 视力受损 ‒ 疾病或外伤致残 检查用药情况，如 抗抑郁药、抗组胺 药、抗精神病药 综合管理 管理和评估疼痛 ‒ 多重用药 ‒ 贫血， 营养不良 甲状腺功能减退症 ‒ 疼痛 否 9.1 9.2 9.3 减少压力和加强社会支持 动员老年人进行身体活动和维持社会联系 促进日常活动 鼓励参与社区的运动方案和发展技能 识别和解决孤独和社会孤立问题（考虑技 术协助的干预措施） 评估 情绪 12 相关条件 评估与管理 社会和自然条件 评估与管理 提供简明结构性心理干预： ‒ 认知行为疗法 ‒ 问题解决咨询或治疗 ‒ 行为激活 ‒ 生命回顾疗法 多种运动 正念练习 治疗抑郁 有严重抑郁症诊断的老年人通常需要专门护理。 他们应该按照世组织界卫生的mhGAP干预指南 进行咨询和治疗 9.4‒9.7 筛查 抑郁症状 询问 6 需要专业照护 缓解抑郁症状的照护路径 心理能力 12 * 这些问题可以在病人健康问卷上找到（PHQ-9） (http://www.cqaimh.org/pdf/tool_phq9.pdf)，是评估抑郁症状的一个工具。 或见mhGAP干预指南的抑郁部分 https://apps.who.int/iris/handle/10665/250239 需要特殊护理时 • 抑郁症的管理需要一个更全面和通常是专家来制定的个性 化护理计划。 • 为了管理抑郁症状，卫生工作者需要就简短的结构式心理 干预进行专门的培训。 • 某些相关疾病，如甲状腺功能减退，可能需要专门的诊断 和管理。 • 入睡困难或易醒， 或睡眠过多。 • 感到疲惫或精力不足。 • 食欲不佳或暴饮暴食。 • 感到消极或认为自己是失败者或让自己或家人失望。 • 在诸如看报纸或电视等事情上集中注意力困难。 • 移动或说话缓慢以至于他人会注意到。 • 烦躁不安以至于走动比平时多。 • 认为你死亡或以某种方式伤害自己会更好。 评估情绪 如果一个人报告了至少一个核心症状 – 感觉失落， 沮丧或绝 望，对做事情没有任何兴趣或乐趣 ‒ 需要对其做进一步的情 绪评估。 如果受试者对两个筛选问题不熟悉，可以使用替代 词语。 抑郁症状 如果一个人至少有一个核心症状和一或两个额外症状，他可 能有抑郁症状。如果一个人有超过两个症状，他可以被诊断 为抑郁障碍。区分抑郁症状和抑郁障碍是很重要的，因为治 疗方法不同。 • 认知衰退和痴呆可能与抑郁症状有关，也必须加以评估。 痴呆的病人通常来找卫生工作者，抱怨情绪或行为问题， 如冷漠，情绪失控或难以进行日常的工作、生活和社会活 动。 • 同时，内在能力的其他领域下降，如感觉或行动能力，可 能会降低功能能力和社会参与度，从而导致抑郁症状。 • 如果在解决抑郁症状的同时干预内在能力的其他组成部 分，如认知或听力，可能会更有效。在制定个性化护理计 划时应考虑这一点。 询问： “在过去两周内，您是否被以下问题所困扰?”* 9 心理能力 缓解抑郁症状的照护路径 ，在 61 9 缓解抑郁症状的照护路径 心理能力 认知行为疗法 认知行为疗法（CBT）是基于情感受信念和行为的影响。患 有抑郁症症状（或确诊为精神障碍）的人可能会有不切实际， 扭曲的消极想法，如果不加以制止，可能会导致有害行为。因 此，CBT通常具有认知成分（帮助人们发展识别和质疑不现实的 负面思想的能力）以及行为成分以增强正面行为并减少负面行 为。步骤包括（1）识别生活中的问题；（2）意识到有关这些问 题的想法，情感和信念；（3）识别消极或不正确的想法；（4） 并重塑此想法使其更现实。 问题解决咨询或治疗 对于处于抑郁状态或处于某种程度的社交功能受损（在没有 确诊抑郁发作或障碍的情况下）的抑郁症状患者，应考虑采用解 决问题的方法。 解决问题的疗法为患者提供了直接而实际的支持。充当治疗 师的卫生专业人员和老年人共同努力，找出并隔离可能导致抑郁 症状的关键问题区域。卫生专业人员和老年人共同将问题分解为 可管理的特定任务并通过针对特定问题制定应对策略解决问题。 管理 抑郁症状 9.1 简明结构性心理干预 简明结构性心理干预措施，例如认知行为治疗，问题解决方 法，行为激活和生命回顾治疗，可能会大大减轻老年人的抑郁症 状。多种运动和正念练习也可以减轻抑郁症状。 在老年人的认可和同意下，并考虑到他们的担忧（例如解决 问题的困难），可以使用多种心理干预措施。除了进行结构性的 心理治疗外，还应考虑进行身体活动，因为身体活动可以改善情 绪（请参见第5章“行动受限”）。 不推荐由没有专门心理健康知识的初级保健医生开具抗抑郁 药处方。 5 接受过心理健康培训的卫生专业人员通常会实施这些干预措施。如果社区 卫生工作者能熟练使用它们并接受了有关老年人心理健康问题的培训，也 可以为老年人提供帮助。这些干预措施不会带来任何危害 62 9 心理能力 缓解抑郁症状的照护路径 9 缓解抑郁症状的照护路径 心理能力 5 9.2 多种运动 根据患者的身体能力和喜好量身定制的运动计划可以在短期内甚 至长期减轻抑郁症状。请参阅第5章行动受限有关内容。 9.3 正念练习 正念包括关注当前时刻发生的事情，而不是沉浸于过去、未 来、愿望、责任或遗憾。对于有抑郁症状的人，后者可能会导致 情绪低落。正念练习有多种类型，其中广泛使用的方法是安静地 坐着或躺着，将注意力集中在呼吸的感觉上。正念运动（例如在 瑜伽或散步期间）对部分人也有帮助。 行为激活 行为激活涉及鼓励患者参加奖励活动，以减轻抑郁症状。 与大多数其他基于证据的心理治疗相比，这种方法学习起 来更快。非专业人员也可以学到它，因此可以增加对抑郁症状的 照护。该干预措施主要由专家进行多阶段干预研究。但是，有可 能将干预措施修改为简短干预措施，并由受过培训的卫生专业人 员将其作为辅助治疗或作为初级保健综合治疗方法第一步的一部 分。 生命回顾疗法 生命回顾疗法涉及由治疗师指导患者记住并评估他们的过 去，以使他们对生活感到安宁或接受他们的生活。这种类型的疗 法可以帮助患者正确看待生活，甚至可以恢复有关朋友和亲人的 重要记忆。生命回顾疗法可以帮助治疗老年人的抑郁症，并可以 帮助那些面临生命终结问题的人。治疗师将生命回顾疗法的重点 放在生命主题上，或者回顾某些时期，例如童年，父母身份，成 为祖父母或工作年限。 63 9 缓解抑郁症状的照护路径 心理能力 评估与管理 相关条件 • 听力丧失。听力丧失的老年人可能会表现出尴尬、焦虑和自 尊心低，参加社交活动和体育活动的可能性较小，从而导致 社交孤立和孤独感，并最终导致抑郁(15)。 • 视力受损和与年龄相关的眼疾，例如与年龄相关的黄斑变性 和青光眼的存在与抑郁症的风险增加相关(16)。视觉功能差的 人经常报告他们感到失落，孤独甚至无望。 • 对疾病或外伤造成的残疾的反应。抑郁是残疾常见的继发性 疾病。因疾病和外伤而致残的人会承受压力；同时还必须应 对生活的转变。适应残疾的阶段包括震惊，否认，愤怒／抑 郁和适应／接受。新发残疾的老年人有患焦虑症和抑郁症的 风险。 以下相关情况的存在表明需要采用与抑郁症治疗不同的方 法。 • 最近6个月有重大损失。 • 躁狂史。躁狂症发作时表现为情绪高涨，精力旺盛和活动增 加。经历躁狂发作的人被归类为双相情感障碍。躁狂病史可 以通过检查同时发生的至少持续一周的几种症状来确定，这 种症状严重到足以干扰工作和社交活动或需要住院或隔离 （请参阅mhGAP干预指南https://www.paho.org/mhgap/en/ bipolar_flowchart.html ）。 • 认知减退。抑郁与认知减退之间的关系很复杂。流行病学研 究长期将抑郁症与阿尔茨海默氏病的发展联系在一起。在抑 郁症中影响的认知功能是注意力，学习和视觉记忆以及执行 功能。抑郁症可能是对个体对轻微认知减退的自我意识的一 种心理反应，这种意识尚未开始影响日常功能。 64 9 缓解抑郁症状的照护路径 心理能力 9 心理能力 缓解抑郁症状的照护路径 9.6 甲状腺功能减退症 甲状腺功能减退是老年人特别是女性的常见病。甲状腺功能 减退的症状可以是非特异性的，并且因人而异，但是它们可能包 括抑郁症状。甲状腺功能减退症应由具有专门知识的卫生工作者 进行评估和管理。 9.7 疼痛 报告慢性疼痛的人常伴有抑郁症状。评估和管理疼痛非常重 要（请参阅第5章行动受限相关内容）。 9.4 多重用药 多重用药可能会导致抑郁症状，而抑郁症症状可能会导致多 重用药。解决多重用药和抑郁症状对于打破恶性循环很重要。除 了主要作用于中枢神经系统的药物外，具有精神性质的药物，例 如抗组胺药和抗精神病药，肌肉松弛药和其他具有抗胆碱能性质 的非精神药物也可能与抑郁症状有关。去除不必要的，无效的药 物以及具有重复作用的药物可减少多重用药。 9.5 贫血，营养不良 贫血和营养不良导致抑郁症可能是由于铁、叶酸、维生素B6 和维生素B12等维生素的缺乏。抑郁症状也可以在贫血的发展中 起作用。食欲不振和对进行日常活动（例如购物和烹饪）缺乏兴 趣会降低老年人的营养质量和数量，从而促进贫血和营养不良的 发展。要控制抑郁症状，控制贫血和改善营养状况至关重要（请 参阅有关营养不良的第6章）。 5 6 65 9 缓解抑郁症状的照护路径 心理能力 评估与管理 社会和自然环境 如果老年人的失能，例如听力丧失或行动受限，则家庭成员 和照护者应特别注意避免社交隔离。社交隔离会导致抑郁症状。 考虑采用电话或互联网作为解决孤独的技术辅助干预措施。 抑郁状态下，人们通常对有趣或令人愉悦的活动失去兴趣。 家庭成员和照护者可以温和的鼓励和支持有抑郁症状的老年人进 行更多的身体活动和参与更多的社会活动，例如基于社区的运动 计划和技能培养。 66 10 社会关怀与支持 社会关怀与支持的照护路径 对于内在能力严重丧失的人，只有在他人的关心，支持和 帮助下，尊严往往才可能实现。社会关怀和支持的可用性对于确 保有尊严和有意义的生活至关重要。社会关怀与支持不仅包括日 常活动（ADLs）和个人护理方面的帮助，还包括便利获得社区 设施和公共服务，减少孤独感和孤独感，提供财务保障，提供合 适的生活场所，骚扰和虐待，并参与赋予生活意义的活动。 询问社会关怀和支持需求的最合适的人员可能因问题而 异。如果老年人的认知减退，则最好是向熟识此人的人（例如 家庭成员，照护者或朋友）提出有关ADLs和财务状况的问题。 关键点 功能发挥下降在老年人中很普遍，尤其是内在能力下降的 人，但这并非是不可避免的。 社区卫生工作者可以通过简单的问卷来筛查功能丧失。 针对老年人优先事项的干预措施可以提高功能发挥。 有效的干预措施包括那些提高内在能力，功能发挥以及提供 社会关怀和支持的措施。 67 AB 10 1. 您在室内走动是否有困难？ 2. 您使用卫生间（或洗手台）是否有困难？ 3. 您自己穿衣是否有困难？ 4. 您使用淋浴设备或淋浴是否有困难？ 5. 您在保持个人外表整洁方面是否有困难？ 6. 您在食物准备方面是否有困难？ 7. 您居住的地方是否有问题？ 8. 您的经济情况是否有问题？ 9. 您是否感到孤独？ 社会关怀与 支持需要 社会关怀方面的帮助（个人协助） 评 估 是 是 评估和修改物理环境，以弥补内在能力的丧失，改善行动能力，防止跌倒 考虑使用辅助技术 评估配偶、家人和其他无薪照护者的需求 审视雇佣 照护者的支持需求 应提供照护服务，如家庭基础护理、日间护理、养老院 补充询问 您是否担心： 1. 您住所的安全性？ 2. 您房屋的状况？ 3. 您房屋的位置？ 4. 您房屋的费用？ 5. 您房屋维修和管理的费用？ 6. 设法独立生活？ 考虑： ‒ 家庭适应 ‒ 备选住宿 ‒ 参照社会福利或社区住房方案或现 支持网络 补充询问 1. 到月底时您的经济情况一般如何？ 2. 您能够管理自己的金钱和其他财务事宜吗？ 3. 您是否愿意接受财务津贴或福利的建议？ 补充询问确认障碍： 你不能完成… 的原因是： 1. 费用，2. 距离，3. 交通，4. 缺乏机会，5. 其他？ 提供一份向老年人提供服务的当地社区清单，例如休闲设施和俱乐部、成人教育提供 者、志愿服务和就业咨询服务 鼓励老年人利用这些服务增加他们的社区参与度 提升方式： ‒ 紧密的社会联系（配偶，家人，朋友，宠物） ‒ 利用当地社区资源（俱乐部，信仰团体，日间照护中心，运动，休闲，教育） ‒ 贡献个人能力的机会（志愿服务，就业） ‒ 利用通信技术联系 考虑： ‒ 提供财务专家建议 ‒ 关于财务决策授权与防止财务滥用的 建议 如果发现任何直接威胁，则应通过社会工作，成人保护或执法 系统进行专家评估 询问 是 否 是 是 观察老年人的行为，其照 护者或亲属的行为或身体 虐待迹象，用于识别潜在 的虐待行为 10. 您是否有兴趣爱好： 爱好，工作，志愿服务， 支持家人，教育或精神活动等 对你重要的活动？ 11. 评估虐待风险 1 社会关怀与支持 社会关怀与支持的照护路径 AB 10 1. 您在室内走动是否有困难？ 2. 您使用卫生间（或洗手台）是否有困难？ 3. 您自己穿衣是否有困难？ 4. 您使用淋浴设备或淋浴是否有困难？ 5. 您在保持个人外表整洁方面是否有困难？ 6. 您在食物准备方面是否有困难？ 7. 您居住的地方是否有问题？ 8. 您的经济情况是否有问题？ 9. 您是否感到孤独？ 社会关怀与 支持需要 社会关怀方面的帮助（个人协助） 评 估 是 是 评估和修改物理环境，以弥补内在能力的丧失，改善行动能力，防止跌倒 考虑使用辅助技术 评估配偶、家人和其他无薪照护者的需求 审视雇佣 照护者的支持需求 应提供照护服务，如家庭基础护理、日间护理、养老院 补充询问 您是否担心： 1. 您住所的安全性？ 2. 您房屋的状况？ 3. 您房屋的位置？ 4. 您房屋的费用？ 5. 您房屋维修和管理的费用？ 6. 设法独立生活？ 考虑： ‒ 家庭适应 ‒ 备选住宿 ‒ 参照社会福利或社区住房方案或现 支持网络 补充询问 1. 到月底时您的经济情况一般如何？ 2. 您能够管理自己的金钱和其他财务事宜吗？ 3. 您是否愿意接受财务津贴或福利的建议？ 补充询问确认障碍： 你不能完成… 的原因是： 1. 费用，2. 距离，3. 交通，4. 缺乏机会，5. 其他？ 提供一份向老年人提供服务的当地社区清单，例如休闲设施和俱乐部、成人教育提供 者、志愿服务和就业咨询服务 鼓励老年人利用这些服务增加他们的社区参与度 提升方式： ‒ 紧密的社会联系（配偶，家人，朋友，宠物） ‒ 利用当地社区资源（俱乐部，信仰团体，日间照护中心，运动，休闲，教育） ‒ 贡献个人能力的机会（志愿服务，就业） ‒ 利用通信技术联系 考虑： ‒ 提供财务专家建议 ‒ 关于财务决策授权与防止财务滥用的 建议 如果发现任何直接威胁，则应通过社会工作，成人保护或执法 系统进行专家评估 询问 是 否 是 是 观察老年人的行为，其照 护者或亲属的行为或身体 虐待迹象，用于识别潜在 的虐待行为 10. 您是否有兴趣爱好： 爱好，工作，志愿服务， 支持家人，教育或精神活动等 对你重要的活动？ 11. 评估虐待风险 1 社会关怀与支持 社会关怀与支持的照护路径 卫生工作者应该知道哪些老年人应该被转诊进行专家评估。方案将会根据可 及性而有所不同。村长，校长，僧侣或信仰团体的领袖在某些情况下反而比 社工更合适。鉴于综合社会护理和支持需要多个层面的支持，定期举行会议 以促进对专家和服务的信任很重要。以下是参与老年人护理的不同专业领域 的专家例子。 • 居住条件：住房服务，社工，职业治疗师。 • 经费：社工，福利咨询服务。 需要专业知识时 • 孤独：社工，志愿服务，初级保健医师。 • 参与：社工，休闲，就业和志愿服务。 • 虐待：社工，成人保护，执法服务。 • 日常生活活动：职业治疗师，社工，护士或多学科老年专家组。 • 室内行动：物理治疗师，职业治疗师，社工或多学科老年专家组。 • 户外行动：物理治疗师，社工，志愿交通服务。 老年人的行为 • 似乎害怕亲属或专业看护者。 • 不愿回答问题，或在回答之前焦虑地看向照护者／亲属。 • 当照护者／亲属进入／离开房间时，行为发生变化。 • 用以下词语形容照护者如 “顽固” 或经常 “疲倦”或 “脾气 暴躁”，或变得易怒／非常焦虑／高度紧张／极易发脾气。 • 表现出对照护者的过分尊重或顺从。 1 看护者／亲属的行为 • 阻碍或避免专家与老年人私下交谈，或持续找理由打断评估 访谈的流程（例如反复进入房间）。 • 坚持回答向老年人提出的问题。 • 在为老年人提供家庭援助方面设置障碍。 • 显示出对必须照顾老年人的高度不满。 • 试图说服调查者，老年人是“疯狂的”或精神错乱的，或由 于混乱而不知道他们在说什么，而事实并非如此。 • 访谈时充满敌意、疲倦或不耐烦，老年人在他们面前非常不 安或漠不关心。 虐待老年人的观察线索 身体虐待 • 割伤，烧伤，擦伤或划痕。 • 不符合解释的伤害。 • 不太可能是意外造成的伤害。 • 隐蔽处的伤害和伤疤。 • 形似手指用力抓握的擦伤 （通常在上臂部）。 • 保护区内的伤害，如腋下。 • 未治疗过的伤害。 • 不同愈合阶段的多重损伤。 • 药物使用不足或过度使用。 10 社会关怀与支持 社会关怀与支持的照护路径 69 10 社会关怀与支持 社会关怀与支持的照护路径 评估与管理 社会支持需求 10.1 个人照护和日常活动的协助（路径A部分） 评估和管理需求 评估一个人是否已经达到无法在没有他人帮助的情况下照顾自 己的地步要用到6个问题。内在能力严重丧失的老年人将从该评估 中受益。 在室内到处走动涉及许多活动，例如从床到椅子的移动，行 走，使用卫生间和上下楼梯。行动受限会增加风险并需要个人照 护。穿衣，喂食，洗澡和美容是ADLs。无法执行ADLs导致需要个 人照护。许多老年人不想依靠他人来完成ADLs，而是希望能够自 己进行管理。 无法完成ADLs和／或行动不便的老年人可以从康复计划中受 益。尽管内在能力受到限制，但康复计划可能关注提高能力，也可 能包括辅助技术和环境适应措施以优化功能发挥。还可以提供交通 服务以帮助户外活动。如果仍然存在困难，则应回顾配偶，家庭成 员和其他无偿照护者的支持，包括考虑他们自己的需求。如果需要 进一步的支持，则应提供自愿，私人或公共家庭照护服务。 10.2 社会支持需求（路径B部分）评估和管理 无论内在能力和功能发挥的水平如何，对社会支持需求的评估 都会使老年人受益。提供社会支持使老年人能够做对他们重要的事 情。这包括对他们生活条件，财务安全，孤独感，获得社区设施和 公共服务的支持，以及反对虐待老年人的支持。 B7 生活条件 老年人居住的地方会影响他们的健康、独立性和幸福感。问题 可能与很多方面有关，包括住所的大小、交通、环境、安全性。补 充问题可以帮助确定要解决的特定领域。 可以通过采取新的安全措施来缓解生活条件问题，在紧急情况 下可以打电话给他人，并进行调整以维持独立生活。经济支持可用 于帮助支付住宿费用，以及进行维修和保养的费用。如其他所有方 法均失败，则应考虑搬至更合适的住所。 70 10 社会关怀与支持 社会关怀与支持的照护路径 10 社会关怀与支持 社会关怀与支持的照护路径B9 孤独 孤独在老年人中很常见，并与抑郁和早逝的可能性增加有关。 有关筛查抑郁症状的指南，请参见第9章。独自一人并不等同于孤 独⸺如果人际关系较差，老年人即使被其他人包围也会感到孤独。 询问一个孤独的老年人增加与家人和朋友的社交接触或结识具有 类似兴趣的其他人是否有助于减轻他们的孤独感是有帮助的。但是， 当问一个老年人，增加联系是否有帮助时，请向他们保证这个问题是 保密的，以帮助克服对透露人际关系本质的任何担忧。 养宠物会减少许多老人的孤独感。应鼓励使用当地的社区设施， 例如俱乐部，宗教团体，日间中心以及体育，休闲或教育服务。老年 人可能会有通过志愿服务或带薪工作做出贡献的机会。可以通过通信 技术增加社交联系。应该对这些与抵抗孤独感的措施进行总体审查。 评估者应注意广泛分布的本地优点。 B8 财务 财政资源与老年人的健康，独立性和幸福感密切相关。问题可 能包括资金太少，无法满足基本需求或无法充分融入社会，而老年 人可能会担心资金用完或无法管理自己的财务。补充问题可以帮助 确定需要解决的特定领域。 可以通过有关财务计划和财务管理的独立建议来缓解财务问 题。可以进行安排，将权力下放给可信任的第三方来管理财务，但 要提供法律保护以防止财务滥用。 71 10 社会关怀与支持 社会关怀与支持的照护路径 B10 社会融入和参与 ICOPE方法的目标是帮助老年人做对他们重要的事情。通过了 解老年人的生活，优先事项和偏好，找出对老年人重要的内容是很 有帮助的，因为有可能找到提高参与度的方法。 休闲活动，爱好，工作，学习和精神活动是参与社会的例子。 每个老年人都是独一无二的，并且对于他们而言重要的事物将具有 不同的，通常非常特定的优先级。应该询问并记录这些内容，以作 为个性化照护计划的指南。 应该提出进一步的问题，以找出任何障碍，例如成本，可及 性和机会。评估人员应了解当地休闲设施和俱乐部，成人教育提供 者，志愿服务和就业咨询服务的可及性，并讨论这些是否可能对老 年人有利。交通可能是一个重要的问题，并且可以使用服务来增加 访问权限。可以补贴其中一些服务的费用，以允许老年人和收入减 少的人群参与。 B11 虐待老人 许多依靠照护的老年人很容易受到虐待，大约六分之一的老年 人会遭受某种形式的虐待，这一数字比以前估计的要高(20)。虐待 可以分为多种形式，包括忽视、心理虐待、身体虐待、性虐待和经 济虐待。 老年人的行为，其照护者或亲属的行为或身体虐待迹象等观察 信息应用于识别潜在的虐待行为。 如果有任何虐待的迹象， 则需要专家评估和管理。需要让老年人知道有疑虑，并寻求专家帮 助。应记录疑虑，并已让老年人知道有关转诊的专业帮助。如果发 现任何直接威胁，则应通过社会工作，成人保护或执法系统进行专 家评估。 72 11 照护者支持 支持照护者的照护路径 当内在能力和功能发挥的下降使一个人依赖他人照护时， 照护往往落在配偶，另一位家庭成员或家庭中的其他人身上。 根据老年人的需求，提供照护他人的负担可能会使照护者的健 康受到威胁。 社区中的卫生保健或社会护理工作者可以监测照护者的 健康状况，并尝试确保照护者在照顾自己的健康并提供照护帮 助。 关键点 照顾内在能力和功能发挥丧失的老年人的负担和压力会损 害作为照护者的家人和朋友的健康。而且，这可以使照护者 （尤其是女性）脱离有薪劳动队伍。 寻找需要帮助的照护者是识别能力下降的老年人的重要部 分。 一系列干预措施–临时照护，建议，教育，经济支持和心 理干预措施–可以支持照护者维持令人满意和健康的照护关 系。 有时，照护会变为虐待。在对老年人或照护者进行评估时， 社区工作者可能会看到虐待的迹象，此时需要专家介入。 73 11 是 是 是 询问 询问 过去两周内，您是否因以下原因产生困扰： ‒ 感觉失落、抑郁或绝望？ ‒ 做事缺乏兴趣或感受不到愉悦？ 询问 您是否因为需要照护而面临收入 损失和／或额外开支？ 重新评估 每6个月 评估 照护者情绪 探讨对照护者的支持，如培训、咨询、 辅导、临时照护（如日托中心）、社区 参与护理服务、支持网络（更多方法见 iSupport： https://www.isupportfordementia.org） 探索当地财政支持选项 加强与正式长期照护系统和 社区支持（如志愿者协会） 之间的联系 作为照护者是否对您的生活造 成了负面影响？ 作为照护者您是否感觉到无人 支持？ ? ? （任一问题） （任一问题） 否 否 否 是 管理抑郁： 见mhGAP干预指南 https://apps.who.int/iris/handle/10665/250239 否 1 （对两个问题） 需要专业照护 用支持和心理教育 解决压力 提供问题解决咨询 提供认知行为治疗 照护者支持 支持照护者的照护路径 11• 治疗抑郁。• 向有抑郁症状的照护者提供解决问题的咨询或认知行为治疗。 • 当怀疑发生虐待时。 需要专业知识时 如果一个人报告了至少一个核心症状 – 感觉失落，沮丧或绝望，对 做事情几乎没有兴趣或乐趣 – 需要对情绪做进一步的评估。 如果受 试者对两个筛选问题不熟悉，可以使用替代词语。 询问：“过去两周内，你有没有被以下问题所困扰？”* • 入睡困难或易醒， 或睡眠过多。 • 感到疲惫或精力不足。 • 食欲不佳或暴饮暴食。 • 感到消极或认为自己是失败者或你让自己或家人失望。 • 在诸如看报纸或电视等事情上集中注意力困难。 • 移动或说话缓慢以至于他人会注意到。 • 烦躁不安以至于走动比平时多。 • 认为你死亡或以某种方式伤害自己会更好。 评估照护者的情绪 1 虐待的风险 接受照护者与照护者之间的双向关系可能是复杂的。健康，快乐的 照护者能够得到巨大的支持，但有时照护关系可能受到单方或双方 参与者的排斥。这可能导致冲突，使老年人易受到虐待。虐待可能 是忽视、利用物质（例如经济上）、身体、情感或性虐待等形式。 忽视也可能是由于无知、缺乏护理技能或缺乏外部支持或监督。老 年人和照护者可能都不会向卫生工作者提及虐待。应根据老年人的 行为，他们照护者或亲属的行为或身体虐待迹象提供观察信息，以 查明潜在的虐待行为（见第10章社会关怀和支持）。 增加虐待发生几率的可能因素有： • 长期关系不良； • 家庭暴力史； • 照护者难以持续提供所需的护理水平或类型； • 照护者的身心健康问题 ，特别是抑郁，男性中还应考虑酗酒和 药物滥用的问题。 虐待发生的可能性不仅与所提供的照护性质有关，甚至与照护者压 力相关因素有关，如痴呆患者的行为构成的挑战。 如果怀疑有虐待发生，需要进行更详细的专家评估，遵循当地的转 诊途径。 * 这些问题可以在病人健康问卷找到（PHQ-9（http://www.cqaimh.org/pdf/tool_phq9.pdf）， 是评估抑郁症状的一个工具。或见mhGAP干预指南 的抑郁部分，在 https://apps.who.int/iris/handle/10665/250239 照护者支持 支持照护者的照护路径 75 11 照护者支持 支持照护者的照护路径 11.1 询问照护者 第74页的路径可指导与照护者的讨论。在此路径中，每位照 护者都接受了采访，被问到三个方面： 1. 照护负担（两个问题），有可能指导支持照护者的实用策 略。 2. 抑郁症的两个核心症状，可能促使对抑郁症进行全面评估 （参见第9章抑郁症状的相关内容）。 3. 照护的财务成本，可能会导致获得当地经济支持和有组织的 社会照料。 与照护者交谈时，工作者应观察疲惫，愤怒，沮丧或失礼的 迹象。另外，卫生工作人员可以询问照护者，他们是否需要社会 关怀提供者的进一步评估或支持。随着时间的流逝，照护的负担 会越来越多。每6个月进行一次重新评估是适当的。 对照护者的角色及其影响的评估最好是远离老年人，以减少 照护者对公开发言的尴尬或犹豫。老年人和照护者的陈述可能因 各种原因而不同，包括老年人的记忆问题。因此，应根据从对内 在能力的全面评估中获得的知识来考虑评估。 11.2 提供给照护者的支持 在健康和社会关怀服务的支持和监督下，经过适当培训的专 业人员和带薪照护者应支持无薪照护者。在社区中，卫生和社会 护理工作者（包括专业人员和志愿者）可以创建一个网络，以共 享可用资源来支持无薪照护者。 iSupport是WHO的在线培训计划，可以帮助认知障碍症患 者的照护者提供良好的照护和照顾自己⸺请参阅https://www. isupportfordementia.org 。 支持重点放在主要的家庭照护者上。为了了解照护者的需 求，服务提供者可以询问要执行的任务，如何执行和执行频率， 寻找可以通过建议，实际支持或创新的辅助技术获得帮助的照护 （请参见第77页的框图）。支持应该反映照护者的选择，并强调 优化照护者的健康。 卫生和社会工作者可以： • 为照护者提供针对特定护理技能的培训和支持，例如，管理 困难的行为； • 考虑提供或安排实际的支持，例如暂停照护进行休养；和 76 11 照护者支持 支持照护者的照护路径 11 照护者支持 支持照护者的照护路径 • 探索失去功能发挥的人是否有资格获得任何政府或非政府来 源的社会福利或其他社会或财务支持。 给予意见。承认照护工作可能会令人非常沮丧并带来巨大压 力。由于照护者与老年人之间失去之前的关系而感到丧亲之情， 也可能使情况变得复杂，特别是如果照护者是配偶的话。 鼓励照护人员尽可能多地让老年人参与自己的生活和护理决 策，以尊重老年人的尊严。 安排暂托服务。当照护工作变成负担或使人筋疲力尽时， 另一个人是否可以暂时照护老年人？这可能是由家庭的另一位成 员，或者是受过专业培训或志愿者培训的社会护理工作者。这种 临时照料，例如日托，可以减轻主要照护者的负担，使他们可以 休息或进行其他活动。日托是一种社区支持服务，一周中的某几 天每天提供几个小时的个人护理（洗澡，进食，剃须，使用卫生 间），康复，娱乐和社交活动计划，餐饮和交通。日托还为照护 者提供支持服务，例如上门拜访，家庭活动，支持小组和照护者 培训。照护之余的休息时间可能有助于保持照护关系的健康和可 持续发展，暂时离开照护者也不一定会对接受照护的人有害。 提供心理支持。尝试通过支持和解决问题的咨询来解决照护 人员的心理压力，尤其是在照护任务复杂且广泛和照护者承受巨 大压力时。 创新辅助技术 诸如远程监控和辅助机器人之类的创新性辅助保健技 术有望增强老年人功能，改善老年人和照护者生活质量， 增加选择，安全性，独立性和控制感。这些技术的使用应 基于老年人或其照护者的需求和偏好，并需要对终端用户 进行适当的培训。应特别注意为研究和发展制定筹资机 制，并确保公平执行。 创新辅助技术的示例： • 社交辅助机器人PARO。该机器人可以提供陪伴(22)。 http://www.parorobots.com • 腰椎型混合辅助肢（HAL）。机械臂可以辅助照护者将 患者从床，椅子转移到浴室。 https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 关键点 • 以人为本的照护是整体的，量身定制的护理，由卫 生工作者和老年人以及支持他们的家人和朋友之间 的协作提供支持。 • 多学科团队可以帮助老年人设定目标。 • 应根据老年人的优先需求和目标，确定以人为本的 照护干预措施。 • 持续，定期的追踪对于实现目标至关重要。 制定个性化的照护计划 个性化照护计划是一种人文主义的方法，它摆脱了传统 的面向疾病的方法，而是专注于老年人的需求，价值和偏好。 一旦确定，个性化的照护计划将指导健康和社会护理的各个方 面，并支持以人为本的现实目标。 制定个性化照护计划的步骤 1. 回顾研究结果并讨论改善功能发挥，健康和福祉的机会 现在，跨学科团队将与老年人及其家人和／或照护人员 （如果适用）一起，回顾以人为本的评估结果以及在照护路径 中提出的干预措施。以人为本的评估将产生一份可纳入照护计 划并与患者讨论的拟议干预措施清单。ICOPE应用程序可以协 助卫生工作者进行此过程。多学科团队可能包括参与老年人照 护的每个人，例如初级保健医师，专科医生，护士，社区工作 人员，社会关怀人员，治疗师（物理治疗，职业治疗，语言治 疗，心理治疗），有薪和无薪照护者，药剂师和志愿者。 2. 以人为本的目标设定 通过以人为本的目标设定来确定目标和优先次序是制定照 护计划的关键要素。对于多学科团队而言，重要的是让老年人 参与有关他们自己的照护的决策，并理解和尊重他们的需求、 价值观、偏好和优先事项。这可能是卫生专业人员如今与患者 之间关系所发生的转变。 照护的目标不仅可以减少对医疗状况的直接影响，还可以 更专注于使老年人能够做自己最看重的事情，例如独立、安全 地老去，保持个人发展，在保留其自治和健康的同时，为社区 做出贡献并为社区做出贡献。除了中长期目标（6到12个月） ，建议还包括短期目标（3个月），以利用更直接的改进或收益 来保持老年人的动力和参与度。 12 78 5. 监测和随访 对照护计划的实施情况进行定期随访对于实现商定的目标 至关重要。这提供了监测进度的机会，并能够及早发现参与干 预措施的困难，干预措施的不利影响以及功能状态的变化。它 还有助于维持老年人与其照护者之间的关系。后续过程包括但 不限于： • 确保逐步成功实施照护计划； • 重复以人为本的评估并记录变化； • 总结实施卫生和社会关怀干预措施的结果，障碍和困难； • 确定变化和新需求； • 商定进一步解决这些变化和需求的方法，包括在需要时采用 新的干预措施，并根据需要修订和改进计划；和 • 重复循环 3. 商定干预措施 作为以人为本的评估和路径的结果，建议纳入照护计划的干 预措施将需要： a) 老年人同意 b) 符合老年人的目标，需求，偏好和优先事项 c) 适合他们的身体和社交环境 然后，卫生保健或社会护理工作者应与老年人进行讨论，以 逐一商定应保留在最终照护计划中的每种干预措施。 4. 最终确定并分享照护计划 卫生专业人员现在应在照护计划中记录讨论的结果，并在与 老年人，其家人，照护者以及可能参与其护理的任何其他人员共 享该文件。ICOPE移动应用程序可以通过向所有参与人员提供照 护计划摘要来支持此过程，其中包括优先目标和确定的条件。 12 功能发挥范围 1. 满足基本需求，例如财务安全，住房和人身安全。 2. 学习，成长和制定决策，包括继续学习和运用知识，解 决问题，保持个人发展以及做出选择的能力。 3. 具有行动能力，这对于做家务，访问社区中的商店， 服务和设施以及参与社会，经济和文化活动是必不可少 的。 4. 建立并维持广泛的关系，包括与孩子和其他家庭成员的 关系，与朋友，邻居，同事的非正式社会关系以及与社 区照护者的正式关系。 5. 做出贡献，这与参与社会和文化活动密切相关，例如协 助朋友和邻居，指导同龄人和年轻人，以及照护家庭成 员和社区。 79 12 识别目标： 与老年人，他们的家庭成员和照护者一起确定目标 (23)： • 问题1 请说明您一生中最重要的事情。 • 问题2 您的生活中有哪些具体目标？ • 问题3 您的健康有哪些具体目标？ • 问题4 根据我们刚刚讨论的生命和健康目标清单，您能否 选择在接下来的3个月中要关注的三个目标？接下 来的6到12个月又是什么呢？ 设立目标： 目标要适应老年人的需求以及他们对问题的定义。 • 问题5 在接下来的3个月中，您要实现的目标一，二或三 具体是什么？接下来的6到12个月呢？ • 问题6 您目前正在做什么[关于目标]？ • 问题7 对您而言，实现这个目标过程中的理想且可以实现 的是什么？ 目标优先： 老年人和照护者之间就优先照顾目标达成共识能够改 善结果。 • 问题8 在这些目标中，您最愿意在未来三个月中为哪一个目标 而努力？不论是您自己完成还是还是在[某某医生及其 团队]的支持下]？接下来的6到12个月又如何呢？ 如何进行以人为本的目标设定 资料来源：改编自Health Tapestry（http://healthtapestry.ca ） 80 关键点 • ICOPE策略的有效实施需要一种将卫生和社会 关怀服务联系起来的综合方法。 • 从社区和社区级工作者开始，优化老年人的内 在能力和功能发挥。卫生和社会部门的系统应 支持集中在社区一级的照护。 • 个性化照护计划是ICOPE策略的核心。为了执 行和管理这些计划，工作人员可能需要案例管 理方面的专门培训。 世界卫生组织关于衰老与健康的世界报告为健康和长期照 护系统设定新方向(1)。它呼吁这些系统着重于优化老年人的 内在能力，以保持和提高其功能发挥为目标。2017年发布的 WHO控制内在能力下降的社区干预措施指南将这一新方向转变 为在社区一级进行评估和照护的实用方法(2)。它们共同促进了 以人为本的健康，社会综合支持。该方法首先以个人为中心的 健康和社会关怀需求评估开始，这部分内容社区一级的工作者 就可以完成。 本章重点介绍了实施ICOPE策略的一些主要考虑因素。世 界卫生组织关于实施ICOPE策略的系统和服务的指南将详细介 绍实施问题（https://apps.who.int/iris/handle/10665/325669 ） 健康和长期照护系统 如何支持WHO ICOPE策略的实施13 81 13.1 国家对执行工作的支持 第一步，世界卫生组织的建议和本手册都需要根据当地 情况，文化和语言进行调整直至适合医护人员，照护者和老年 人。包括适应过程在内可以作为为新方法建立广泛的支持的开 始。 ICOPE策略的实施将需要利益相关者在各个级别和各个阶 段的持续合作，这些利益相关者包括决策者，卫生专业人员， 社会关怀工作者，研究人员，社区和老年人。本地知识将支持 将全球指南转化为可行且可接受的服务配置。 促进健康老龄化需要卫生和社会关怀部门的参与。当国家 政策支持对卫生和社会关怀采取综合方法时，两个部门都将能 够更好地采用和应用ICOPE策略。因此，政策应具体说明卫生 保健和社会关怀之间的联系将如何在国家，地区和社区各级发 挥作用。 奖励，筹资机制和表现监测可鼓励重点转向优先照顾老年 人，以优化内在能力和功能发挥。信息系统应以在国家和地方 各级监测这种转变。 13.2 预算和人力资源需求 应该分析实施ICOPE策略的意义，以确定在何处需要追加 投资，例如在培训卫生工作者，使用技术和调整卫生信息系统 方面。特别是，社区卫生和社会工作者以及基层医疗团队需要 支持，来了解和应用新方法。国家和地方专业协会可以在所有 利益相关者参与过程中扮演重要角色。 13 国家实施的关键注意事项 计划将ICOPE方法整合到健康和长期照护系统中应确保： • 可行性⸺经济方面和组织方面 • 可持续性⸺效率和劳动力 • 一致性⸺与支持健康老龄化的政策保持一致 • 完整性⸺卫生与社会关怀服务之间的联系 82 13.3 卫生和社会服务方面的照顾和支持相结合 所有综合照护干预措施均应遵循知识转化的原则，世界卫生 组织在2005年将其定义为“相关利益相关者对知识的综合，交流 和应用，以加速全球和地方在加强卫生系统和改善人民健康方面 收益的创新”。世界卫生组织2012年的衰老与健康知识转换框架 是专门为将这些原则应用于照顾患有多种合并症和／或难以获得 医疗服务的老年人而开发的(24)。 世界卫生组织2016年以人为本的综合保健服务框架提出了确 保高质量综合护理的关键方法(6)。综合护理的一个重要要素是强 大的病例管理，以支持照护计划的设计，协调和监控，而照护计 划可能跨越健康和社会关怀的多个领域。卫生和社会关怀工作者 可能需要案例管理以及ICOPE建议的临床方面的专门培训。 WHO ICOPE实施框架强调了在服务和系统层面实施ICOPE 的关键行动(25)。该指南涵盖了服务和系统管理员为提供综合护 理而需要采取的措施（第84页）。该框架建议根据现有卫生和社 会服务的程度采取具体行动。 13.4 协调地方卫生和社会关怀服务以提供支持 应该执行ICOPE干预措施以支持老龄化。也就是说，应提供 保健和社会关怀服务，以使老年人能够安全、独立和舒适地生活 在自己的家庭和社区中。旨在通过优先考虑初级和社区关怀的照 护模式来提供干预措施。这包括对以家庭为基础的干预，社区参 与和完全整合的转诊系统的关注。 只有认识到并支持社区工作者在增加获得初级卫生保健和全 民健康覆盖方面的关键作用，才能实现这一重点。世界卫生组织 关于优化社区卫生工作者计划的卫生政策和系统支持指南，就社 区卫生工作者的选择，培训，核心能力，监督和报酬提出了循证 建议(26)。 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 当需要专业护理时，二级和三级卫生工作者网络必须支持 社区卫生工作者的工作。明确的转诊标准和路径的建立必须在 实施层面得到各方的共识，然后监测其质量控制。需要明确安 排随访，以确保照护计划仍然合适和提供的医疗保健和支持仍 然有效。在健康状况发生重大变化之后，或者在老年人经历重 大生活事件（例如居住地变更或配偶或照护者死亡）之后，随 访和支持尤其重要。 13 ICOPE执行框架行动摘要 服务行动 • 紧密结合人群与社区。让老年人、他们的家人和民 间社会均参与提供服务；支持和培训照护者。 • 支持协调多学科团队提供服务。确定社区中需要照 顾的老年人，进行综合评估并制定综合照护计划； 建立卫生和社会关怀工作者网络。 • 面向社区照护提供服务。通过社区工作者和适当基 础设施支持的服务，以功能发挥为重点，提供有效 且可接受的照护。 系统行动 • 加强治理和问责制度。让利益相关者参与政策和 服务开发；制定政策和法规以支持综合照护和对 老年人虐待应对措施；进行持续的质量保证和质 量改进；定期审查公平提供护理的能力。 • 强化系统。发展劳动力，筹资和人力资源管理；使 用技术在服务提供者之间交换信息；收集和报告内 在能力和功能发挥的数据；使用数字技术来支持自 我管理。 84 13.5 社区参与及支持照护者 照护者需要社区中其他资源的帮助。社区邻里之间更积极和 直接地参与对老年人的照料和支持，可能需要地方组织和政治意 愿，特别是要鼓励志愿服务和促进老年人社区成员的贡献，例如 参加老年人俱乐部和社团。 同时，医疗保健体系对其合作伙伴负有支持健康老龄化的责 任–社区，社区组织以及老年人的家庭成员和其他无偿照护者。 如第11章所述，此职责包括关注照护者的健康和福祉，以及与社 区和社区组织的相互支持，合作与协调，以创造健康的环境，促 进健康老龄化。 85 参考文献 9. painHEALTH. 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Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal setting discussions between older adults and volunteers facilitated by an eHealth application: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. 86 24. Knowledge translation. Geneva: WHO; no date (https://www.who. int/ageing/projects/knowledge_translation , accessed 2 April 2019). 25. Integrated care for older people: Guidance for systems and services. Geneva: WHO; 2019 (https://apps.who.int/iris/ handle/10665/325669 , accessed June 2019). 26. Community-based health workers (CHWs). Geneva: WHO; no date (https://www.who.int/hrh/community , accessed 2 April 2019). 87 www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int
プライマリケアにおけるパーソンセンタ ドーな 評価と手順に関するガイダンス I C O P E ハンドブック 高齢者のための包括的ケア
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 参考文献 ii iii 1 5 9 19 25 33 41 51 59 67 75 78 81 86 謝辞 略語 高齢者のための包括的ケア（ICOPE） 能力の最適化のために：全ての人のヘルシーエイジングに向けて 高齢者のニーズの評価と個別化されたケアプランの作成 認知機能低下を有する高齢者のケア手順 移動能力を改善するためのケア手順 栄養障害に対するケア手順 視覚障害に対するケア手順 聴覚障害に対するケア手順 抑うつ症状に対するケア手順 社会的ケアや支援のためのケア手順 介護者を支えるためのケア手順 個別化されたケアプランの作成 医療・介護制度によってWHO ICOPEをいかに実装化するのか？ CONTENTS 目次 i 謝 辞 このハンドブックは高齢者のケアと支援に献身的な貢献をした 世界中の多くの方々が築いた実績を記述したものです。 世界保健機構（WHO）の高齢化/ライフコース部局のIslene Araujo de Carvalho 氏とYuka Sumi氏が中心となってこの ハンドブックが作成されました。Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Curtin University, Australia) 並びにFinbarr Martin (King’ s College London, United Kingdom) はハンドブックの執筆やケアパスの作成のコ アメンバ とーして従事してくれました。Jura出版社からのSarah JohnsonとWard Rinehart は責任者として最終版の執筆に当 たってくれました。 WHOの世界各地域オフィスや様々な部局からの多くのスタッフ も、関連するそれぞれのセクションの執筆やケアパスの作成に 貢献してくれました： Shelly Chadha (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (WHO Department of Mental Health and Substance Abuse), Tarun Dua (WHO Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (WHO Department of Nutrition for Health and Development), Zee A Han (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Dena Javadi (WHO Department of Alliance for Health Policy and Systems Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alarcos Cieza (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (WHO Department of Ageing and Life Course), Juan Pablo Pena-Rosas (WHO Department of Nutrition for Health and Development), Taiwo Adedamola Oyelade (Family and Reproductive Health Unit, WHO Regional Office for Africa), Ramez Mahaini (Reproductive and Maternal Health, WHO Regional Office for the Eastern Mediterranean), Karen Reyes Castro (WHO Department of Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention), Enrique Vega Garcia (Healthy Life Course, Pan American Health Organization/ WHO)。 このハンドブックは、多くの専門家や学識経験者からの豊富な 助言によって内容の充実が図られました： Matteo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pública de Navarra, Spain), Peter Lloyd- Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gutierrez Robledo (Institutos Nacionales de Salud de Mexico, Mexico), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Helene Payette (Universite de Sherbrooke, Canada), Ian Philp (University of Stirl ing, United Kingdom), Leocadio Rodriguez- Manas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (WHO Collaborating Centre for Frai l ty, Clinical Research and Geriatr ic Training, Gerontopole, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kristina Zdanys (University of Connecticut, United States of America), and the WHO Collaborating Centres for Frailty, Clinical Research and Geriatric Training (Gerontopole, Toulouse University Hospital, France) and for Public Health Aspects of Musculoskeletal Health and Aging (University of Liege, Belgium). Australian National Health and Medical Research Council やGlobal Alliance for Musculoskeletal Health 並びに Chulalongkorn University, Thailandからスタッフの動員や専門 家会議の開催など多大な協力をいただきました。 2018年12月に行われたWHO Clinical Consortium on Healthy Ageingの年次集会の参加者からも豊富な助言と協力をいただき ました。 WHO高齢化/ライフコース部局は日本国政府、ドイツ国政府、 神奈川県（日本）からの経済的支援に対して謝意を表します。 ii ABBREVIATIONS 略語 ADLs BMI CBT ICOPE MNA OSN PTA SPPB WHO activities of daily living（日常生活活動） body mass index（体格指数） cognitive behavioural therapy（認知行動療法） integrated care for older people（高齢者のための包括的ケア） mini nutritional assessment（ミニニュー トリショナルアセスメント） oral supplemental nutrition（経口栄養補助剤（食品）） pure tone audiometry（純音オーディオメトリー ） short physical performance battery（簡易版身体能力評価セット） World Health Organization（世界保健機構） ケアには専門的な知識や技術が必要であることを示しています。 iii
キーポイント ヘルスケアシステムにおいて、すべての人のヘ ルシーエイジングを支援する鍵は、たとえ加 齢によって徐々に低下するにしても、内在的 能力と機能的能力を最適化することです。 内在的能力の低下に関連する重要な状況が迅 速に診断され管理されれば、要介護状態にな ることを予防することができます。 地域でプライマリーケアに従事する医療・介 護従事者は、このガイダンスに従うことで、能 力が低下した高齢者を特定し、その低下を回 復または遅らせるための適切なケアを提供す ることができます。このアプローチはシンプル で低コストです。 内在的能力の低下に関連する状況は相互に関 連しているため、評価と管理には包括的でパー ソンセンタードなアプローチが必要です。 2015年のエイジングと健康に関するワールドレポートでは、 ヘルシーエイジングの目標を、ウェルビーイングを可能とす る機能的能力を身につけそれを維持することと定義していま す。機能的能力とは、人々が価値ある存在であり、価値ある ことを行うことを可能にする健康関連の属性と定義されてい ます。機能的能力は、個人の内在的能力、個人を取り巻く環 境、およびそれらの間の相互作用から成り立っています。内 在的能力とは、個人が引き出すことのできるすべての身体的 および精神的能力が合わさったもの（1）です。 このヘルシーエイジングの概念は、高齢期のヘルスケアの新 たな目標、すなわち加齢に伴って内在的能力と機能的能力を 最適化するという目標を呼び起こします。 2017年10月、世界保健機関（WHO）は、高齢者のための 包括的ケア：コミュニティレベルにおける内在的能力の低下 を管理するための介入に関するガイドライン（2）を発表し ました。このガイドラインでは、医療・介護従事者が高齢者 のためのパーソンセンタードな包括的ケア（ICOPE）をコ ミュニティレベルで実行するために、13のエビデンスに基 づく推奨を示しています。ICOPEのアプローチは、ヘルシー エイジングの鍵となる内在的能力と機能的能力の最適化に焦 点を当てたものです。これらの推奨は、国のガイドラインの 基盤となりうるものです。また、これらは、プライマリーケ アプログラムやユニバーサルヘルスカバレッジのためのエッ センシャルケアパッケージにおいて、要介護状態を予防する ためのサービスを含めることを支援するために使用すること ができます。 高齢者のための 包括的ケア（ICOPE）1 1 このハンドブックのガイダンスは、地域の医療・介護従事者 が ICOPE 勧告を実践するのに役立ちます。移動能力の低下、 栄養不良、視覚障害、聴覚障害、認知機能の低下、抑うつ症 状など、内在的能力の低下に関連する重要な健康状態を管理 するためのケアパスを提供しています。これらのパスは内在 的能力の低下をすでに経験している可能性の高い高齢者を特 定するためのスクリーニング検査から始まります。医療・介 護従事者は、このスクリーニング検査を地域で容易に行うこ とができます。これが、高齢者の健康と社会的ケアのニーズ をより詳細に評価するための入口となります。この評価は、 次に能力の低下を回復させたり、遅らせたり、予防したり、 病気を治療したり、社会的ケアのニーズを満たすための戦略 を統合した個別のケアプランにつながります。個々の対象者 を中心とした評価とケアプランの作成には、通常、プライマ リーケアの場において、プライマリーケア医や看護師などの 訓練された医療専門職が必要です。しかし、内在的能力の低 下は、一般的に、高齢者と介護者が暮らす地域社会で、集学 的チームの支援を受けて管理することができます。 なぜ高齢者のための包括的ケア （ICOPE）が必要なのか？ 世界の人口に占める高齢者の割合は、かつてないほど大きく なっています。2017年には、60歳以上の高齢者が9億6,200 万人いると推定され、世界人口の13％を占めています（3）。 この割合は、今後数十年の間に、特に低・中所得国で急速に 増加すると考えられます。2050年までには、5人に1人が 60歳以上の高齢者になると言われています。この傾向は約 50年前から始まっています。これは、世界の多くの地域で、 社会経済の発展に伴い、出生率が急速に低下し、平均寿命が 急速に延びていることを反映しています。 高齢者の健康を維持することは、人的・社会的資本への投資 であり、国連の持続可能な開発目標（SDGs）を支えるもの です（4）。同時に、増加する高齢者のケアは、医療システム に対する課題も引き起こします。保健医療資源は、年齢層別 にバランスよく配分する必要があります。高齢化に対する公 衆衛生のアプローチを根本的に変えることが必要です。 高齢者への健康管理に対する従来のアプローチは、医学的状 況に焦点を当て、その診断と管理が中心でした。 疾患に対処することは重要ですが、疾患に焦点を当てすぎる と、聴覚、視覚、記憶、動作やその他のよくある加齢に伴う 内在的能力の低下などを見落としがちになります。すべての 人の幸福は、これらの問題を特定し管理することによって、 人生のある時期に恩恵を受けることになります。ヘルスケア システム全体で高齢者の内在的能力に注意を払うことは、大 きくまた増加している高齢者の福祉に広く貢献することにな ります。 ほとんどの医療従事者は、内在的能力の低下を認識し、効果 的に対応するための指針やトレーニングを受けていません。 人口の高齢化に伴い、内在的能力の低下を防ぎ、ヘルシーエ イジングを促進し、高齢者の介護者を支援するための介入を 含む包括的な地域に根ざしたアプローチを開発することが急 務となっています。WHOのICOPEアプローチは、このニー ズに応えるものです。 この指針は誰のためのものか？ このハンドブックの主な対象者は、地域やプライマリーケア の現場で働く医療・福祉従事者です。また、この指針は、内 在的能力や機能を失った人を評価し、ケア計画を立案するた めに、必要に応じて専門的な知識を要する医療従事者に専門 的な情報を伝えるものです。 2 さらに、医療、看護、保健、公衆衛生の分野でのトレーニン グの開発を担当する専門職は、ここで記載されたコンセプト と実践的なアプローチの両方を利用できると思われます。そ の他の対象者として、国、地域、地区のプログラムマネ ジャーなどヘルスケアの管理者や政策立案者、また公衆衛生 プログラムに資金を提供したり、その実施をする機関、また 地域で高齢者にサービスを提供する非政府組織や慈善団体が 含まれます。 この指針は何を提供しているのか この指針は、内在的能力の低下を管理し、高齢者の健康と社 会的ケアのニーズに総合的に対応するための地域レベルの介 入についてのWHOのガイドラインに基いて、地域で働く医 療・介護従事者が内在的能力の低下を同定し管理することを 支援することを目的としています。 この指針では、以下の方法を記載しています。 ◦ パーソンセンタードケアの目標を設定する（第2章）。 ◦ 自己管理を支援する（第2章）。 ◦ 内在的能力の低下に伴う状態を管理するための複数の介 入を含むケアプランを作成する（第3章）。 ◦ 内在的能力の低下をスクリーニングし、医療および社会 的ケアのニーズを評価する（第4～10章）。 ◦ 介護者の支援（第11章）、 ◦ および個別のケアプランの作成（第12章） 指針となる原則 このガイダンスは、以下の原則に基づいています。 高齢者は最良の健康状態を維持する権利がある。 高齢者は、社会的・経済的地位、出生地や居住地、 その他の社会的要因にかかわらず、ヘルシーエイ ジングの決定要因にアクセスする機会を等しく持 つべきである。 ケアはすべての人に差別なく平等に提供されるべ きであり、特に性別や年齢による差別はあっては ならない。 状況に応じたICOPEの アプローチ 国民皆保険（全ての人が適切な予防、治療、リハ ビリ等の保健医療サービスを、支払い可能な費用 で受けられる状態）は、SDGsの健康目標（4） を達成するための基盤です。SDGsを達成するた めには、高齢者の健康と社会的ケアのニーズに包 括的にかつ長期的なケアの継続性を持って対応す る必要があります。WHOのエイジングと健康に 関する戦略と行動計画（5）では、内在的能力を 最適化することによるヘルシーエイジングを促進 するための医療システムの役割が概説されていま す。ICOPEの提言（2）とこの指針は、この戦略 の目標達成に貢献します。 この指針は、WHOの包括的なパーソンセンター ドの保健サービスの枠組みを実装するためのツー ルでもあります（6）。この枠組みは、保健サービ スの管理と提供の方法を、包括的なパーソンセン タードのアプローチに移行させることを求めてい ます。この枠組みの中で、ICOPEは以下に基づい た高齢者のケアを提案します。 ◦ 個人のニーズ、嗜好、目標の評価 ◦ 個別のケアプランの作成 ◦ 内在的能力と機能を維持するという一つの目 標に向かって、可能な限りプライマリーケア と地域に根ざしたケアを通して提供される包 括的サービス。 3 4 WHOのエイジングと健康に関するワールドレ ポートでは、ヘルシーエイジングをウエルビーイ ングを育む機能的能力を身につけ維持すること と定義しています(1)。 この指針では、内在的能力（図1）の低下、高 齢者の社会的ケアのニーズ、介護者の支援に関 連する以下の優先課題に取り組むことで、ヘル シーエイジングを支援します。 ◦認知機能の低下（第4章） ◦移動手段の制限（第5章） ◦栄養障害（第6章） ◦視覚障害 (第7章) ◦聴力低下 （第8章） ◦抑うつ症状 （第9章） ◦社会的ケアと支援 （第10章） ◦介護者支援 （第11章） 内在的能力は、ライフコースの中で どのように変化するのか？ 図2は、成人してからの内在的能力と機能的能力の典型的な パターンを示しています。内在的能力と機能的能力は、エイ ジングや基礎疾患の結果として、加齢とともに低下します。 この典型的なパターンは、3つの期間に分けることができま す：能力が比較的高く安定している時期、能力が低下してい く時期、そして能力が著しく低下し要介護となる時期です。 能力の最適化のために： 全ての人のヘルシーエイジングに向けて2 心理機能 聴力 視力 活力 認知機能 移動能力 図1． 内在的能力の主な領域 5 内在的能力と機能的能力 WHOは、内在的能力を個人の身体的および精神的能力（心理的機能を含む）の組み合わ せと定義しています。機能的能力とは、内在的能力と生活環境との組み合わせや相互作用 になります。 さまざまな内在的能力の平均的パターンには幅があります。 このような違いは、一国の中でもまた様々な国の間でも見ら れます。これは、平均寿命の差がなかなか縮まらないことに 反映されており、オーストラリア、日本、スイスなどの国々 では82歳以上となっており、中央アフリカ共和国、チャド、 ソマリアなどの国々では55歳未満です。 内在的能力のばらつきは高齢者の方が若い人よりもはるかに 大きく、このような多様性は加齢変化の特徴の一つです。あ る人は、別の人と10歳以上の年齢差があっても、同様の内 在的能力や機能的能力をもっている場合もあります。これが、 暦年齢が健康状態の指標にならない理由です。 内在的能力の最適化のための介入 内在的能力の低下に関連する状態を特定することで、能力低 下を遅らせたり、止めたり、元に戻したりするための介入の 機会が得られます（図2）。臨床現場や地域の医療従事者は、 内在的能力の低下に関連する指標を特定することができます。 時間をかけて繰り返し評価を行うことで、予想以上に大きな 変化をモニターすることができ、機能的能力が失われる前に 特定の介入を行うことができるのです。 このようにして地域で行われる介入は、フレイルや要介護状 態を防ぐことができます。複数の要素からなる複合介入は、 より効果的であると思われます。 6 内在的能力を決定する特性の多くは修正すること ができます。これらは、健康に関する行動や疾患 を含みます。したがって、内在的能力を最適化す るための効果的な介入を導入することには強い根 拠があります。この根拠がICOPEアプローチと この指針の基盤となっています。 内在的能力の低下に関連するさまざまな健康状態 はいくつかのレベルで相互に関連しています。た とえば、難聴は認知機能の低下と関連しています。 栄養は運動の効果を高め、筋量や筋力の増加に直 接影響を与えます。これらの相互作用のため、内 在的能力の低下をスクリーニング、評価、管理す るための包括的なアプローチが必要です。 図2． ヘルシーエイジングのための公衆衛生の枠組み： ライフコースを通じた公衆衛生活動の機会 出典：世界保健機構 2015 (1) 高く安定した能力 保健サ ビース 長期的ケア 環境 低下しつつある能力 顕著な能力の低下 機能的能力 内在的能力 慢性疾患の予防、 早期発見・管理の実現 能力低下からの回復 または抑制 能力向上のための行動の支援 能力向上のための行動の推進 進行した慢性疾患の 管理 尊厳ある人生の保証 参加への障害の除去、 能力低下の補填 ICOPEアプローチ 7 8 パーソンセンタードケアは、高齢者が様々な疾患や健康問 題を抱えただけの人間ではない、という捉え方をしていま す。すなわち、すべての人々は、年齢にかかわらず、固有 の経験、ニーズと嗜好をもつ個人であるという捉え方です。 パーソンセンタードケアは、個々の健康問題または症状に よって変化するよりはむしろ、個人の医療と社会介護ケア のニーズに対応するものです。パーソンセンタードな包括 的アプローチは、個人の健康やニーズが身近な人や地域社 会に与える影響など、個人の日常生活を重視します。 次の一般的な手順で示すように、包括的ケアのアプローチ で高齢者の医療と社会介護ケアのニーズを満たすための5 つのステップがあります。 高齢者のニーズの評価と 個別化されたケアプランの作成 キーポイント 高齢者のための包括的ケア（ICOPE）スク リーニングツールを用いて、内在的能力の 低下と関連する優先度の高い状態を持つ地 域の高齢者を同定することができます。 これらの状態と同定された人々は、徹底的 な評価を受けるために、プライマリケアの 診療所を紹介され、個々のケアプランが作 成されることを知らされます。 ケアプランは、内在的能力の低下を管理し て、機能的な能力を最適化するために、運 動、経口栄養補給、認知刺激、転倒を防止 するための家のリフォームなど、複数の介入 を含む可能性があります。 3 9 内在的能力の低下を 管理するための コミュニティレベルの介入 高齢者の人生、価値、優先するものと 社会的状況を理解する 疾患の包括的管理 リハビリテーション 緩和ケア・エンドオブライフケア 一般的な健康と生活様式の アドバイスまたは通常ケア を強化する 内在的能力の 喪失がない YES YES NO NO NO YES 地域において内在的能力の 喪失をスクリーニングする スクリーニング ステップ1 プライマリケアにおける パ ソーンセンタ ドーアセスメント ステップ2 内在的能力の喪失と関連した 状態をより重視して評価する 基礎疾患の評価と管理 社会的および身体的な 環境の評価と管理 社会的ケアサービス（自宅、施設）の ニーズの評価 10 社会的ケアとサポートプラン 社会参加への障害をなくす 環境への適応 3 一般的なケア手順 プライマリケアにおける パーソンセンタード アセスメントと手順 10 パーソンセンタードの目標設定 多くの専門にわたるチーム 多因子介入、基礎疾患、セルフケアと自己管理な どの管理、および社会的ケアと支援などを含むケ アプランを設計する。 個人のケアプラン作成 ステップ3 専門的な高齢者のケアに 結びついた照会経路と ケアプランのモニタリングを 確実にする ステップ4 地域とかかわりを持ち、 介護者を補助する ステップ5 パーソンセンタードの目標設定 多くの専門にわたるチーム 多因子介入、基礎疾患、セルフケアと自己管理な どの管理、および社会的ケアと支援などを含むケ アプランを設計する。 個人のケアプラン作成 ステップ3 専門的な高齢者のケアに 結びついた照会経路と ケアプランのモニタリングを 確実にする ステップ4 地域とかかわりを持ち、 介護者を補助する ステップ5 11 内在的能力の低下と関連した優先度の高い状態 試験 円にチェックを入れて、 すべての領域を完全に評価する 認知機能低下 （第4章） １．3つの言葉を覚えて下さい：桜、猫、電車（例） ２．時間および空間の認識：今日は何年何月何日ですか。 いまどこにいますか？（家、診療所など）？ どちらかの質問が間違っている、 または、知らない ３．3つの言葉を思い出せますか？ 3 つの言葉全部を思い出すことが できない 限られた運動能 （第5章） 椅子立ち上がり試験：腕を使わずに、椅子から５回立ち上がる。 14秒以内に椅子から５回立ち上がれたか？ いいえ 栄養失調症 （第6章） 1．体重減少：意図せずに最近3 ヵ月間に、３kg以上減少しましたか？ はい 2．食欲不振：食欲不振がありましたか？ はい 視力障害 （第7章） 眼に何か問題はありますか：遠くを見たり、読書が困難、眼の病気、 現在加療中（糖尿病、高血圧など）。 はい 聴力障害 （第8章） ささやき声が聞こえるか（ささやき声試験）、スクリーニングの聴力検査結果が 35dB以下であるか、または、自動化したアプリを用いた digits-in-noise試験をパスする。 失敗 抑うつ症状 （第9章） 過去2週間、あなたは次のことで悩みましたか？ ◦気分が落ち込む、抑うつ的になる、または絶望的になる？ ? はい ◦何かをすることにほとんど関心がないか、楽しくない？ はい 表1. WHO ICOPE スクリーニングツール 12 ステップ 1 内在的能力の低下を スクリーニングする このガイダンスにあるプロセスとツールを用いて、訓練さ れたヘルスケア従事者は、地域または家庭で内在的能力を 喪失した人々を見つけることができます。そのために、彼 らはICOPEスクリーニングツール（表1）を使用できます。 ICOPEスクリーニングツールは第4 ～ 9章に示される各 ケア手順の第一段階で、内在的能力（5ページの上の図1） の領域を通じて、6つの関連した状態をカバーします。地 域支援戦略（例えば地域保健従事者による自宅への訪問と 携帯電話を用いた自己評価）は、症例を捜し出すのに用い られます。 この第一段階で能力の損失の徴候を示すか、それを報告す る人々は、完全な評価に進まなければなりません。完全な 評価は、必要な訓練を受けたヘルスケア専門家を必要とす ることになりますが、必ずしも医師が行う必要はありませ ん。 医療やケア従事者は、常にICOPEスクリーニングツール で見いだすことができないものがあれば、更に徹底的な評 価を確実に行わなければなりません。評価所見は、個人的 なケアプランの作成に十分な情報を与えるものでなければ なりません。 アルツハイマー病、うつ病、骨関節炎、骨粗鬆症、白内障、 糖尿病と高血圧などのような、基礎疾患の診断はパーソン センタードな評価にきわめて重要です。そのような診断は プライマリケアの診療所で必ずしも利用できない複雑な診 断検査を必要とすることがあります。状況に応じて、第２ または第３レベル（より高度な）の高齢者専門のケアが必 要なケースがあります。 2D． 社会的、身体的環境および社会的ケアと サポートの必要性を評価する 社会的および身体的環境の評価と社会的およびサポート・ サービスのあらゆるニーズを見いだすこといずれもが内在 的能力の喪失のある人々のために必要です。これがプライ マリケアにおける高齢者のパーソンセンタードな評価の本 質的な部分です。社会的ケアのニーズは、他者の援助なし でさまざまな日々の作業を遂行することができるかどうか、 高齢者に尋ねることによって明らかにできます。第10章 のパスウェイは一般に社会的ケア・ニーズを評価して、決 定するための一連の質問を提示しています。さらに、第4 ～ 9章の各治療手順は、治療の優先度により選択しうる社 会的なケア・ニーズの候補を示しています。 ステップ 2 プライマリケアにおけるパーソンセンタードな 評価を保証する 高齢者の健康とプライマリケアにおける医療と社会介護 ケアのニーズに関するパーソンセンタードな評価は、同 時に内在的能力を最適化するために極めて重要です。 2A．高齢者の生活・人生を理解する パーソンセンタードな評価は、従来の病歴徴取だけでな く、個人の生活・人生、価値観、優先順位、彼らの健康 とその管理の過程における嗜好を完全に理解することか ら始まります。 2B． 内在的能力の低下に関連する状態を より深く評価する 評価では内在的能力の喪失と関連する状態もまたより詳 細に評価します。第4 ～ 9章に示される内在的能力の領 域全体を通して鍵となる状態のための治療手順は、3つの 構成要素に大きく分類され、地域におけるスクリーニン グが最初、プライマリケアの評価が中間、個人的なケア プランが最後になります。 2C．基礎疾患を評価し管理する 可能性のある慢性疾患に加えてポリファーマシー（複数 の薬物の使用）の有無を調べる必要があります。 ポリファーマシーと起こりうるいかなる副作用も内在的 能力の複数の領域で喪失を引き起こす可能性があるので、 常にチェックが必要です（Polypharmacy、18ページの BOXを参照）。 13 3 ステップ 3ケアの目標を定義して、個人的なケアプランを作成する 3A．高齢者と一緒にケアの目標を定義する 内在的能力と機能的な能力の最適化に向けた一体的目標は、 包括的ケアを確実にすること、更に介入による高齢者の変 化のプロセスと効果をモニターすることを可能にします。 高齢者と介護者が初めから意思決定と目標設定に関係して いることは必須である－そして、その目的は個人の優先す るもの、ニーズと嗜好によって設定され、優先されます。 3B．ケアプランを設計する パーソンセンタードな評価からの情報により、個々のケア プランが立案しやすくなります。この個々のケアプランに は、内在的能力のさまざまな領域での喪失に対応するため の介入を実行するために、包括的アプローチが用いられま す。すべての介入を検討し、一緒に適用する必要がありま す。 自己管理のサポートは、高齢者に健康状態を 管理し、合併症を予防し、内在的能力を最大 にして、生活の質を維持するために必要とな る情報、技術とツールを提供することを含ん でいます。 これは高齢者が「ひとりでやる」ことを期待 されているとか、彼らに不適切あるいは過剰 な要求が課せられることを意味しているわけ ではありません。そのかわりに、ヘルスケア 従事者、家族や他の介護者との相談や協力関 係の中で、自分の自律性と自分自身のケアを 管理する能力を認識させることが重要です。 WHOの高齢者モバイルヘルス（mAgeing）イニシア ティブは、セルフケアと自己管理をサポートするこ とによって、ヘルスケア専門家の日常のケアを補完 することができます。携帯電話によって健康情報、 アドバイスと注意を送ることによって、健康的な行 動を促し、高齢者がそれらの内在的能力を改善して、 維持するのをサポートすることができます。 mAgeingプログラムのセットアップの方法と参考テ キスト・メッセージに関する情報は以下を参照して ください。 https://www.who.int/ageing/health-systems/が mAgeing. 14 3 一般的なケア手順 プライマリケアにおける パーソンセンタード アセスメントと手順 内在的能力の喪失と関連した大部分の優先度の高い状態に は、同じ基本的な生理的および行動的決定要因があるので、 この包括的なアプローチは重要です。それゆえ、介入はす べての領域に有益となります。例えば、集中的な筋力ト レーニングは、運動機能の喪失を予防する鍵となる介入で す。同時に、筋力トレーニングは間接的にうつ病と認知機 能低下を予防し、転倒予防に役立ちます。栄養は運動の効 果を強化して、同時に筋肉量と筋力を増加させます。包括 的、統一的アプローチを通して、要介護リスクを上げる一 連の因子を改善することができるかもしれません。 個人的なケアプランは以下のような多くの構成要素を持ち ます： ◦ 内在的能力の喪失を管理する多因子介入のパッケージ。 多くのケアプランは、栄養を改善して、運動を促す介入 を含みます； ◦ 基礎疾患、多病と老年症候群の管理と治療。WHOは、 内在的能力の低下に関与する可能性のある関連する慢性 疾患の多くに対処するために臨床ガイドラインを作成し ました。すべてのヘルスケア提供者はこれらのガイドラ インを参照すべきです； ◦ セルフケアと自己管理のサポート； ◦ あらゆる進行した慢性状態（緩和ケア、リハビリテー ション）の管理、または、高齢者が意義と尊厳のある生 活を確実に続けられるようにします； ◦ あらゆる機能的喪失を補うための環境への適応を含む社 会的ケアと支援； ◦ 家族、友人と地域サービスの助けを得ながら、社会的ケ アニーズを満たす計画。 医療および社会的ケア従事者は、地域またはプライマリケ ア環境でのケアプランの実施を支援することができます。 地域のヘルスケア提供者からのアドバイス、教育、励まし に支えられた自己管理で、内在的能力の低下の原因となる いくつかの要因を修正することができます。高齢者、プラ イマリケア従事者、家族や社会が関与するパートナーシッ プは高齢化しても人々のウェルビーイングを維持するもの と思われます。 15 3 一般的なケア手順 プライマリケアにおける パーソンセンタード アセスメントと手順 ステップ 4 高齢者の専門ケアと連携した、紹介手順と ケアプランのモニタリングを確実にする このガイダンスで推奨されている介入を実施するには、さ まざまなレベルとタイプのケアサービスを統合した定期的 かつ継続的なフォローアップが不可欠です。このようなア プローチは、合併症や機能状態の変化の早期発見を促し、 それによって不必要な緊急事態を回避して早期に行動する ことによりコストも節減します。 定期的なフォローアップは、ケアプランに向けた進捗状況 を監視する機会と、必要に応じての追加の支援を提供しま す。フォローアップと支援は、健康状態、治療計画、また は個人の社会的役割や状況の大きな変化（たとえば、居住 地の変更、または配偶者の死亡）の後に特に重要になる可 能性があります。 転倒などの予期せぬ事態が発生した場合の急性期治療、緩 和ケアおよびエンドオブライフケア、または退院後の迅速 なケアを確保するには、強力な紹介手順（システム）が重 要です。 専門的な老年医学的ケアへの連携も重要です。医療システ ムは、人々が必要なときに専門的な急性期ケアに適時にア クセスできるようにする必要があります。専門の急性期ケ ア老年科病棟が、一般的な病院ケアよりも短い入院期間と 低コストで高品質のケアを提供しているという十分なエビ デンスがあります。 老年科専門ケアの役割 老年科専門医は、老年症候群（失禁、転倒、せん 妄など）、ポリファーマシー、認知症などの病気な どの長期にわたる複雑な状態の高齢者に専門知識 を集中させ、日常生活活動に制限のある人々にケ アを提供します。疾病数が年齢とともに増加し、 複雑な臨床像を呈するようになった時には、プラ イマリケア医は老年科専門医に相談すべきでです。 ICOPEアプローチでは、老年科専門医は高齢者の ケアを担当する学際的なチームの一部であり、プ ライマリケアチームの管理を支援し、専門的なケ アが必要な場合に介入します。 16 3 一般的なケア手順 プライマリケアにおける パーソンセンタード アセスメントと手順 ステップ 5 地域一体となって、介護者をサポートする 介護にはしばしば困難が伴い、能力を失った人々の介護者 はしばしば孤独・孤立を感じ、心理的苦痛やうつ病のリス クが高くなります。個々のケアプランには、介護者を支援 するためエビデンスに基づく介入を含めるべきです。介護 者はまた、高齢者の健康状態に関する基本的な情報と、椅 子からベッドに安全に移動する方法や入浴を手伝う方法な ど、ある範囲の実践的なスキルを身につけるトレーニング を必要とします。 高齢者と介護者は彼らが利用できる地域に密着した資源に ついての情報を持っておく必要があります。特にボラン ティア活動を奨励し、地域在住高齢者が貢献できるように することで、地域や近隣地域をより直接的にケアの支援に 関与させる機会を模索する必要があります。このような活 動は、高齢者が集まるような協会やグループでしばしば行 われています。 第11章には、介護者の負担を評価し、自らの介護と支援 をする無給の介護者のニーズに対処するための介護パス ウェイが含まれています。 ICOPEアプローチは、コミュニティまたはプライマリケ アレベルに基づいており、極めて多くの人々が利用できま す。同時に、このアプローチでは、栄養士や薬剤師など、 それを必要とする人々のための専門的かつ三次的なレベル の（高度な）ケアとの強い連携が求められます。 ICOPEハンドブック・アプリ モバイルアプリケーションは、スクリーニングから 評価、個別のケアプランの立案まで、実施するすべ てのステップで、ヘルスケアおよび社会的ケア従事 者をガイドするために利用できます。アプリはまた、 印刷可能なPDF形式でケアプランに含まれる評価と 介入の結果の要約を作成することができます。 17 3 一般的なケア手順 プライマリケアにおける パーソンセンタード アセスメントと手順 ポリファーマシー ポリファーマシーは、一般的に同時に5つ以上の薬を使用するこ とであり、副作用の合併リスクが高くなります。複数の薬剤の使 用は、健康への悪影響のリスクを高め、内在的能力の不必要な喪 失をもたらす可能性があり、緊急入院の原因となることもありま す。複数の医療機関を受診したり、最近入院した高齢者は、ポリ ファーマシーのリスクが高くなります。多病の高齢者は、薬物動 態および薬力学を変化させる可能性のある加齢に伴う生理学的変 化の影響をより受けやすい可能性があります。 ポリファーマシーは、内在的能力の複数の領域にわたる喪失の原 因となる可能性があるため、パーソンセンタードな評価には、高 齢者が服用している薬のレビューを含める必要があります。 ポリファーマシーは、不要で効果のない薬や効果の重複する薬を 中止することで減らすことができます。 適切に処方し、医療過誤を減らす方法： ◦完全な投薬履歴を取得する； ◦薬が能力に影響を与える可能性があるかどうかを検討する； ◦重度の急性疼痛の場合を除いて、診断前に処方しない； ◦定期的に、そして新しい薬を処方する前に処方を見直す； ◦ 処方薬の作用、副作用、薬物相互作用、モニタリング要件およ び毒性を知る; ◦2つ以上の病態の治療に対して1つの薬の使用を試みる； ◦患者のために処方薬説明書を作成する; ◦そして、各薬物について患者と介護者を教育する。 薬物が安全に中止できるか確信がない場合、適切な専門医に紹介 します。 18 4 認知機能 認知機能低下のケア手順 認知機能低下は、もの忘れの進行や注意力の欠失、問題解 決能力の低下を意味します。認知機能低下の正確な原因は わかっていませんが、脳の加齢、病気（たとえば、高血圧 や脳梗塞などの心血管病やアルツハイマー病）あるいは身 体活動の不足や社会的孤立、教育年数と関係しています。 認知機能低下は日常生活に支障をきたし始めると大きな問 題となります、すなわちこれが認知症を発症するというこ とにつながります。 この手順は、認知症ではないが何らかの認知機能低下のあ る高齢者に適用されることが強く望まれます。この方法で 医療従事者は社会的ケアや支援の必要性を検討できるで しょう（第10章を参照）。 キーポイント 認知機能低下はライフスタイルの改善や認知刺激、社会 活動により抑制、あるいは時にはもとに戻すことが出来 ます。 糖尿病や高血圧などの適切な治療は認知機能の低下を抑 制できるかも知れません。 聴力や脚力などの他の能力低下も認知機能に影響を与え うるので同様に評価され、対処されるべきです。 認知症の人に対する多岐にわたる介入を立案、遂行する のには専門家によるケアが必要です。 19 一般的な健康やライフスタ イルに関するアドバイスあ るいは通常のケア 認知機能低下の スクリーニング 認知機能低下なし 認知機能低下なし •栄養障害＊ •せん妄 •ポリファーマシー •脳血管障害 •うつ症状 栄養障害の手順を参照 原因（健康状態、薬物中毒、薬剤の使用）を 同定し、除去する 投与薬剤を見直し、適切に減薬 脳血管病（脳梗塞や一過性脳虚血発作）の 既往を確認し、再発の予防 うつ症状の手順を参照 6 9 PASS 複合的運動 認知刺激（療法）を 行う 認知機能の評価 1 FAIL FAIL 認知機能低下の疑い PASS 関連状態 i 社会的および身体的環境 評価と管理 認知機能のさらなる 低下を予防する 社会的ケアや支援の必要性を評価する 認知機能低下により自立性が障害されている 場合は、mhGAP介入ガイドの認知症の項を参照 https://apps.who.int/iris/handle/10665/250239 日常生活において個別のケアと支援を提供する 自分でトイレに行く手技を維持できるようア ドバイスする 介護者の負担度や苦労度を評価する（介護者 のための手順を参照） 介護者への支援を含めた社会的ケアおよび支 援の計画を立てる 11 10 心血管病とリスク因子＊＊ 評価と管理 簡単な記憶と見当識のテスト １．３つの単語を記憶： これから言う３つの単語を覚えるよう指示してくだ さい。簡単で具体的な単語を選んでください（例： 桜、猫、電車、など）。 ２．時間と場所の見当識： 次に「今日は何年何月何日ですか？」と「いま居る ところはどこですか？（家、病院、など）」を尋ね てください。 ３．３つの単語の再生： そして、さっき覚えてもらった３つの単語を思い出 して言ってもらうよう指示してください。 採点方法 見当識の質問で２つのうち一つでも答えられない か、３つの単語の再生において、すべてを思い出せ ない場合、認知機能低下が疑われ、さらなる検査が 必要となります。 あなたは記憶に問題がありますか？ あるいは場所や時間、例えば今居る場所や 今日は何日かといった質問に答えるのに 問題がありますか？ 質問 ? YES 4.1 4.2 5.1 評価と管理 ＊ ビタミン不足、電解質異常、重度の脱水 ＊＊心血管リスク因子：高血圧、脂質異常症、糖尿 病、喫煙、肥満、心臓病、脳梗塞や一過性脳虚血 発作の既往。 認知機能低下および認知症のリスク軽減について はWHOのガイドラインを参照： https://apps.who.int/iris/handle/10665/312180 疾患群の包括的な管理を提供する 心血管リスクを減じる •禁煙を指導する •高血圧や糖尿病を 適切に治療する •体重コントロールのための 食事療法を提供する YES NO 認知機能低下のケア手順 認知機能 4 20 4 認知機能 認知機能低下のケア手順 認知機能を検査する さらなる詳細の認知機能の評価にはできればその国で検証された 方法を用いるのが望ましいと思われます。右下の表は初期医療の 現場で高齢者に対して用いられる認知機能テストを比較したもの です。 学校教育年数のテストへの影響 認知機能障害のスクリーニングや診断に用いられるほとんどの標 準的な認知機能テストは最低限の学校教育を受けていることを前 提としています。５～６年以下の学校教育年数の場合または教育 を受けていない場合、テストでの評価は困難です。その場合は質 疑応答や臨床的な判断に委ねられます。これらの低教育年数の 人々には（可能であれば）大人のための読み書きのプログラムに 参加することが認知機能の維持に強く推奨されます。 もし標準的な評価ツールがない場合は医療従事者は本人、あるい は本人をよく知る人に記憶、見当識、話言葉に問題がないか、あ るいは仕事や日常生活に支障がないか、を尋ねると良いです。 認知機能テストが出来なかったり、記憶や見当識の障害が訴えら れたら（本人あるいはよく知る人から）、認知機能障害が示唆さ れます。そのような場合は日常生活活動（ADLs, activities of daily living）や手段的日常生活活動（IADLs, instrumental activities of daily living）も評価すべきです。これらの情報は個 別化ケア計画の一環としての社会的ケアおよび支援の計画を練る のに重要です。 認知機能低下が日常生活に支障をきたすようであれば、認知症 あるいはアルツハイマー病（認知症の中で最も多い）などを診断 するためにさらなる検査が必要です。認知症の検査や対処法に 関してはWHO mhGAP intervention Guide を参照。 https://apps.who.int/iris/handle/10665/250239 1 専門的なケアが必要な時とは ・認知症の診断と治療の時 ・せん妄などの関連疾患、脳心血管病が合併する時 Mini-Cog http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf 短時間でできる。言語能力、 教育歴、人種差に左右されな い。 選択する単語の組み合わせに よって点数が異なるかも知れ ない。 2～4分 テスト 長所 短所 時間 Montreal cognitive assessment (MoCA) https://www.mocatest.org/ 軽度認知機能障害を同定しや すい。多言語に訳されている。 教育歴や文化の違いによって バイアスを受ける。公表デー タが多くない。 10～15分 Mini mental state examination (MMSE) https://www.parinc.com/products/pkey/237 広く使われ、研究されている。 年齢や文化によるバイアスや 天井効果がある。 7～10分 General practitioner assessment of cognition (GPCOG) http://gpcog.com.au/index/downloads 教育歴や文化の違いによるバ イアスが少ない。多くの言語 に訳されている。 本人の家族や介護者などから の回答を得るのは若干、難し いかもしれない。 5～6分 初期医療の現場において用いられる認知機能テストの例 認知症とは？ 認知症とは脳内の変化によって慢性的に進行する病気です。認知症は認知 機能の低下をもたらし、洗濯、食事、手洗いやトイレといった日常生活に 支障をきたします。 詳細に関してはWHO mhGAP intervention Guide を参照。 (https://apps.who.int/iris/handle/10665/250239) 21 認知機能低下のケア手順 認知機能 4 4.1 認知症状を呈する病態 可逆性の認知機能低下をきたす病態としては脱水、栄養障 害、感染、投与薬剤の問題があります。適切に対処するこ とにより、認知機能は改善します。 重度の脱水 重度の脱水や他の栄養状態の問題はせん妄（認知症の症状 に似ている）を起こし、ひどい場合、死に至ります。 せん妄 せん妄とは急激かつ強度に、注意を集中できなくなること です。また自分がどこに居るのか、今は何時であるとかが 全くわからず混乱します。せん妄は短時間で発症し、日内 においても症状が出たり、消失したりします。感染症、薬 剤の投与、代謝異常（例えば低血糖や低ナトリウム血症）、 薬物中毒や離脱症状などの急性の全身の病態に起因するこ とがあります。 ポリファーマシー ２つ以上の薬剤の投与は相互作用して有害な副作用（第３ 章、18ページのボックスを参照）を起こすことがありま す。鎮静薬や催眠薬は高齢者において最も認知機能障害を 起こしやすい薬剤です。 評価と管理 関連疾患 可逆的な認知機能低下の医学的原因を明らかにす るには網羅的な診断が必要です。症状を説明する いくつかの原因を並行して考慮することにより迅速 で正確なケアが可能となります。 4 認知機能 認知機能低下のケア手順 認知機能低下の診断プロセスに入る前の重要なステップは、認知機能低下を呈する 関連状態の存在を評価し、まずこれらに対処することです。 大手術と全身麻酔 大手術と全身麻酔はよく知られた認知機能低下のリスクで す。医師は認知機能低下が大手術のあとから起こったのか を聞くべきです。もしそうであるならば、今後、大手術を 受けた後にさらに認知機能低下が起こる確率が高くなる可 能性があります。このリスクについて将来、手術や麻酔の 際には手術チームや麻酔医の間で共有され、議論される必 要があります。 脳血管障害 脳血管障害は認知機能低下に強く関わっています。脳梗塞、 微少梗塞、一過性脳虚血発作の既往のある患者においては、 さらなる発病を予防することが認知機能低下を抑制する第 一歩です。 22 認知機能低下のケア手順 認知機能 4 4 認知機能 認知機能低下のケア手順 • 認知機能低下のある人は認知刺激療法によって効果を 得ることが出来ます。 • 他のICOPE介入、例えば複合的運動（第5章、移動能 力の低下を参照）も脳の健康に役立ちます。 • 認知機能以外の内在的能力のうち、特に聴力、視力、 気分の変化は認知機能に影響を与えます。最大の効果 を得るためにはこれらも対処される必要があるかもし れません。認知機能低下のある人はこのような他の能 力が様々な形で低下しています。 4.2 認知刺激療法 認知刺激療法は認知機能の低下を軽減するかもしれません （7）。認知刺激療法は認知活動や想起、複数の感覚刺激や 他の人との関わりを通じて参加者を刺激します。 認知刺激療法は個別あるいはグループで行われます。グ ループの方が良い場合があります：グループにおけるお互 いの繋がりが役立つかもしれません。また健康増進などの 共通の目的がある場合はグループの方が適しており、かつ 有効かもしれません。 標準的なグループでの取り組みは一週間に２回、１回45 分で７週にわたって行われます。案内役がこれらの集まり を先導します。典型的には、１回の集まりは認知機能とは 関係のない軽いウォームアップで始まり次に認知機能に関 係する課題に移ります。 その課題はたとえば、場所や日付、時間などの情報を描い たボードなどを用いた見当識を尋ねるものを含みます。毎 回の集まりでは異なる話題について行われます。たとえば、 子供のころの話、お金の使い方、顔や景色についてなどで す。これらの集まりでは一般的に事実の想起は避けられ、 その代わりに「これらの（単語あるいはモノ）に共通した ものは何ですか？」といった質問が行われます。 誰が認知刺激療法を行えるか？ 先進国においては認知刺激療法を行うのは精神科医や臨床 心理士です。あるいは適切に訓練された非専門家がサポー トを受けながら、行うこともできます。しかし、認知機能 低下が顕著な人に対してより個別化の介入を提供する場合 はより詳細な検討と計画が必要であり、専門的なスキルが 要求されます。それゆえ、認知刺激療法を行うに当たって は精神科医などの専門家への照会に関する基準を個々のプ ロトコルに含むべきです。 家族と介護者は認知刺激において重要な役割を果たすこ とができます。家族や介護者に、今日は何曜日であるとか、 日付、天気、時間、人の名前などについての情報を日常的 に与えるよう促すことが重要です。この情報によって高齢 者が時間や場所についての見当識を保つのに役立ちます。 また新聞やラジオ、テレビの番組表、家族のアルバム、家 財道具などの現物を見せたり触ったりすることも、コミュ ニケーションを促進し、高齢者に最近の出来事にも関心を 持たせ、記憶を刺激し、自分たちの経験をシェアしたり、 価値を認めたりするのに役立ちます。 認知機能低下 の管理 5 23 認知機能低下のケア手順 認知機能 4 認知機能低下により自立性に制限が生じると、社会的ケア を受ける必要性が高まります。医療従事者は介護者に患者 の日常生活のケアの立案に助言を与えることにより、患者 の自立性を最大化し、機能を向上させ、スキルを獲得させ、 支援の必要性を最小限にします。 家族と介護者は以下のことができます • 今日の日付、近所のイベント、訪問者がだれか、どの ような天気か、家族の最近の出来事などについての情 報を提供します。 • 友人や家族と家や近所で会えるよう勧めたり、アレン ジします。 • 転倒や怪我のリスクを軽減できるよう自宅を安全にし、 その状態を保ちます。 • 自宅において、たとえば、トイレ、寝室、外への扉、 などといった標識（掲示板）を貼り、本人の行きたい 場所に行けるようにします。 • （本人の能力に合わせて）仕事（職業的活動）を調整し てあげたり、一緒に手伝います。 評価と管理 社会的および身体的環境 重度の認知機能低下の人をケアする介護者は厳しい 要求に答えなければなりません。このストレスは介 護者の健康に影響を与えます。介護者のニーズに答 えるには第11章を参照。 11 24 運動機能を改善するための ケア手順 5 移動能力 運動機能はヘルシーエイジングにおける重要課題です。自 分で移動ができ、要介護にならないことは非常に重要です。 各個人において、ある場所から他の場所に移動する身体能 力は「locomotor capacity=移動能力」と呼ばれます。 多くの高齢者とその家族は、移動能力の低下を受け入れざ るを得ず、それに伴う苦痛は避けられないと考えています。 しかしそれは違います。実際に高齢になっても運動機能を 維持、向上する効果的な方策は存在します。 キーポイント 運動機能の制限は多くの高齢者で共通にみられますが、 決して避けられないものではありません。 地域におけるヘルスケアワーカーは簡単なテストで運動 能力の低下をスクリーニングできます。 高齢者それぞれの能力と必要性に即した習慣的な運動プ ログラム設定が、移動能力を維持、向上するために最も 重要です。 移動能力が低下した高齢者においても、環境を整え且つ 補助器具を用いることは運動機能維持に最良の手段です。 25 運動能力 の評価 汎用されている健康や生 活習慣に対する助言や一 般的なケアを強化します （SPPBまたは 他の身体能力テスト） 上肢を使わずに14秒間に 5回の椅子からの 立ち上がりが可能 スクリーニング 運動能力低下の評価 椅子からの立ち上がり 処方の見直しと 処方薬の削減 包括的な疾患のマネジメント 疼痛のマネジメントの考慮 ‒ ポリファーマシー ‒ 変形性関節症、骨粗鬆症＆ その他の骨、関節の制限 ‒ フレイル＆サルコペニア ‒ 痛み 緻密な監督下の複合的運動を提供 リハビリテーションへの紹介を考慮 たんぱく質摂取の増量を考慮 運動機能を補助する器具の提供を考慮 在宅での複合的運動を推奨 アドヒアランスの向上のための 自己管理をサポート 5.3 5.2 5.4 5.5 5.6 1 2 正常な運動能力 （SPPBスコア 10-12点） 低下した運動能力 （SPPBスコア 0‒9点） 付随状況 評価とマネージメント 社会的&身体的環境 評価とマネジメント 特別なケアが必要 移動能力 5 運動機能を改善するための ケア手順 身体的環境を評価し転倒リスクの軽減 自宅の改装などの転倒防止策 の遂行 移動能力を助ける器具の提供を考慮 歩行のための安全なスペースを提供 複合的運動 運動能力が制限されている人達への複合的運動プ ログラムには、全身運動と重要な筋肉群（背筋、 大腿、腹部、下半身）への特化した交差運動を組 み合わせます。 複合的運動プログラムは、個々の能力と必要性に 合わせたテーラーメイドのものにすべきです。 “Vivifrailプロジェクト” は、個々の能力に適し た運動プログラムを設定できるように開発されて います。 http://www.vivifrail.com/resources WHOの身体能力への国際推奨項目については、 30ページのboxを参照下さい。 5.1 NO YES NO to all YES 26 簡易にできる身体能力評価セット （SPPB） 様々な身体能力検査がありますが、その評価基準が優れている 点とカバーする身体能力の範囲の点からSPPBが推奨されます。 所要時間を計測するSPPBは3種類の4点満点のタスクから成 り立っており、0点（最低）から12点（最高）までの評価が可 能です。 まずそれぞれのテストにおいて、それができそうか、できなさ そうかを聞きます。もしできなさそうでしたら、その旨の点数 をつけて次のステップに進みます。 1．バランステスト：両足を右図のそれぞれのポジションに置 き、10秒間立ってもらいます。それぞれのポジションにお ける点数を合計します。 2．歩行スピードテスト：4m歩行の時間を計測： < 4.82秒 4点 4.82 ‒ 6.20秒 3点 6.21 ‒ 8.70秒 2点 > 8.70秒 1点 不可 0点 3．椅子からの立ち上がりテスト： 5回の椅子から立ち上がりの時間を計測 < 11.19秒 4点 11.2 ‒ 13.69秒 3点 13.7 ‒ 16.69秒 2点 16.7 ‒ 59.9秒 1点 > 60秒 または 不可 0点 1 2特殊なケアが必要な場合 移動能力は、他の内在性要素（認知機能、活力、心理的能力） とともに評価されるべきです。もしも身体的、精神的機能に明 らかな低下があったり合併症を有している場合、運動内容の決 定はより複雑になります。専門家の知識を基に適切な運動プロ グラムの設定が必要です。リハビリテーション科への紹介も考 慮されるべきです。 A. 両足揃え起立 10秒起立可 1点 10秒未満起立可 0点 不可 0点 もし実施しようとすることも無理で あればバランステストは終了 B. 半足ずらし起立： 4m歩行の時間を計測： 10秒起立可 1点 10秒未満起立可 0点 不可 0点 もし実施しようとすることも無理で あればバランステストは終了 C. 継ぎ足起立： 4m歩行の時間を計測： 10秒起立可 2点 3～9.99秒起立可 1点 3秒未満 0点 実施不可 0点 この簡単なテストで高齢者が低下した移動性についてさらなる 評価が必要かどうか判断できます。 まず最初に：「手を使わずに5回椅子から立ち上がることがで きそうですか？」と聞きます。（指示者がまずやって見せます） 答が「はい」の場合、以下を指示します： ‒ 椅子の真ん中に座って下さい ‒ 胸の前で腕を交差させます ‒ 完全に立ち上がってまた座ります ‒ これを休むことなくできるだけ早く5回繰り返します このテストにかかった時間を測ります。もし、14秒以内に5 回の立ち上がりができなかった場合は、更なる評価を行います。 椅子からの立ち上がりテスト 最終のSPPBスコア = 上記の3件のテストからの得点の合計 SPPBテストに関する情報 http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstructions_scoresheet.pdf 運動機能を改善するための ケア手順 5 移動能力 27 移動能力 5 運動機能を改善するための ケア手順 椅子からの立ち上がりテストはこれらのテストの一つです。 これは他の２つのテストの後に実施するとよいでしょう。 • バランステスト – それぞれの足の位置で10秒起立を続 ける • 歩行速度テスト – 4mを何秒で歩けるかを測定する それぞれのテストのスコアは総計されます。低い総得点は 移動能力の低下を意味します。得られた総得点に従い、そ の後の方針は２つに分かれます。 評価テストについての更なる情報といかにスコア化するか については、前のページをご参照下さい。 特殊なケアが必要な場合（追加情報） 特別なケアは以下の高齢者に必要です • 精神状態や他の機能に影響を与える持続的疼痛 • 関節の重大な障害 • 軽微な外傷による骨折 • 安全な実施を妨げるリスク（次ページの BOX） • 移動のために適切な補助用具の選択が必要な場合 移動能力は3つの簡単なテストからなる各個人のパフォー マンススコアから十分な評価が可能です。これらのテスト は「簡易版身体能力評価セット（SPPB）」として知られて います。 評価 移動能力 28 運動機能を改善するための ケア手順 5 移動能力 5.1 複合的運動プログラム 移動能力の低下した高齢者へ、複合的運動プログラムは 個々の能力や必要性に合わせて最適化されるべきです。 移動能力の低下した高齢者への複合的運動プログラムには 以下が含まれます： • 筋力/負荷を加えたトレーニング これらはダンベル・ バーベル、ゴムバンド、さらにスクワット、足の踏み 込み、椅子からの立ち上がりといった自分の体重を抵 抗とした運動が含まれます。 • 有酸素/心肺機能トレーニング これには少し息が切 れますが、会話は可能といったレベルまで心拍数を上 げる早い歩行や自転車漕ぎが含まれます。 • バランストレーニング バランス機能を鍛えるもので す。これには静的なものと動的なものがあります。ま た個々の状況に応じて開眼、閉眼で行うことがありま す。例として片足立ちや一本の線の上を歩くタンデム 歩行などが含まれます。 • 柔軟トレーニング 筋肉や関節可動域といった軟部組 織の伸展性を向上させるものです。これにはストレッ チ、ヨガ、ピラティス運動などが含まれます。 栄養 たんぱく質摂取量の増量と他の栄養に関する介入は 運動プログラムによる効果を高めてくれます。 第6章：低栄養を参照して下さい。 運動における安全 運動プログラムを計画したりアド バイスしたりする場合、運動の強度や時間に関連する 高齢者の健康状態を確認すべきです。 もし高齢者が以下の質問のどれかに「はい」と答えた 場合、熟練した医療スタッフが個別に運動プログラム を設定するべきです。 • これまで安静時に胸痛を感じたことがありますか？ • この6か月の間に心臓発作がありましたか？ • これまで気が遠くなったり、意識を失ったことは ありますか？ • この１年間で転倒しましたか？ • この１か月間で骨折しましたか？ • 自宅での衣類の着脱などの一般的な日常生活活動 で息が切れますか？ • 関節や筋肉の病気で運動に制限がありますか？ • 医療従事者から運動を制限すべきだと言われてい ますか？ Vivifrail プロジェクトは個別の運動プログラムの設 定のために実践的な手引きをいたします。 http://www.vivifrail.com/resources 6 管理 低下した移動能力に対し 29 移動能力 5 運動機能を改善するための ケア手順 運動の制限 もし痛みが可動性を制限している場合、遂行 可能な単位時間からなるペースで身体運動を行うことが身 体の抵抗性を増し、痛みを抑えることに繋がります。運動 機能が高度に低下している高齢者ではベッド上や椅子に 座って運動を開始することも考慮します。認知症などで認 知機能が低下している高齢者においてはより簡易でフレキ シブルな運動プログラムが推奨されます。 5.2 運動の自己管理へのサポート 自己管理のサポートは複合的運動プログラムの継続とそれ により得られる効果を向上させます。SPPBスコアが 10-12の高齢者は自宅や地域コミュニティでの運動が可能 です。運動機能がより落ちている高齢者は運動中の見守り やガイダンスが必要です。 WHOのmobile health for ageing （mAgeing） handbook では、スマホアプリが自己管理、自己マネジメントをサ ポートすることにより、いかに医療従事者のルーチンケア を補ってくれるかを説明してくれます。 更なる情報 http://www.who.int/ageing/health-systems/mAgeing WHO の身体活動に対する国際的推奨 全ての高齢者は、個々の健康状態を考慮し年齢に 応じた身体活動へのアドバイスにより大きな利益 を得られるでしょう。以下の項目は65歳以上の高 齢者の身体活動に対するWHOの国際推奨になりま す。 毎週少なくとも150分間の中強度の有酸素運動 か最低75分間の高強度の有酸素運動またはそ れに相応する運動の組み合わせ １回に最低10分間の運動 より効果を高めるため、週あたり300分間の中強 度の有酸素運動または150分間の高強度の有酸素 運動またはそれに相応する運動の組み合わせ 筋肉強化の運動を週２回あるいはそれ以上 もし運動能力が十分でなければ、バランス強化 の運動を週３回あるいはそれ以上 もし推奨どおりに運動ができなければ、個々の できる範囲での実施 更なる情報 http://www.who.int/dietphysicalactivity/pa/en/index.html 30 運動機能を改善するための ケア手順 5 移動能力 5.3 ポリファーマシー 一部の薬剤は移動性を低下させたり、バランスを低下させ る可能性があり、一部の高齢者には不要で且つ有益な効果 がない可能性があります • 抗てんかん薬 • ベンゾジアゼピン系薬 • 非ベンゾジアゼピン系睡眠導入薬 • 三環系抗うつ薬 • 選択的セロトニン再取り込み阻害薬（SSRI） • 抗精神病薬 • オピオイド 不必要で効果がない薬剤の服用を中止するのに加え、同一 の効果を持つ複数の服用薬剤を減薬することが必要です。 もし服用薬剤を安全に中止できるか疑問が生じた場合は、 適切な専門家の意見に従いましょう。 5.4 疼痛 疼痛評価 動きに伴う激しい疼痛により、運動を制限さ れたり、できなくなったりします。そこで疼痛の強さを客 観的に評価することが必要です。疼痛の評価は運動プログ ラムの設定と疼痛のマネジメントに活用します。簡易な疼 痛評価は以下のwebsiteで可能です。 https://www.aci.health.nsw. gov.au/__data/assets/ pdf_ file/0015/212910/Brief_Pain_Inventory_Final.pdf 疼痛管理（9） 筋骨格系における可動性の障害はしばしば持続 性の疼痛を伴います。しかし、持続性疼痛に対する特定の生物 学的原因が明らかになることはまれです。したがって疼痛管理に おける最善の方法は、疼痛と複数の要因に対し適切な対処をす ることです。複数の要因には身体的要因（筋力、関節可動域、 我慢できる範囲）、精神的要因、栄養、睡眠などが含まれます。 もし疼痛が、運動と活動性に最大の障壁になっている場合は、 疼痛管理の専門家によるマネジメントが必要になってきます。 痛みへの介入には以下があります： • 自己管理 5.2 • 運動や他の身体活動 • 使用薬剤には、アセトアミノフェン、非ステロイド系抗炎 症薬、ガバペンチン、オピオイドなどが含まれます。 • マッサージ、関節徒手整復、関節可動化などの徒手療法 • 心理療法と認知行動療法 （うつ症状には第 9 章を参照） • 鍼治療 • 脊椎注射 / 硬膜外注射 • ラジオ波除神経 これらの介入法の中でいくつかは地域内で可 能です。地域内で可能でないものについては 医療機関などのアドバイスを得て行います。 9 評価と管理 関連状況 31 移動能力 5 運動機能を改善するための ケア手順 移動能力に制限のある高齢者は毎日の日常生活に介助が必 要な時があります。その際にはまずソーシャルケアの必要 性についての評価が必要です（第10章を参照）。移動能力 に制限のある高齢者に対する特別なソーシャルケアの選択 には、身体的環境の確認や補助用具の必要性を明らかにす ることが重要です。運動プログラムは転倒予防に寄与する ことでしょう。 5.5 転倒リスクを抑えるための 身体的環境の評価 身体的環境の評価の中に、自宅の周りを確認し危険がない かを確認し、アドバイスすることが含まれます。例として、 散らかっているものの整理、滑りやすい床マットの撤去、 床や階段のでこぼこの除去、家具を移動し障害のない広い 空間の形成、照明の改善、特に夜間におけるトイレへのア クセスの改善（壁への手すりの設置など）。階段を登れな い高齢者や車椅子利用者に対し玄関への通路にスロープを 付けることが推奨されます。移動に制限をもつ高齢者が環 境にいかに適応していくか援助することが最も重要です。 特別な講習を受けた後に、地域や施設に所属するヘルスケ アの専門職は各個人の自宅の評価をします。もし実際の訪 問が不可能な場合、プライマリケアを担当するケアワー カーが高齢者本人や介護者にどのように安全な家庭環境を 構築するかの一般的なアドバイスを行います。 高齢者の転倒リスクについての十分な評価や環境整備 には特殊な知識が必要です。 5.6 補助器具の考慮と提供 移動に制限を持つ高齢者は移動時の補助器具が必要かもし れません。補助器具の第一の目的は、個々の身体機能と自 立性を維持・向上させ、日常の諸事への参加を促進し、全 体的な健康度を向上させることです（10）。補助器具には 杖、松葉杖、歩行器、車椅子、義肢装具が含まれます。補 助器具に関しては、その価格や入手が可能かどうかによっ て選択の幅が狭まることがあるかもしれませんが、もし可 能であれば、医療者で補助器具に詳しい人から良いアドバ イスを得て、より適切なものを選び、その安全な使用法の 指導を受けることが望まれます。 内因性の体力低下は転倒のリスクを高めます。身体的環 境さらには課題や活動のやり方がリスクを左右する要素 になります。 身体的環境の評価に加え、転倒の評価には以下の項目が あります： • 転倒の既往をその起こった状況も含め注意深く聞く こと ; • 歩行、バランス、移動能力、筋肉と関節の機能、柔 軟性の評価 ; • 転倒の恐怖、視力、認知機能、心血管と神経機能の 状態、排尿さらに夜尿（夜間の排尿のための起床） • ポリファーマシーになっていないか処方の確認（プ ランの作成に第 3 章を参照） 高齢者によってはさらなる評価と問題への対応が必要に なります。それには失神（眼前暗黒感）、てんかん、パー キンソン病のような神経変性疾患が含まれます。 評価と管理 社会的＆身体的環境 32 6 活 力 栄養障害に対する ケア手順 WHOでは個人の内在的能力に寄与する生理学的要因を活力 （vitality）という言葉で表現しています。この活力にはエネ ルギーバランスと代謝が含まれる場合があります。このハ ンドブックは、高齢者の活力が低下する主な要因の1つであ る栄養障害に焦点を当てています。 キーポイント プライマリケア医療従事者は、栄養状態の初期評価を簡 便に実施できます。この評価は高齢者の健康状態の評価 の一部である必要があります。栄養状態の完全な評価に は専門知識と時には血液検査が必要です。 不十分な栄養と身体活動の低下の両方が筋肉量と筋力の 低下につながります。 十分な量のバランスの取れた食事は通常高齢者に必要な ビタミンとミネラルを提供しますが、ビタミンDとB12 の不足が起こりがちです。 栄養障害はしばしば体重減少につながりますが、常にで はありません。 筋肉は脂肪に置き換わりますが、その際には体重の変動 はありません。 栄養障害のもう1つの側面は肥満ですが、このガイダン スでは取り上げていません。 33 過去3カ月で3kgを超える 意図しない体重減少が あったか？ 食欲不振があったか？ ? ? 栄養状態良好 （MNA score: 24‒30 points） 栄養障害のリスク （MNA score: 17‒23.5 points） 栄養障害 （MNA score: < 17 points） ―急性イベントや疾患の後 ―地域在住高齢者（年一回） ―要介護高齢者（3カ月に一回） 栄養状態 のアセス メント 問い NO NO （どちらかの問いで） YES 栄養指導の提供 十分な食事摂取ができないなら 経口栄養補助を考慮 体重の頻回なモニタリング 複合運動介入を考慮 栄養介入が必要 たんぱく質を強化した 経口栄養補助の投与 （400‒600kcal） 栄養指導の提供 体重の頻回なモニタリング 再評価 例：Mini nutritional assessment（MNA）（8） 経口栄養補助 経口栄養補助（oral supplemental nutrition：OSN）は 高品質たんぱく質、エネルギーならびに適切なビタミ ン、ミネラルを個々の必要度、嗜好、身体機能状態に 合わせて補給するものである。 i 一般的な健康とライフスタイルの アドバイスまたは通常のケアの強化 一般的な健康とライフスタ イルのアドバイスまたは通 常のケアの強化 社会的ならびに身体的環境 評価と管理 健康のための栄養摂取に関する障壁を取り除く 家族とのそして地域での食事会を推進する 食事の準備や提供を支援する 6.2 6.3 6.2 併存するコンディション 評価と管理 ―フレイル ―サルコペニア 1 1 2 1 疾病の包括的管理 筋肉機能の改善のための リハビリテーションを考慮 スクリーニング 地域高齢者の栄養障害 評価のため 特別なケアが必要 6 活 力 栄養障害に対する ケア手順 34 6 活 力 栄養障害に対する ケア手順 栄養提供に関するアドバイス •プライマリケア医療従事者は高齢者に健康的な食事を勧めた り、アドバイスすることができます。特別なケアが必要かどう かにかかわらず、栄養障害のリスクがある、または低栄養の影 響を受けている人を含めすべての高齢者はこのアドバイスの恩 恵を受けることができます。食事の際や食事の合間に、毎日何 を食べたかを記録すると、健康的な食事を摂りやすくなりま す。 •入手可能で、十分なエネルギー（炭水化物）、たんぱく質、およ びビタミンやミネラルなどの微量栄養素に富む食品を教えてあ げてください。またこれらの食品の適切な摂取量についてアド バイスしてください。 •たんぱく質の吸収は年齢とともに減少するため、高齢者には十 分なたんぱく質を摂取するように指導してください。健康な高 齢者には、体重1kgあたり1.0～1.2gのたんぱく質摂取が推奨さ れます。体重減少や急性の病気や外傷があるケースでは、体重 1kgあたり最大1.5gを必要とする場合があります。高たんぱく質 摂取は糸球体内圧の上昇と糸球体の過剰濾過につながる可能性 があるため、腎機能を確認する必要があります。 •筋肉内で筋たんぱく質の合成を促し、食欲の増進につながる身 体活動を指導してください。 •皮膚でのビタミンD生成を促進するために日光に当たることを促 してください。食品中のビタミンDだけでは、高齢者が最適なレ ベルを維持するのに十分ではありません。ビタミンDレベルが適 切かどうかは血液検査が必要です。 •多くの場合、高齢者は十分な食事量を食べていません。高齢者 がより多くの食事を摂取できるように、特に一人暮らしの高齢 者や社会的に孤立している高齢者には、孤食ではなく家族や仲 間と一緒に食べるような場（ソーシャルダイニング）をできる だけ提供、提案してください。 1 専門知識が必要な場合 地域および医療・介護施設のプライマリケア従事者は、すべて の高齢者が健康的な食事摂取を維持できるようにアドバイスと 支援をします。栄養障害またはそのリスクがある人々は、その 原因と危険因子を同定し、個別の栄養計画のための専門知識を 備えた専門家が必要です。 必要に応じて、現在の栄養状態が適切であると思われる場合で も、栄養障害の根底にある、または栄養障害につながる可能性 のある状態の評価や情報を取得します。これらの栄養障害に関 連する状態・兆候とは、消耗状態、急激な体重減少、口腔内の 痛み、嚥下困難・嚥下時の痛み、慢性的な嘔吐または下痢、お よび腹痛の存在が含まれます。 優れたツールが利用可能です（11）。 その例： 栄養状態のアセスメント 2 覚えておいてください！ 医療従事者は、上記のアドバイスを高齢者だけでなく、家族や 他の介護者にも知らせる必要があります。 Mini nutritional assessment (MNA) (8) DETERMINE nutrition risk assessment (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire (https://www.flintbox.com/public/project/2750/) Short nutritional assessment questionnaire 65+ (SNAQ65+) (http://www.fightmalnutrition.eu/toolkits/ summary-screening-tools). 見開きページのケア手順では、mini nutritional assessment（MNA）を使用しています。 35 6 活 力 栄養障害に対する ケア手順 ほとんどの栄養評価ツールでは次のことについての問いが 含まれています。 ◦食物と水分の摂取 ◦最近の体重減少（疾病診断の時の質問と同様） ◦移動能力 ◦最近の精神的ストレスまたは急性疾患の有無 ◦心理的な問題 ◦生活状況 また、次の内容に関しても記録します。 ◦体重 ◦身長 ◦body mass index（BMI – weight in kg/height in ㎡） ◦上腕や下腿周囲長 栄養状態の 評価 身体組成と老化 通常、約70歳を過ぎると筋肉量が減少し、活力に 重要で潜在的に有害な影響を与える可能性があり ます。不十分な栄養と不十分な運動の両方が、筋 肉量と筋力の低下につながります。 老化に伴い体重が減少するか、または変化がない 場合もありますが、老化に伴い脂肪量が増加しや すくなることにより、老化に伴う有害な変化をマ スクしている可能性があります。したがって、栄 養不良の人で除脂肪組織の喪失があっても、許容 範囲またはむしろ高いBMI値を示す可能性があり ます。 訓練を受けた非専門家でも、握力を測定するため の握力計などのツールを使用して骨格筋機能、た んぱく質欠乏性栄養障害を評価することが可能で す。握力が低いということは、運動とより多くの たんぱく質を含む食事の必要性を示しています。 36 6 活 力 栄養障害に対する ケア手順 6.2 栄養障害のある高齢者に対して 栄養障害（たとえば、MNAスコアが17未満）と特定され た人の場合、栄養介入をすぐに開始する必要があります。 プライマリケア医療従事者はすぐに標準的な食事療法のア ドバイスの提供が可能です（35ページのボックスを参照）。 専門知識のある医療従事者は、できるだけ早く食事療法の アドバイスを提供し、必要に応じて経口的栄養補助を提供 する必要があります（以下を参照）。 栄養介入は、移動能力の低下など内在的能力の他の領域に 対処する別の介入とともに、栄養不良の原因となる根本的 な要因に対処する包括的なケアプランの一部である必要が あります。特に適切なエネルギーとたんぱく質の摂取によ り、複合的な身体運動プログラムがより効果的になります （移動の制限については第5章を参照）。 経口栄養補助 経口栄養補助剤（食品）（OSN）には、追加の高品質のた んぱく質、カロリー、および適切な量のビタミンとミネラ ルが含まれます。個人のニーズ、嗜好、身体的制限に合わ せたOSNの計画を立てるには、専門知識が必要です。こ の評価により、栄養豊富な食品、ビタミンまたはミネラル のサプリメント、または特殊な市販製品または非市販の栄 養製剤（食品）のいずれかから、最適なサプリメントの方 法を選択できます。 感覚障害（味覚と嗅覚の低下）、咀嚼障害や嚥下困難など の口腔の健康状態の悪化、孤立、孤独、低所得、複雑な長 期慢性状態はすべて、高齢者の栄養障害のリスクを高めま す。 6.1 栄養障害のリスクがある高齢者に 対して 栄養障害のリスクがある高齢者（たとえば、MNAスコア が17～23.5）は、栄養に関するアドバイスの恩恵を受け ることができます（35ページのボックスを参照）。栄養障 害を発症するリスクのある人は、その予防のために、栄養 介入の実施が望ましいです。 高齢者栄養障害に対する 栄養管理 5 37 6 活 力 栄養障害に対する ケア手順 地域の医療従事者は、OSNを使用している人をサポート およびモニターすることが可能です（ボックスを参照）。 血液検査 血液検査は、個々の栄養計画に有用です。血液検査は、不 足しているビタミンやミネラルを特定することができます。 特定の経口栄養補助剤（食品）または注射薬は、これらの 欠乏を治療することができます。たとえば、よくあるビタ ミンDとB12の欠乏症を治療するには、錠剤や注射薬の使 用が必要です。 経口栄養補助は人が十分なカロリーと栄養密度の 高い通常の食品を摂取できない場合、またはカロ リー摂取量を増やすために通常の食事に加えて一 時的な方法として使用すべきです。 OSNのキーポイント まずは食事のことを最初に考えます。OSNの 必要性が緊急でない限り、可能であれば食事 療法の改善、およびより頻繁な食事を最初に 試す必要があります。 OSNはそれらの食事に追加しての使用を考慮 します。OSNは食事に取って代わるべきでは ありません。OSNを使用している人ではでき るだけ食事を継続する必要性を理解する必要 があります。 OSNをどのように組み合わせるか、一度にど れだけ使用するか、いつ使用するかについて の指導が必要です。 OSNは食事の時間ではなく、食事の合間に使 用する必要があります。 OSNを継続して摂取し、可能な限り食事を続 けるために家族、介護者、医療従事者からの 継続的な支援と励ましを必要とすることがよ くあります。 しばらくすると、ある種のOSNの味や食感に 飽きてくるかもしれません。さまざまなフレー バーを試したり、種類を変更することが役立 つ場合があります。 体重は定期的にモニターし記録する必要があ ります。 理想的には栄養障害のリスクがなくなり、食 事から適切な栄養が摂取でき、OSNの中止が できることを目標とします。 38 6 活 力 栄養障害に対する ケア手順 評価と管理 関連状況 6.3 サルコペニアとフレイル サルコペニアとフレイルは、栄養不良に関連する可能性の ある病態です。より良い栄養と運動を含むライフスタイル の介入は、両方を予防、治療できる可能性があります。 サルコペニア サルコペニアは筋肉量、筋力、および身 体機能が低下している状態を表します。それは、疾病、栄 養不良、または身体活動の不足（たとえば、長時間ベッド に横たわっている）に起因する可能性があります。または、 明らかな原因がなく、老化プロセスに関連している可能性 もあります。 フレイル フレイルとは体重減少、筋力低下、身体活動 量の低下、倦怠感、および動作緩慢（歩行速度の低下な ど）を伴う状態を指します。フレイルはトラウマ、病気、 身内との死別などのような身体的または心理的ストレスか ら生じる場合もあります。フレイル状態は放置しておくと 身体機能が低下し、要介護状態になる可能性があります。 評価と管理 社会・身体的環境 介護者や地域社会は、高齢者の栄養状態の悪化に関係する 障壁を除去することができるかもしれません。たとえば、 地域にある様々な組織は高齢者向けの交流会での食事イベ ントを企画することもできます。 地域の医療・ケア従事者は地域高齢者の食料品の入手、財 政・収入支援や、食事を準備するための支援を促進したり、 地域の宅配サービスなどを介して給食や弁当を高齢者に供 給したりすることができます。 39 40 7 視覚障害に対する ケア手順 視覚機能 視覚は内在的な能力の重要な要素であり、人々が移動した り、仲間や環境と安全に交流したりすることを可能にしま す。視覚障害の原因には、近視や遠視、白内障、緑内障、 黄斑変性症など、加齢とともに多くなるものがあります。 視覚障害があると、家族やその他の社会的関係の維持、情 報へのアクセス、安全な移動（特にバランスと転倒のリス ク）、手作業の遂行が困難になります。このような困難は、 不安や抑うつにつながる可能性があります。 視覚の評価は、パーソンセンタードな評価の重要な要素で す。 キーポイント プライマリーケアや保健活動に従事する専門職は、簡単 な視力検査を行うだけで、視力が著しく低下しているか どうかを調べることができます。 視覚障害を有する人の多くは、その治療が可能です。診 断されている眼疾患の有無を尋ね、評価し、確認するこ とが重要です。 眼鏡は、近視や遠視による視力低下を補正することがで きます。 補助器具（拡大鏡、望遠鏡）により、眼鏡では矯正でき ない視覚障害の方をサポートすることが可能です。 家庭や地域社会では、照明を改善するなどの簡単な方法 で、視覚障害を有する高齢者の機能的な能力を向上させ ることができます。 41 7 視覚機能 視覚障害に対する ケア手順 特別なケアが必要 遠くを 見る 近くを 見る 視覚障害および眼疾患の評価＊ 眼疾患の治療 視覚障害の管理 眼鏡の処方箋の見直しと更新、または新しい眼鏡の提供 机や携帯電話の拡大鏡などの補助視覚装置を含む、目のリハビリテーションを 考慮する NO YES 既製の簡易老眼鏡で 解決できるのか？ FAIL 1 2 3 4 心血管危険因子の管理 毎年、専門の眼科を紹介して 網膜チェックを行う 目の副作用を防ぐための 薬の見直し 視力低下時の日常生活に関する アドバイス 転倒防止のための住宅設備の導入 （照明､色のコントラスト） 通常の歩行経路から危険を除去 YES －高血圧 －糖尿病 －ステロイドの使用 質問 遠くが見えにくい、読みにくい、 目の病気、現在治療中など、目に何か問題が ありますか？（例：糖尿病、高血圧）? 再検査 視覚障害がなくても 毎年検査を繰り返す 視力検査 WHO簡易アイチャートを 使って －近くを見る視力検査の前に必ず 遠くでの視力検査をする －眼鏡をかけていない状態での テスト －片目ずつテストし、次に両眼の テストをする 評価と管理 関連条件 評価と管理 社会的・物理環境 FAIL YES 視覚障害（14） 遠視の障害 •軽 度－視力が6/12より悪い •中程度－視力が6/18より悪い •重 度－視力が6/60より悪い •盲 目－視力が3/60より悪い。 近視の障害 •既存の補正で近見視力がN6より悪い、 またはM.08 i 7.4 7.5 7.9 7.10 遠方の視力が低下した場合は、必ず 包括的診療科への紹介が必要です。 老眼鏡の提供 アイケアやライフス タイルに関するアド バイスを強化し、人 や環境に応じた視覚 衛生上のアドバイス を提供する。 42 7 視覚機能 視覚障害に対する ケア手順 WHO簡易視力チャートで遠近感を測る Eが指す方向を示して、Eテストのやり方を人の近くで実演する。小さ なEから大きなEまでテストする。 1. 4つの小型Eを3mの位置に置いてテストする。 7.1 視力は、小さなEの4つのうち3つ以上の方向が見えれば、6/18 以上です（遠方視力スクリーニングテストのPASS）。 小さなEのうち少なくとも3つが見えない場合（遠視スクリーニ ング検査で不合格）は、視覚障害や目の病気の評価が必要です。 以下の追加検査は、視力の推定に役立つ可能性があります。 2. 大型のEを3mの位置に置いてテストする。 7.2 Eが見えていれば視力は6/60。 3mの距離で大型のEを3つ以上見ることができない場合 3. 大型のEを1.5mに置いてテストする。 7.2 4つのうち3つ以上が見えれば、視力は3/60。 2 1 視力の衛生 視力の衛生には、環境と人の両方が関係しています。環境要因や 行動は、視覚機能を促進することもあれば（例：照明、コントラ スト、色の使用）、有害なこともあります（例：長時間の電子メ ディアの視聴、近見の使用時間の長さ）。個人の衛生状態には、 頻繁に手を洗う、目をこすらない、まぶたには刺激の少ない石鹸 しか使わない、目元用の化粧品を控えるなど、目の衛生に関する 一連の行動が含まれます。 4 専門的なケアが必要な場合 眼疾患が診断されている人や、眼疾患があると判断 された人は、眼科専門医が検査の頻度や種類を決定 します。 • 50歳以上の方には、少なくとも年1回、視力低下の簡易検 査を実施してください。 • WHOの簡易アイチャートを使って、遠方と近方の視力を検 査することができます。使い方は右記の通りです。 • プライマリーケア医がスクリーニングを行うことができま す。眼科医の評価に関する正式なトレーニングは必要あり ません（13）。 • 市販の老眼鏡で問題が解決する場合は、総合的な検査は必 要ないかもしれません。 プライマリーケアでの視力検査 近視の検査 簡単なアイチャートを持っている人 7.3 本人に近視検査カードを好きなだけ近づけさせます。最大のEから最小 のEまでテストします。 最大4つのEのうち、3つ以上のEの方向を識別できれば、近視スクリー ニングテストは合格です。 そうでない場合は、市販の老眼鏡で対応できるかどうかを確認します。 老眼鏡を使用しても、最大のEのうち少なくとも3つが見えなければ（近 見視力検査で不合格）、視覚障害や眼疾患の評価が必要です。中型サイ ズは、本の活字に近い。最小のサイズは、書籍や雑誌の最小の活字に近 いものです（見えなくても構いません）。 3 43 7 視覚機能 視覚障害に対する ケア手順 outside_English_FA.pdf 6/9/10 5:07:09 PM 7.1 WHO簡易視力チャート （遠見視力用の4つの小さい E） ◦ 小さなEは、1.3cm×1.3cmの大きさで、お互いに1.3cmの位置にあります。 ◦ 真っ白な紙に真っ黒なE。 44 7 視覚機能 視覚障害に対する ケア手順 outside_English_FA.pdf 6/9/10 5:07:09 PM 7.2 WHO簡易視力チャート （遠見視力用の4つの大きい E） ◦ 大サイズのEは4.2cm×4.2cmで、4.5cm間隔で配置されています。 ◦ 真っ白な紙に真っ黒なE。 45 7 視覚機能 視覚障害に対する ケア手順 english Inside_FA.pdf 6/9/10 5:08:06 PM 7.3 WHO簡易視力チャート（近見視用） 46 7 視覚機能 視覚障害に対する ケア手順 ◦ 老眼鏡は、多くの高齢者が近くのものを見るのに役立 ちます。しかし、中には老眼鏡では解決できない人も います。例えば、遠視の方や乱視のある方は、眼科医 が検査した上で眼鏡を処方する必要があります。 ◦ 標準的な診断検査では、訓練を受けた専門家がスリッ トランプを使って眼球を詳細に検査します。この器具 は、例えば白内障の診断に使用され、手術の必要性を 判断するのに役立ちます。網膜と視神経の検査では、 他の機器を使用したり、時には画像を撮影したりして、 早期の変化を検出し、視力低下を防ぐための治療の指 針とします。糖尿病の方は、定期的に網膜を検査する ことが特に重要です。 7.4 視覚障害の評価と眼科疾患 ◦ 片目または両目の視力が突然または急速に低下した場 合は、基本的な目と視力の検査を行い、眼科専門医に 紹介する必要があります。 ◦ プライマリーケア医も目の診察をすることができます。 目が赤い、分泌物がある、傷がある、疼痛の持続、日 光に耐えられない、白内障があるなどの変化がある場 合は、眼科医に診てもらう必要があります。 ◦ プライマリーケア医は、一般的な眼疾患の兆候を調べ るために目を検査することができます。この検査は一 般的に包括的ではないため、専門家による検査が必要 です。上記のような目の状態が続く場合は、専門的な 眼科治療を受けることが推奨されます。 視覚障害や眼病の評価 白内障 白内障とは、眼球の水晶体が濁ることで、クリ アな視界が得られないのは、多くの場合、加齢 が関係しています。白内障は、現在でも失明の 主要な原因となっています。喫煙と紫外線への 暴露を減らすことで、白内障を予防したり、そ の進行を遅らせたりすることができます。糖尿 病と肥満は、追加のリスク要因となります。 白内障による視覚障害と失明は、白内障手術が 安全であるため、避けることができます。 47 7 視覚機能 視覚障害に対する ケア手順 評価と管理 視覚障害 7.5 老眼鏡 50歳以上の方の中には、近距離のものを見たり読んだり するのが苦手な方が多くいらっしゃいます。そのような方 には、老眼鏡（リーダー）をお勧めします。 シンプルな老眼鏡は低価格で手に入ります。倍率も様々な ものがあります。老眼鏡は、近くにあるものを大きく見せ るだけです。単純な老眼鏡で問題が解決しない場合は、眼 と視力の総合的な検査を受けることをお勧めします。 可能であれば、50歳以上の方は、定期的に眼科医による 検査を受けてください。簡単な視力検査や読影検査は、眼 科医が行う総合的な検査の代わりにはなりません。 7.6 不可逆的な視力低下 眼鏡では十分な視力矯正ができない視覚障害の方は少なく ありません。このような方には、眼鏡よりも大きな拡大率 を提供する視覚支援機器（机上や携帯型の拡大鏡）をお勧 めします。本や新聞を読む、お金を確認する、ラベルを読 む、小さな物や大きな物の一部を確認するなど、近視によ る作業を可能にします。 地域の医療従事者やリハビリテーション従事者は、これら の上記の機器を手に入れる手助けをすることができます。 視覚障害リハビリテーション 不可逆的な視覚障害の方には、心理的なサポートに加えて、 オリエンテーション、移動能力、日常生活活動のトレーニ ングを含む包括的な視覚障害リハビリテーションサービス が必要です。アイケアやリハビリテーションの専門家は、 視覚機能を高めるためのスキル、すなわち、認識、固視、 走査、追跡などのスキルを視覚障害の方にトレーニングす ることができます。これらのスキルは、通常、拡大鏡を効 果的に使用するために必要ですが、他の状況でも役に立つ ことがあります。 48 評価と管理 関連疾患 7.9 ステロイドの使用 一部の人では、ステロイドの長期投与により、眼球内の圧 力（眼圧）が上昇したり、白内障を発症することがありま す。この圧力の上昇は、視神経の損傷を伴う視力低下につ ながり、治療しなければ失明する可能性もあります。長期 のステロイド治療を受けている人は、定期的な眼科検診と 眼圧検査が必要です。 7.7 高血圧症 高血圧は、網膜疾患や緑内障などの重要な危険因子です。 7.8 糖尿病 糖尿病の方は、毎年、眼科専門医による眼科検査を受け、 糖尿病性網膜症の有無を確認する必要があります。 7 視覚機能 視覚障害に対する ケア手順 49 7 視覚機能 視覚障害に対する ケア手順 コントラストをつける。物体の中や間にコントラストが あると、見やすく、見つけやすく、避けやすくなります。 例えば、段差の端にコントラストの強い印をつける（特に 片目でしか見えない人のために）、食べ物が際立つように 色のついた皿を使う、文字を書くときには黒のペンを使う、 などです。弱視の人やその家族、介護者は、家庭用・台所 用の道具の柄に色をつけて、より見やすく安全にすること ができます。たとえば、包丁の柄を明るい色の粘着テープ で巻いたり、ペイントしたりすることができます。 最も読みやすい文字を使用してください。印刷物やコン ピューター、電話機の電子ディスプレイ画面では、統一さ れた背景色からはっきりと浮かび上がる大きなsan serif体 の活字（本ハンドブックの活字のようなもの）が一番読み やすいと思います。 生活用品は、より大きな文字でコントラストのついたも のを選ぶ。店頭では、文字や数字を大きくしたり、コン トラストを効かせた商品がよく売られています。例えば、 時計や大判の本などがそうです。レジャー用品では、大き なゲーム盤や駒、大きな文字や記号を使ったトランプなど を購入したり、作ったりします。 視覚だけでなく聴覚にも配慮したツールを使用する。時 計、温度計、体重計など、多くの商品に音声機能が搭載さ れています。また、多くの携帯電話やコンピュータプログ ラムに音声合成機能が搭載されています。 視覚障害の方がよりよい機能を享受するためには、さまざ まな方法があります。家族や介護者も協力できます。どこ で視覚支援機器を入手するか、どのようにサービスを受け るかについては、状況に応じて本ガイダンスを地域ごとに 適応する必要があります。 7.10 視覚障害者への対応 視覚補助器具の提供だけでなく、簡単な変更を加えること で、視覚障害の方が自分の活動を維持し、生活の質を保つ ことができます。家の中や普段の行動範囲を変えることで、 普段の仕事や余暇活動をより安全で簡単なものにすること ができます。次のような例があります。 照明の改善。良い照明は、特に近見視力に重要です。光は、 人の側面から（影ができないように）差し込むのがベスト です。 眩しさを抑える。明るい方がいいに決まっています。し かし、太陽や明るい光のまぶしさが気になる人もいるで しょう。 障害物を動かす。 家具やその他の硬い物などの危険物は、 その人の通常の歩行経路から移動させるか、そこに必要で あれば、常に同じ場所に置いておくべきです。 評価と管理 社会的・身体的環境 50 8 聴覚障害に対する ケア手順 聴 覚 加齢性難聴は高齢者で最も多い感覚障害でしょう。未治療 の難聴はコミュニケーションに影響し、社会的孤立につな がります。認知機能低下など他の能力の低下が、さらに社 会的な影響を悪化させることもあります。難聴は認知機能 低下や認知症のリスク、うつ病、不安、平衡機能障害、転 倒、入院、早期死亡といった多くの健康問題に関連します。 このため、地域レベルで高齢者の内在的能力をモニタリン グする際には、聴覚の評価が重要です。そして、高齢者の 健康や社会的ケアの必要性を評価する場合、より詳細な聴 覚の評価が求められます。 キーポイント コミュニティそして医療機関でプライマリケア従事者は、 簡便なポータブル機器や囁語検査（whispered voice test）で難聴のスクリーニングができます。 家庭内や地域でも、簡単な取り組みで難聴の影響を減ら すことができます。はっきり喋る、顔を見て話す、雑音 を減らす、といったコミュニケーションの工夫で、より よく聞こえるようになります。 聴力の改善法には補聴器や人工内耳がありますが、専門 知識・設備が必要です。 51 問診： －危険因子 （騒音曝露、聴器毒性薬剤） －耳痛 －病歴 活動性の耳漏、突発性・ 急性進行性の難聴 －めまい －慢性中耳炎 －片側性難聴 NO PASS 耳のケアに関する 一般的なアドバイ スの強化 FAIL 聴力検査 Hearing capacity 8 聴覚障害に対する ケア手順 聴 覚 評価と管理 社会的・身体的環境 2 1 3 Provide emotional support and help with managing emotional distress Provide auditory aids across the house (telephone, door bells) (to any) YES 8.1 8.5 8.4 8.4 2 (to all) －囁語検査：囁語を聞き取れる または －オーディオメトリー：35 dB以下 または －アプリのdigits-in-noise test 聴覚喪失 (Audiometry: ≥ 81 dB) 中等度-高度難聴 (Audiometry: 36‒80 dB) 正常範囲内 (Audiometry: ≤ 35 dB) 聴覚の評価 (診断的オーディオメトリー) 専門的治療へ 再評価 年1回 －検査と聴覚補償機器の提供 （補聴器、人工内耳） 耳のケアに関する 一般的なアドバイスの強化 補聴器 補聴器が入手できない場合、 他のコミュニケーション方 法とともに、読唇や手話を 指導する 精神的支援、精神的苦痛の対処 に関する支援 自宅内に補助具を設置する (電話、ドアベル) 当事者、家族、介護者に対し、 つながりを保ち、関係を維持す る工夫について指導する 特別なケアが必要 52 聴覚障害に対する ケア手順 1 下記3つのテストのうち1つを使って、初期アセスメントを行います。 囁語テスト（whisper voice test） 聴力が正常か、診断的オーディオメトリーによる評価が必要かどう かをスクリーニングする方法です。 スクリーニングオーディオメトリー（15） 機器があれば実施してください スクリーニングオーディオメトリーでは正常聴覚の上限において、 言語域の音域（500‒4,000Hz）を評価することができます。結果 は合格か要再検査かで示されます。音圧35dB以下を聴取できれば 基準範囲内と判定されます。専門家でなくても、短時間のトレーニ ングで正確な聴覚検査が可能です。 アプリのdigit-in-noiseテスト 自動化されたdigit-in-noiseテスト（ノイズ音の中の数字を聴き取る 検査）によって、診断的オーディオメトリーをすべきかどうか判断 できます。携帯電話のアプリを入手できます ‒ 例: Available as a mobile phone app – for example: Available as a web-based service – for example: hearWHO: https://www.who.int/deafness/hearWHO (free, in English) hearZA: https://www.hearza.co.za/ (free, in English) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (free, for iPhone users, in English, French, German and Spanish). from HearCom: http://hearcom.eu/prof/DiagnosingHearingLoss/ SelfScreenTests/ThreeDigitTest_en.html (free, in Dutch, English, German, Polish and Swedish). 聴覚の評価 一般的な耳のケアに関するアドバイス 耳に汚れた指を入れない、食品を触る前には手を洗う、汚れた 手で食事をしない トイレの後には必ず手を洗う 汚れた水で手を洗ったり、泳いだりしない 耳に物を入れない －熱い・冷たい油 －ハーブ －灯油のような液体 2 囁語テスト（whisper voice test） 被験者の右または左後方に、腕の長さほどの距離を取って立 つ。 被験者か補助者に、耳珠を押さえて対側の耳を塞ぐように指 示する（耳珠は耳の前方にあり、耳孔を部分的に覆っている 突起です）。 息を吐いた後、4つの単語を囁く。 一般的で、相互に関連性のない単語を用いる。 被験者に単語を繰り返えして喋るように指示する。一語ごと に繰り返させ、反応を待つ。もし被験者が3語以上正答すれ ば、明瞭に聞こえており、その耳は正常な聴力であると考え られる。 対側に移動し、別な単語を用いて反対側の耳を検査する。 3 被験者にとって馴染みのある囁語を用いる。 例： －キリン －椅子 －雲 －段ボール －積み木 －ジュース －お風呂 －馬 専門的なケアが必要な場合 •高度の難聴／聴力喪失の場合の評価 •聴覚補償機器のフィッティング •難聴の原因となる、あるいは難聴に寄与する背景問題の管理 8 聴覚障害に対する ケア手順 聴 覚 53 聴覚障害に対する ケア手順 8 聴覚障害に対する ケア手順 聴 覚 8 聴覚障害に対する ケア手順 聴 覚 聴覚の評価 語音オーディオメトリー 高齢者に対する語音オーディオ メトリーの追加実施は有用です。この検査では録音された 単純な単語を徐々に音量を上げて再生し、被験者には単語 が聞えた段階でその単語を繰り返すよう指示します。語音 オーディオメトリーの結果は、純音オーディオメトリーの 結果と照らし合わせます。純音オーディオメトリーの結果 と一致性をみることで、純音オーディオメトリーでは認め られなかった音声認識の非対称性や、一側のみ補聴器を作 成する場合、どちらの耳が適しているか判断します。 ティンパノメトリーでは鼓膜の反応性（または可動性）を 評価します。純音オーディオメトリーと語音オーディオメ トリーの結果から、聴覚障害の種類を判断する一助になり ます。 8.1 包括的評価のための3つの検査 専門機器を用いた3つの検査によって、聴覚を評価できま す － 診断的純音オーディオメトリー、語音オーディオメ トリー、内耳評価のためのティンパノメトリーです。これ らの検査によって、リハビリテーションの必要性を判断で きます。これらの検査を行うには専門的なトレーニングが 必要です。 純音オーディオメトリーでは被験者の様々な周波数の純音 を聴き取る能力を評価します。被験者が聴き取れる聴力閾 値まで、録音された音源の音量を上げていきます。周波数 125 Hz（非常に低い）から8000 Hz（非常に高い）の聴 力閾値を評価するために、気導と骨導のテストを行います。 これによって、難聴の程度と種類を判断できます。 54 聴覚障害に対する ケア手順 8 聴覚障害に対する ケア手順 聴 覚 8 聴覚障害に対する ケア手順 聴 覚 難聴の管理 ◦難聴の人とその家族、介護者に、機能を改善する可能性 があるコミュニケーションの工夫について、わかりやすく 説明しましょう。→ 8.5 ◦内耳障害を引き起こす薬剤があり、難聴や平衡障害の原 因となります。ストレプトマイシンやゲンタマイシンと いった抗菌薬や、キニンやクロロキンなどの抗マラリア薬 が含まれます。他にも聴覚に影響を与える薬剤があります。 可能であればこれらの薬剤を減らすことで、さらなる聴覚 低下を防ぐことができるかもしれません。 8.3 聴力喪失した高齢者に対して 高度の難聴がある高齢者（高度または聴力喪失）や、前述 の介入で改善が見込まれない場合には、聴覚補助機器の フィッティングのような特別なケアが必要になります。聴 覚補助機器を提供するには、検査や処方、フィッティング に専門技術が必要です。 難聴の管理には、コミュニケーションの工夫と聴覚補助機 器の両者を考慮すべきです。 難聴の管理に対しては、その人の内在的な聴覚を完全に評 価することで一番よいアプローチができます。認知機能障 害や歩行能力の障害、上肢巧拙運動障害、家族やコミュニ ティからのサポート状況にもすべて配慮が必要です。 8.2 中等度から高度の難聴の高齢者に対して ◦難聴の人とその家族に対し、補聴器のような聴覚補助機 器の有用性、入手場所や使用方法を説明しましょう。使用 後、医療従事者は使用についてサポートし、継続するよう 勧めます。 ◦オーディオメトリーだけで補聴器が必要かどうか判断す べきではありません。多くの難聴の人は騒音があるときの コミュニケーションが難しいと感じています。補聴器を勧 める前に、どのような必要性があるのかすべて評価しなく てはなりません。 55 専門的な難聴管理に関するその他の危険信号 専門的な診断や管理が必要となる難聴の原因に なり得る状況として、下記が挙げられます。 ◦耳痛 ◦慢性中耳炎（中耳感染） ◦突発性または急速進行性の難聴 ◦中等度から高度の難聴を伴うめまい ◦活動性の耳漏 ◦騒音曝露や聴器毒性薬剤の使用などの危険因 子の存在 8 聴覚障害に対する ケア手順 聴 覚 磁気誘導ループと増音器 磁気ループと増音器も有効です。 磁気誘導ループ（またはヒヤリングループ）は空間（会議 室やサービスカウンターなど）の周囲に這わせるワイヤー です。ワイヤーはマイクやアンプの信号を特定の補聴器に 送ります。 8.4 聴覚補助機器 補聴器 補聴器は通常、難聴の高齢者にとって一番重要な 機器です。補聴器は音を増強します。多くの場合有効で、 耳に入れたり引っ掛けたりして使用するので簡便です。補 聴器は難聴を完治したり、治療したりするものではないこ とを説明することも重要です。 人工内耳 人工内耳は補聴器が無効の高度難聴の例に有効 な場合があります。人工内耳は外科的に耳の内部に埋め込 まれます。音を電気信号に変換し、聴神経に送ります。人 工内耳が有効かどうかは慎重に評価しなくてはなりません。 人工内耳が入手できない、適していない場合には、高齢者 とその家族に読唇や手話のトレーニングについてアドバイ スしましょう。 追加のガイダンスについて「発展途上国における 補聴器やサービスに関するWHOのガイドライ ン」を参照してください。 http://apps.who.int/iris/handle/10665/43066 56 聴覚障害に対する ケア手順 8 聴覚障害に対する ケア手順 聴 覚 8 聴覚障害に対する ケア手順 聴 覚 難聴による影響を極力小さくすることで、自立性を維持し、 高齢者が日々の生活に必要な地域サービスに頼る必要性を 減らすことができます。 難聴は時に精神的ストレスや社会的孤立につながります。 このため聴覚リハビリテーションは心理的さらには社会的 に重要と位置づけられており、高齢者と介護者に個別の目 標を持って行われます。 ・定期的な社会的交流は認知機能障害や抑うつ、その他の 難聴に起因する感情的・行動的悪影響のリスクを減らすで しょう。特定のストレスが生じた場合、社会的サポート網 が一助となります。 ・配偶者や家族の力で、孤独や孤立を防ぐことができます。 彼らには対処法のアドバイスが必要なこともあります。た とえば、難聴のある人にコミュニケーションをとり続ける べきで、社会的ネットワークに参加し続けられるような活 動を計画すること、などです。難聴の人との話し方につい て、右のboxを参考にしてください。→ 8.5 ・自宅の環境対策として、自宅内で聴き取ることのできる ドアベルや電話器の設置が挙げられます。 8.5 家族や介護者に対する コミュニケーションの工夫 医療従事者は家族や介護者に対して、難聴の人と 会話する時にシンプルな工夫を取り入れることを 勧めましょう（14）。 お互いの顔を見て話しましょう。 口元がよく見えるよう、明るくしましょう。 話し始める前に、話し手に注意を向けてもら いましょう。 大きな騒音や雑音のような注意をそらす物を 避けましょう。 はっきり、ゆっくり喋りましょう。決して叫 んではいけません。 話しかけるのを諦めないで下さい。孤立や抑 うつにつながります。 これらの工夫は聴覚補助機器の使用の有無に関わ らず有効です。 評価と管理 社会的・身体的環境 57 58 9 抑うつ症状に対する ケア手順 精神機能 「抑うつ症状」（または気分の落ち込み）という用語は、2 週間以上にわたり2つ以上の症状を同時に持ち、大うつ病 の診断基準を満たさないものに適用されます。この抑うつ 症状は、長期的に障害をもつ高齢者や社会的に孤立してい る高齢者、過酷な介護を求められる介護者により生じやす いのです。この問題は、抑うつ症状を管理し、包括的なア プローチを行う際に重要です。 抑うつ症状は、とても大切な心理的な能力の現れですが、 ある一面を捉えているに過ぎません。その他、不安、パー ソナリティ、性格などがあり、その対応は複雑で、技術習 得が必要です。 この章では、高齢者の抑うつ症状の防止と管理に関するガ イダンスを示します。さらなる詳細なガイダンスやうつ病 への介入については、WHOのホームページをご覧ください。 （mhGAP介入ガイド https://apps.who.int/iris/handle/10665/250239） キーポイント 地域におけるプライマリケア医は一連の質問をおこない、 抑うつ症状のある人を特定し、うつ症状とうつ病を区別 します。 簡便な構造化された心理的介入法を使用し、適切な指導 のもとで訓練を受ければ非専門医であっても、地域およ びその他のプライマリケアにおける抑うつ状態の患者を 助けることができます。 うつ病は通常は専門医による包括的治療が必要です。 聴覚や機動性などの精神以外の内在的能力の衰えは、機 能的障害をもたらし社会活動の参加を減らし、抑うつ症 状の発現に関与することがあります。 59 気分低下、抑うつ、 絶望感はあるか？＊ やる気や興味の低下が あるか？ ? ? うつ徴候 （0－2つの症状） うつ病 （3つ以上の症状） NO NO （上のうちいずれか） (to all) YES 9 抑うつ症状に対する ケア手順 精神機能 一般的健康の強化 ライフスタイルのアドバイス 通常のケア 聴取 2週間以上にわたり 悩まされているか否か うつ病の治療 大うつ病と診断された高齢者には一般的に専門的なケアが必要です。 WHOmhGAP介入ガイドの推奨されているアドバイスや治療を受ける べきです。 https://apps.who.int/iris/handle/10665/250239 －過去6ヶ月の大きな喪失 －マニアの歴史 －認知機能障害 －難聴 －視覚障害 －病気や怪我による障害 薬の見直し 抗うつ薬、抗ヒスタミン薬、 抗精神病薬など 病態の包括的管理 疼痛の評価と 治療 －ポリファーマシー －貧血 －栄養障害 －甲状腺機能低下症 －疼痛 NO 9.1 9.2 9.3 ストレスを減らし、社会的支援を強化する モバイル機器を用い高齢者の意欲を高め、 社会的なつながりを促す 日常生活の機能性を促進する 地域における運動プログラムへの参加への 奨励とスキル開発 孤独と社会的孤立を特定し、対策を講じる （テクノロジーの助けを借りる介入を検討） 気分の評価 2 付随状況の 評価と管理 評価と管理 社会と身体的環境 9.4–9.7 うつ徴候の スクリーニング 簡素に構造化された心理的介入： －認知行動療法 －問題解決のカウンセリング またはセラピー －行動活性化 －回想法 多様な運動療法 マインドフルネス訓練 ＊ 高齢者では悲嘆、うつ、落ち込む、など 多彩な表現を使用する 特別なケアの必要性 60 12 ＊These questions can be found in the Patient Health Questionnaire (PHQ-9) (http://www.cqaimh.org/pdf/tool_phq9.pdf), which is one tool for the assessment of depressive symptoms. Or see the depression section of the mhGAP intervention guide, at https://apps.who.int/iris/handle/10665/250239. 特別なケアが必要な場合 •うつ病の管理にはもっと包括的で通常は専門家による個別 のケアプランが必要です。 •抑うつ症状を管理するために、構造化された心理学の特定 なトレーニングを受けた医療従事者が必要です。 •甲状腺機能低下症などの特定の関連症状には、専門的な診 断と管理が必要な場合があります。 •転倒したり、眠り続けたり、眠りすぎたりすることがある。 •疲れている、または気力がない。 •食欲不振または過食がある。 •自分自身のことを考えると不快になったり、自分自身または 家族を失望させたと思う。 •新聞を読んだりテレビを見ることに集中できない。 •歩行速度が落ちたと周囲から指摘されたり、話し方が遅かっ たりする。 •いつも以上にそわそわして動き回り、または落ち着きがない。 •何らかの方法で自分自身を傷つけたり、死んだほうがいいと 思う。 気分の評価 次のような主な症状の少なくとも1つ認めた場合さらに気分の評 価が必要になります。（例えば、落ち込んでいる、抑うつ的、 または絶望的で、物事を行うことへの興味や喜びがほとんどな い）2つのスクリーニングの質問事項に適さない場合、別のよう な問いかけをします。 9 抑うつ症状に対する ケア手順 精神機能 うつ病の症状 少なくとも1つの中核症状と1つまたは2つの追加の症状が あれば、うつ病の可能性があります。また、3つ以上の症 状がある場合、うつ病の診断を受けるかもしれません。抑 うつ状態とうつ病は、その治療法が異なるため、区別する ことが重要です。 •認知機能低下と認知症はうつ症状を伴っている場合があ り、評価する必要があります。認知症者はしばしば、ア パシーや、感情的な抑制困難、仕事や家庭で社会活動を 行うことが困難になるような気分や日常生活の障害を伴 い医療機関を受診します。 •同時に、感覚や移動など、他の内在的機能障害により身 体機能の低下や社会参加が困難になり、抑うつ病状態と なります。 •抑うつ症状へ同時に対応すれば、認知や聴覚などの他の 内在的能力の機能低下に対する介入はより効果的になる かもしれません。個別ケアプランを作成するうえで考慮 する必要があります。 質問： 2週間以上、次のような問題に悩まされていますか？＊ 下記3つのテストのうち1つを使って、初期アセスメントを行いま す。 囁語テスト (whisper voice test) 聴力が正常か、診断的オーディオメトリーによる評価が必要かどう かをスクリーニングする方法です。 スクリーニングオーディオメトリー (15) 機器があれば実施してください スクリーニングオーディオメトリーでは正常聴覚の上限において、 言語域の音域(500-4,000 Hz)を評価することができます。結果は合 格か要再検査かで示されます。音圧35 dB以下を聴取できれば基準 範囲内と判定されます。専門家でなくても、短時間のトレーニング で正確な聴覚検査が可能です。 アプリのdigit-in-noiseテスト 自動化されたdigit-in-noiseテスト (ノイズ音の中の数字を聴き取る検 査）によって、診断的オーディオメトリーをすべきかどうか判断で きます。携帯電話のアプリを入手できます ‒ 例: 61 9 抑うつ症状に対する ケア手順 精神機能 精神機能 認知行動療法 認知行動療法（CBT）においては感情は信念と行動の影響 を受けるといった考えに基づいています。うつ病の症状を もつ（または精神疾患と診断された）人々は、非現実的で ゆがんだ否定的な考えを持ち、注意しないと有害な行動を とる可能性があります。このようにCBTは典型的には、ま ず、認知的な要素として患者の非現実的で否定的な考えに 気付かせ、行動的要素として前向きな行動を増やし後ろ向 きな行動を減らします。手順として(1) 彼らの人生の中の 問題点を同定する、(2) これらの問題について考え、その 問題に関する感情、信念を認識させる、(3)その問題点に対 する否定的または不正確な思考を特定する、(4)この考えを より現実的にするために思考を再構築させます。 問題解決のカウンセリングと治療法 問題解決のカウンセリングと治療法は、うつ病と診断され ていないが、抑うつ症状をもつ人々で、苦痛を感じている か、ある程度の社会的機能が損なわれているものに対して 行われます。 問題解決療法は、その対象者に直接かつ実践的な支援を提 供します。セラピストとして活動する医療者と高齢者が協 力し、抑うつ症状の原因になる主要な問題を特定してゆき ます。同時に、彼らは問題を解決し特定の問題に対処する 戦略を立てることにより、これらを管理可能な課題へと変 えてゆきます。 うつ病の症状を 管理する 9.1 簡潔に構造化された 精神心理学的介入 認知行動療法、問題解決のアプローチ、行動活性化法、回 想法などのシンプルで構造化された精神心理学的介入は、 高齢者の抑うつ症状を大幅に軽減させることがあります。 複合運動とマインドフルネス訓練も抑うつ症状を軽減させ ることができます。 高齢者の同意を得て、高齢者特有の問題を解決することが 難しいことを理解しながら、多くの精神心理学的介入を試 みます。精神心理学的な治療は構造化されており、そこに 運動療法を組み入れ、運動を有効的に活用しながら、高齢 者の気分を改善させます。（運動制限がある場合は第5章 参照） しかしながら、メンタルヘルスの専門知識をもたないプラ イマリケア医による抗うつ薬の投与は推奨できません。 5 メンタルヘルスの訓練を受けた医療専門家が通常、これらの介入を行 います。地域保健専門職はこれらの技術に熟練し、高齢者特有のメン タルヘルスの問題に対する訓練を受けていればそれらを提供すること もできます。これらの介入には有害なことはありません。 62 99 抑うつ症状に対する ケア手順 精神機能 9 抑うつ症状に対する ケア手順 精神機能 精神機能 5 9.2 多様な運動療法 人の身体能力と嗜好に合わせた運動プログラムは、短期的 にも長期的にも抑うつ症状を軽減させます。 行動が制限さ れる場合は、第5章を参照してください。 9.3 マインドフルネス訓練 マインドフルネスとは、過去、未来、願望、責任、後悔な どの一連の思いに捉われず、今この瞬間に何が起こってい るかに集中することです。この方法は、抑うつ症状のある 人にとっては負のスパイラルになる可能性があります。マ インドフルネス訓練には、実に多くの種類があります。広 く行われている方法は、静かに座り、横になったりして、 呼吸をしている状態に集中することです。ヨガやウォーキ ングなどのように身体の動きに集中することが役立つこと もあります。 行動の活性化 抑うつ症状を軽減する手段として、やりがいのある活動に 参加するように促し行動の活性化を図る方法があります。 この手法は、他のエビデンスに基づく心理的治療よりも速 やかに習得できます。非専門家も学べ、患者の抑うつ症状 のケアの機会を増やすことができます。 この方法は、主に 専門家によって実施され複数セッションとして研究されま した。 しかし、訓練を受けた医療専門家によってより簡素 なものに変更され、プライマリケアにおける補助治療や包 括的なケアの第一段階として提供される可能性があります。 回想法 回想法は、セラピストが患者に自分の過去を思い出させ、 その価値を見出し、自身の人生を安らぎとともに受容させ る治療法です。この治療法では、人生を俯瞰し、友人や愛 する人についての大切な記憶を思い出します。高齢者のう つ病の治療に役立ち、人生の最終段階に向かう人に救いの 手を差しのべます。 セラピストは、本人の今まで生きてきた目的に基づき、幼 少期や仕事に就いていた頃や親や祖父母として過ごした時 間など、特定の期間を振り返り、治療を行います。 63 9 抑うつ症状に対する ケア手順 精神機能 精神機能 評価と管理 関連状況 ◦ 難聴 難聴の高齢者は、羞恥心を持ち、不安や自尊心の 喪失を呈する可能性があると多く報告されています。そ して、社会的活動や身体活動の低下につながり、社会的 孤立や孤独を経験し、最終的にはうつ病になりやすくな ります（15）。 ◦ 視覚障害および加齢性黄斑変性症や緑内障などの主要 な加齢性眼疾患があると、うつ病の発症リスクが増加し ます（16）。多くの視覚機能低下者は、不幸、孤独、さ らには絶望を感じていると報告されています。 ◦ 病気や怪我による障害への反応 さまざまな障害を持 つとうつ病になりやすくなります。病気や怪我で障害を もつとストレスを受け、生活様式を変更しなければなり ません。障害をもったまま日常生活に適応できるように なるまでには、ショックを感じ、否定し、怒りや抑うつ 症状を伴いながら、それを受け入れ適応する必要があり ます。高齢者が新たな障害を持つと不安やうつ病を発症 するリスクが生じます。 次のような状態では、うつ病の治療とは異なるアプローチ が必要になります。 ◦過去6か月以内の大うつ病 ◦ 躁病の既往 躁は気分高揚とエネルギーと活動の増加の エピソードです。躁病の症状を経験した人々は、双極性 障害に分類されます。躁病では、仕事や社会活動を著し く妨げたり、入院または監禁が必要になるほど深刻な症 状が同時に生じ、少なくとも1週間以上継続します。 mhGAP介入ガイド https://www.paho.org/mhgap/en/biolar_flowchart. html を参照してください。 ◦ 認知機能の低下 うつ病と認知機能低下は複雑に絡み 合っています。疫学研究では、うつ病の存在はアルツハ イマー病の発症に関連するとされています。うつ病で影 響される認知機能は、注意、学習、視覚的記憶、および 実行機能です。うつ病は、日常生活の障害を生じていな い軽度の認知機能低下に対する個人の自己認識に対する 精神的反応である可能性があります。 64 9 抑うつ症状に対する ケア手順 精神機能 精神機能 99 抑うつ症状に対する ケア手順 精神機能 9.6 甲状腺機能低下症 甲状腺機能低下症は、高齢者、特に女性によく見られます。 その症状は非特異的であり、人によって異なりますが、う つ症状が含まれる場合があります。専門知識を持つ医療従 事者が評価し管理する必要があります。 9.7 疼痛 慢性疼痛を訴える患者は、抑うつ症状を示し易くなります。 痛みを適切に評価し管理することが重要となります（移動 能力の制限については第5章を参照してください） 9.4 ポリファーマシー ポリファーマシー（多剤併用）は抑うつ症状を引き起こす 可能性がある一方、抑うつ症状はポリファーマシーを引き 起こす可能性があります。ポリファーマシーへの対応と同 時に抑うつ症状に対処することは、悪循環を断ち切るため に重要です。主に中枢神経系作動薬に加え、抗ヒスタミン 薬や抗精神病薬などの向精神薬、筋弛緩薬、および抗コリ ン作用を持つ他の非向精神薬は、抑うつ症状と関連してい る可能性があります。不要で効果のない薬を中止するだけ でなく、効果が重複している薬を排除することで、ポリ ファーマシーをなくすことができます。 9.5 貧血、栄養障害 貧血と栄養障害では、鉄分及び葉酸、ビタミンB6、ビタミ ンB12などのビタミンが不足し、抑うつ症状を引き起こす 可能性があります。一方、うつ病の症状が貧血の発症に影 響を与える可能性があります。食欲不振や日常の活動（買 い物や料理など）への関心の欠如は、貧血と栄養障害の発 症を促進し、高齢者の栄養の質と量を低下させる可能性が あります。うつ病の症状を良くするには、貧血を管理し、 栄養状態を改善することが重要です。 5 6 65 9 抑うつ症状に対する ケア手順 精神機能 精神機能 評価と管理 社会的および身体的環境 高齢者が難聴や運動の制限などの機能喪失を呈した場合、 家族や介護者は社会的孤立を避けるために特に注意を払う 必要があります。社会的孤立は、抑うつ症状を引き起こす 可能性があります。電話またはインターネットを駆使した 支援活動を検討し、高齢者を孤立させないように配慮して ください。 うつ病では、以前は面白くて楽しかった活動に興味を失い ます。家族や介護者は、コミュニティベースの運動プログ ラムやその技術開発により、より多くの身体活動を行い、 社会的なつながりを強くし、穏やかな励ましとサポートが 大切となります。 66 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 内在的能力が著しく低下した人にとって、尊厳を保つこと は、他者からのケア、支援、手助けがあって初めて可能に なることが多いと思われます。尊厳のある有意義な生活を 送るためには、社会的ケアと支援の利用が不可欠です。社 会的ケアと支援には、日常生活活動（ADL）や身の回りの 世話だけでなく、地域の施設や公共サービスへのアクセス を容易にすること、孤立感や孤独感を軽減すること、経済 的な安定を図ること、適切な生活の場を提供すること、嫌 がらせや虐待からの解放、人生に意味を与える活動への参 加などが含まれます。 社会的ケアと支援のニーズについて誰に尋ねるのが最も適 切かは、質問によって異なります。高齢者の認知機能が低 下している場合、ADLや経済に関する質問は、家族、介護者、 友人など、その人をよく知っている人に聞くのが最適でしょ う。 キーポイント ⃝ 機能的能力の低下は、高齢者、特に内在的能力が低下し ている人によく見られますが、必然的なものではありま せん。 ⃝ 地域医療従事者は、簡単な質問で機能的能力の低下をス クリーニングすることができます。 ⃝ 高齢者の優先事項に合わせた介入を行うことで、機能的 能力を改善することができます。 ⃝ 効果的な介入には、内在的能力、機能的能力、および社 会的ケアと支援の提供を改善するものが含まれます。 67 AB 1. 室内での移動が困難ですか？ 2. トイレの使用が困難ですか？（便器を使うこ とが困難ですか？） 3. 自分で服を着るのが難しいですか？ 4. お風呂やシャワーを使うのが難しいですか？ 5. 身だしなみを整えるのが苦手ですか？ 6. 自分で食事をするのが難しいですか？ 7. 住んでいる場所（住居）に問題が ありますか？ 8. 経済的な問題はありますか？ 9. 寂しさを感じますか？ 10. 余暇の趣味、仕事、ボランティア、 家族のサポート、教育、精神的な 活動など、自分にとって大切なこ とを追求することができますか？ 11. 高齢者虐待のリスクを 評価する 評価する 社会的ケアと 支援ニーズ 社会的ケアによる支援（個人的な支援や補助具の使用） YES YES 内在性能力の低下を補い、移動性を向上させ、転倒を防止するための身体的な環境の評価と調整 支援技術、補助器具、適応器具の使用を検討する 配偶者、家族、その他のインフォーマルな介護者によるサポートの評価、および介護者のニーズの評価を含む 有償の介護従事者によるサポートの必要性を検討する 在宅介護、デイケア、介護施設など、介護者やサービスの利用が可能であること 補足的な質問をする 以下の理由で不安を感じていますか。 1. 住んでいる場所の安全・安心について 2. 住んでいる家の状態は？ 3. あなたの家の場所は？ 4. 住居にかかる費用？ 5. 家の修理やメンテナンスについて 6. 今いる場所で自立して生活するためには？ 検討する ‒ リフォーム ‒ 代替施設 ‒ 社会福祉や地域の住宅プログラ ム、既存の支援ネットワークを 紹介する 補足質問をする 1. 一般的に、月々の家計はどうになっていますか？ 2. 自分のお金や財務を管理することができますか？ 3. 経済的な手当や給付についてアドバイスが欲しいですか？ 課題を特定するために補足的な質問をする。 あなたが...を追求することができないのは、以下の理由からでしょうか： 1. 費用、2. 距離、3. 交通手段、4. 機会の欠如、5. その他？ レジャー施設やクラブ、学習教室、ボランティア活動、雇用相談など、高齢者 が利用できる地域社会のサービスのリストを提供する。 高齢者の参加を増やすために、これらのサービスを利用するように促す。 促進する方法を検討する ‒ 身近な社会的つながり（配偶者、家族、友人、ペット） ‒ 地域社会のリソースの利用（クラブ、信仰団体、デイセンター、 スポーツ、レジャー、教育） ‒ 貢献する機会（ボランティア活動、雇用） ‒ 通信技術によるつながり 検討する ‒ 専門家による財務アドバイスの紹介 ‒ 金銭的虐待を防止するための金銭的 意思決定の委任に関する助言 差し迫った脅威がある場合は、ソーシャルワーク、市区町村、 または法的相談窓口を通じた専門家による評価を紹介する。 高齢者の行動、介護者や親族の行動、あるいは身体 的虐待の兆候に基づく観察情報は、潜在的な虐待を 特定するために使用されるべきです。 ASK YES NO YES 1 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 YES 医療従事者は、高齢者が専門家の評価を受けるために誰に紹介さ れるべきかを知っておくべきです。手順は、利用可能性に応じて 異なります。自治会長、学校の校長、僧侶、信仰グループのリー ダーなどは、環境によってはソーシャルワーカーの代わりになる 適切な人の例です。包括的な社会的ケアと支援には多方面からの サポートが必要であることを考えると、専門家やサービス間の信 頼関係を育むための定期的なミーティングが重要です。高齢者の ケアに関わるさまざまな専門家の専門分野の例を以下に示します。 •生活条件：住宅サービス、ソーシャルワーカー、作業療法士。 •金銭面：ソーシャルワーカー、給付金相談窓口。 •孤独：ソーシャルワーカー、ボランティアサービス、主治医。 •参加：ソーシャルワーカー、レジャー、雇用、ボランティアサ ービス •虐待：ソーシャルワーカー、市区町村、法的相談窓口。 •日常生活活動：作業療法士、社会福祉士、看護師、または学際 的な高齢者専門チーム。 •屋内移動：理学療法士、作業療法士、ソーシャルワーカー、ま たは学際的な高齢者専門家チーム。 •屋外移動：理学療法士、社会福祉士、ボランティア輸送サービス。 専門的な知識が必要な場合 高齢者の行動 •家族やプロの介護職を怖がっているように見える。 •質問されても答えようとしなかったり、答える前に不安そうに 家族介護者を見たりする。 •家族介護者が部屋を出入りすると行動が変わる。 •家族介護者のことを、「意志が強い」、「疲れている」、「気性が 荒い」などと言ったり、「イライラする」、「不安が強い」、「ス トレスが多い」、「すぐにキレる」などと言ったりする。 •介護者に対して大げさに敬意を表したり、極端に敬遠したりす る。 1 高齢者虐待の可能性を示す観察の手がかり 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 介護者・親族の行動 •専門家と高齢者が二人きりで話すのを妨げたり、評価面接の流 れを中断する理由を探し続けたりしている（例えば、何度も部 屋に入ってくる）。 •本来、高齢者に向けられている質問に自ら答えようとする。 •高齢者が自宅で援助を受ける際に障害となる。 •高齢者の世話をしなければならないことに強い不満を示してい る。 •実際にはそうではないのに、高齢者が「気が狂っている」とか 「頭が鈍っている」とか、あるいは「混乱していて何を言って いるのかわからない」などと、専門職を説得しようとする。 •質問中に敵意をむき出しにしたり、疲れていたり、焦っていた り、高齢者の前で非常に落ち着きがなく、無関心だったりする。 身体的な虐待 •切り傷、やけど、あざ、ひっかき傷。 •説明のつかない傷。 •偶発的に発生したとは考えにくい傷。 •隠された場所にある怪我や傷。 •乱暴な扱いで指のような形をしたあざ（多くの場合、上腕部）。 •脇の下など、本来傷のつきにくい保護された部分の傷。 •治療していない傷。 •治癒段階の異なる複数の傷。 •薬の飲みすぎ、使いすぎ。 68 AB 1. 室内での移動が困難ですか？ 2. トイレの使用が困難ですか？（便器を使うこ とが困難ですか？） 3. 自分で服を着るのが難しいですか？ 4. お風呂やシャワーを使うのが難しいですか？ 5. 身だしなみを整えるのが苦手ですか？ 6. 自分で食事をするのが難しいですか？ 7. 住んでいる場所（住居）に問題が ありますか？ 8. 経済的な問題はありますか？ 9. 寂しさを感じますか？ 10. 余暇の趣味、仕事、ボランティア、 家族のサポート、教育、精神的な 活動など、自分にとって大切なこ とを追求することができますか？ 11. 高齢者虐待のリスクを 評価する 評価する 社会的ケアと 支援ニーズ 社会的ケアによる支援（個人的な支援や補助具の使用） YES YES 内在性能力の低下を補い、移動性を向上させ、転倒を防止するための身体的な環境の評価と調整 支援技術、補助器具、適応器具の使用を検討する 配偶者、家族、その他のインフォーマルな介護者によるサポートの評価、および介護者のニーズの評価を含む 有償の介護従事者によるサポートの必要性を検討する 在宅介護、デイケア、介護施設など、介護者やサービスの利用が可能であること 補足的な質問をする 以下の理由で不安を感じていますか。 1. 住んでいる場所の安全・安心について 2. 住んでいる家の状態は？ 3. あなたの家の場所は？ 4. 住居にかかる費用？ 5. 家の修理やメンテナンスについて 6. 今いる場所で自立して生活するためには？ 検討する ‒ リフォーム ‒ 代替施設 ‒社会福祉や地域の住宅プログラ ム、既存の支援ネットワークを 紹介する 補足質問をする 1. 一般的に、月々の家計はどうになっていますか？ 2. 自分のお金や財務を管理することができますか？ 3. 経済的な手当や給付についてアドバイスが欲しいですか？ 課題を特定するために補足的な質問をする。 あなたが...を追求することができないのは、以下の理由からでしょうか： 1. 費用、2. 距離、3. 交通手段、4. 機会の欠如、5. その他？ レジャー施設やクラブ、学習教室、ボランティア活動、雇用相談など、高齢者 が利用できる地域社会のサービスのリストを提供する。 高齢者の参加を増やすために、これらのサービスを利用するように促す。 促進する方法を検討する ‒ 身近な社会的つながり（配偶者、家族、友人、ペット） ‒ 地域社会のリソースの利用（クラブ、信仰団体、デイセンター、 スポーツ、レジャー、教育） ‒ 貢献する機会（ボランティア活動、雇用） ‒ 通信技術によるつながり 検討する ‒ 専門家による財務アドバイスの紹介 ‒ 金銭的虐待を防止するための金銭的 意思決定の委任に関する助言 差し迫った脅威がある場合は、ソーシャルワーク、市区町村、 または法的相談窓口を通じた専門家による評価を紹介する。 高齢者の行動、介護者や親族の行動、あるいは身体 的虐待の兆候に基づく観察情報は、潜在的な虐待を 特定するために使用されるべきです。 ASK YES NO YES 1 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 YES 医療従事者は、高齢者が専門家の評価を受けるために誰に紹介さ れるべきかを知っておくべきです。手順は、利用可能性に応じて 異なります。自治会長、学校の校長、僧侶、信仰グループのリー ダーなどは、環境によってはソーシャルワーカーの代わりになる 適切な人の例です。包括的な社会的ケアと支援には多方面からの サポートが必要であることを考えると、専門家やサービス間の信 頼関係を育むための定期的なミーティングが重要です。高齢者の ケアに関わるさまざまな専門家の専門分野の例を以下に示します。 •生活条件：住宅サービス、ソーシャルワーカー、作業療法士。 •金銭面：ソーシャルワーカー、給付金相談窓口。 •孤独：ソーシャルワーカー、ボランティアサービス、主治医。 •参加：ソーシャルワーカー、レジャー、雇用、ボランティアサ ービス •虐待：ソーシャルワーカー、市区町村、法的相談窓口。 •日常生活活動：作業療法士、社会福祉士、看護師、または学際 的な高齢者専門チーム。 •屋内移動：理学療法士、作業療法士、ソーシャルワーカー、ま たは学際的な高齢者専門家チーム。 •屋外移動：理学療法士、社会福祉士、ボランティア輸送サービス。 専門的な知識が必要な場合 高齢者の行動 •家族やプロの介護職を怖がっているように見える。 •質問されても答えようとしなかったり、答える前に不安そうに 家族介護者を見たりする。 •家族介護者が部屋を出入りすると行動が変わる。 •家族介護者のことを、「意志が強い」、「疲れている」、「気性が 荒い」などと言ったり、「イライラする」、「不安が強い」、「ス トレスが多い」、「すぐにキレる」などと言ったりする。 •介護者に対して大げさに敬意を表したり、極端に敬遠したりす る。 1 高齢者虐待の可能性を示す観察の手がかり 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 介護者・親族の行動 •専門家と高齢者が二人きりで話すのを妨げたり、評価面接の流 れを中断する理由を探し続けたりしている（例えば、何度も部 屋に入ってくる）。 •本来、高齢者に向けられている質問に自ら答えようとする。 •高齢者が自宅で援助を受ける際に障害となる。 •高齢者の世話をしなければならないことに強い不満を示してい る。 •実際にはそうではないのに、高齢者が「気が狂っている」とか 「頭が鈍っている」とか、あるいは「混乱していて何を言って いるのかわからない」などと、専門職を説得しようとする。 •質問中に敵意をむき出しにしたり、疲れていたり、焦っていた り、高齢者の前で非常に落ち着きがなく、無関心だったりする。 身体的な虐待 •切り傷、やけど、あざ、ひっかき傷。 •説明のつかない傷。 •偶発的に発生したとは考えにくい傷。 •隠された場所にある怪我や傷。 •乱暴な扱いで指のような形をしたあざ（多くの場合、上腕部）。 •脇の下など、本来傷のつきにくい保護された部分の傷。 •治療していない傷。 •治癒段階の異なる複数の傷。 •薬の飲みすぎ、使いすぎ。 69 評価と管理 社会的支援ニーズ 10.1 日常生活における対人ケアと介助の必要 性の評価と管理（方針のセクションA） 6つの質問は、人の助けを借りずに自分の身の回りのこと をすることができなくなったかどうかを評価するために使 用されます。内在的能力が著しく低下している高齢者は、 この評価を受けるとよいでしょう。 屋内での移動には、ベッドから椅子への移動、歩行、トイ レへの移動と使用、階段の使用など、さまざまな活動が含 まれます。移動能力が限られていると、個人的なケアを受 けるリスクが高まったり、必要になったりします。服を着 たり、食事をしたり、入浴したり、身だしなみを整えたり することはADLに含まれます。ADLができないと、パー ソナルケアが必要になります。多くの高齢者は、ADLの 手助けを他人に頼りたくなく、自分でなんとかすることを 望んでいます。 ADLや移動の問題を抱える高齢者には、リハビリテーショ ンのプログラムが有効です。これは能力の向上に焦点を当 てたものですが、内在的能力に限界があるにもかかわらず、 機能的能力を最適化するための支援技術や環境適応を含む こともあります。屋外での移動を支援するために輸送サー ビスを提供することも含まれます。 困難が残る場合は、配偶者、家族、その他の無償の介護者 からの支援を、それらの必要性の検討も含めて見直すべき です。さらなる支援が必要な場合は、ボランティア、民間、 または公的な在宅介護サービスを提供すべきです。 10.2 社会的支援ニーズの評価と管理 （方針のセクションB） 内在性能力や機能的能力のレベルに関わらず、社会的支援 ニーズの評価は高齢者にとって有益です。社会的支援を行 うことで、高齢者は自分にとって大切なことを行うことが できます。これには、生活環境、経済的安定、孤独感、コ ミュニティ施設などの地域資源や公共サービスへのアクセ ス、高齢者虐待に対する支援などが含まれます。 B7 住居環境 高齢者が住む場所は、その人の健康、自立、幸福に影響を 与えます。問題は、場所の大きさ、アクセス、状態、安全 性、セキュリティなど、さまざまなことに関連しています。 補足的な質問は、対処すべき分野を特定するのに役立ちま す。 70 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 B9 孤独感 孤独感は、高齢者によく見られ、うつ病や早期死亡の可能 性を高めることに関連しています。抑うつ症状のスクリー ニングに関するガイダンスは、第9章を参照してください。 一人でいることと孤独であることは同じではありません。 高齢者は、他の人に囲まれていても、人間関係の質が悪け れば、孤独になることがあります。 孤独な高齢者に、家族や友人との社会的な接触を増やした り同じような興味を持つ人と会ったりすることが孤独感を 軽減するのに役立つかどうかを尋ねることは有益です。し かし、接触を増やすことが助けになるかどうかを高齢者に 尋ねるときは、個人的な人間関係の状況を明らかにするこ とへの不安を解消するために、その質問はプライベートな ものであることを安心できるよう説明してください。 ペットを飼うことで、多くの高齢者が孤独感を軽減するこ とができます。クラブ、信仰団体、デイセンター、スポー ツ、レジャー、教育サービスなど、地域のコミュニティ施 設の利用を奨励すべきです。ボランティア活動や雇用を通 して貢献する機会もあるでしょう。社会的なつながりは、 通信技術の利用によって増やすことができます。孤独と闘 うために、これらの対策の全般的な見直しを行うべきです。 評価者は、地域の幅広い資源を認識する必要があります。 住環境の問題は、新たなセキュリティ対策を導入したり、 緊急時の連絡先を確保したり、自立した生活を維持するた めの適応策を講じたりすることで、軽減することができま す。住居費や修理・メンテナンスのために、経済的な支援 が受けられる場合もあります。すべてがうまくいかない場 合は、より適切な住居への移転を検討する必要があります。 B8 経済 経済的資源は、高齢期の健康、自立、幸福感と強く関連し ています。問題は、基本的に必要なお金が足りない、ある いは社会に参加するために必要なお金が少なすぎるなどの 場合です。また、高齢者はお金がこの先枯渇するのではな いか、あるいは自分で金銭管理ができなくなるのではない かと心配することがあります。さらに質問をすることで、 対処が必要な分野を特定することができます。 経済的な問題は、家計や財産管理に関するアドバイスに よって軽減することができます。金銭的な虐待を防ぐため の法的保護が整備されているようであれば、信頼できる第 三者に金銭管理の権限を委譲する取り決めを行うことがで きます。 71 10 社会的ケアや支援 のためのケア手順 社会的ケアと支援 B10 社会的関与と参加 ICOPEアプローチの目的は、高齢者が自分にとって大切 なことを行えるように支援することです。高齢者の生活、 優先順位、嗜好を理解することで、高齢者にとって何が大 切かを知ることは、社会参加を増やす方法を見つけること ができるかもしれないので、役に立ちます。 余暇活動、趣味、仕事、学習、精神的活動などが社会参加 の例です。すべての高齢者は個性的であり、自分にとって 重要なことはそれぞれ異なります。しばしば非常に具体的 な個人個人の優先順位を持っています。個別のケアプラン を立てるためには、これらを尋ね、記録する必要がありま す。 さらに、費用、アクセス性、機会などの課題を特定するた めの質問をする必要があります。評価者は、地域のレ ジャー施設やクラブ、学習教室、ボランティアサービス、 雇用相談サービスなどの利用の可能性について知っておく 必要があり、これらが高齢者の関心事になるかどうかを議 論しておくことが大切です。交通手段は重要な問題かもし れませんが、アクセスを良くすることによりサービスが利 用できるかもしれません。これらのサービスの中には、高 齢者や低所得者が参加できるように料金が補助されている ものもあります。 B11 高齢者虐待 介護を必要とする高齢者の多くは虐待を受けやすく、高齢 者の約6人に1人が何らかの虐待を経験しており、この数 字は以前の推定値よりも高くなっています（20）。虐待に は、ネグレクト、心理的虐待、身体的虐待、性的虐待、経 済的虐待など、さまざまな形態があります。 高齢者の行動、介護者や家族の行動、または身体的虐待の 兆候に基づく観察情報は、潜在的な虐待を特定するために 使用されるべきです。 虐待の疑いがある場合は、専 門家による評価と管理が必要です。あなたが懸念している こと、専門家の助けを求めることを高齢者に伝える必要が あります。あなたの懸念を記録し、高齢者に専門家の助け を求めることを伝えなければなりません。差し迫った脅威 を確認した場合は、ソーシャルワーク、市区町村、または 法的相談窓口を通じて、専門家による評価を依頼してくだ さい。 72 内在的能力や機能的能力の低下により介護が必要となった 場合、多くの場合、介護は配偶者、家族や家庭の別の人に かかってきます。高齢者のニーズに左右され、介護の負担 が介護者の健康状態を損ねることがあります。 地域レベルでの医療従事者や介護従事者は介護者の健康状 態を観察し、介護者自身の健康に必要なケアや介護の援助 を受けているか調査することができます。 キーポイント ◦ 内在的能力や機能的能力の有意な低下をきたした高齢者 への介護の負担やストレスは介護者として仕えている家 族や友人の健康を害する可能性があります。また、その 介護は彼らに―特に女性―とって無報酬で行われていま す。 ◦ 援助を必要としている介護者を見つけることは能力が低 下した高齢者を見出し対応する上でも重要な部分です。 ◦ 介護者へのさまざまな介入範囲―レスパイトケア、アド バイス、教育、財政支援や精神的介入―があり、それぞ れ満足で好ましい関係を維持できるよう介護者を支援で きます。 ◦ 介護は虐待を伴うことがあります。福祉従事者は高齢者 や介護者を評価し虐待のサインに気づくことがあります。 この時には、専門家への紹介が必要です。 11 介護者支援 介護者を支えるための ケア手順 73 YES YES YES 問い 問い この2週間以下のことに悩んでいますか： ̶気分の落ち込み、うつや絶望感？ ̶物事に対しほとんど興味を持てないまたは楽しめない？ 問い 介護のために所得の損失 さらに/もしくはさらなる支出に 直面していませんか？ 再評価 6ヶ月ごと 評価 介護者の気分 介護者支援を探る、例えば訓練、カウ ンセリング、指導、レスパイトケア、 また、デイケアや地域の介護活動、支 援ネットワークなど （iSupprotによる提案 https://www.isupportfordementia.org） 地域財政支援のオプションの 調査 公的介護制度とボランティア 協会のような地域サポートと の連携の強化 （…）を介護する仕事はあなたの 人生に負の影響を与えています か？ 介護としての仕事で他の支援が ないと思いますか？ ? ? （どちらかの問いで） （どちらかの問いで） NO NO NO YES うつ病の対応： mhGAP介入ガイド参照 https://apps.who.int/iris/handle/ 10665/250239 NO 1 Specialized care needed 支援や心理教育に伴う負担への取り組み 問題解決カウンセリングの提供 認知行動療法の提供 （両方の問いで） 11 介護者支援 介護者を支えるための ケア手順 74 11 介護者支援 介護者を支えるための ケア手順 •うつ病を治療するため •抑うつ症状を来した介護者への問題解決カウンセリン グや認知行動療法を提供するため •虐待関係を疑った時 専門的知識が必要な場合 人に主症状ー気分の落ち込み、うつ症状もしくは絶望感ま たは物事に対し興味や楽しみが持てないーが一つでも当て はまれば、さらに情緒の評価を行います。もし２つのスク リーニング問題での言葉に馴染まなければ別の言葉を使用 してもかまいません。 問い：“この2週間、次のような問題にどのくらい頻繁に 悩まされていますか？” •寝付きが悪い、途中で目が覚める、また逆に眠り過ぎる •疲れた感じがする、または気力がない •あまり食欲がない、または食べ過ぎる •自分はダメな人間だ、人生の敗北者だと気に病む、また自 分自身あるいは家族に申し訳ないと感じる •新聞を読む、またはテレビを見ることなどに集中すること が難しい •他人が気づくくらいに動きや話し方が遅くなる •そわそわしたり、落ち着かず、普段よりも動き回ることがある •死んだ方がまし、あるい自分を何らかの方法で傷つけよう と思ったことがある 介護者の情緒の評価 1 虐待のリスク 要介護者と介護者との相互関係は通常複雑です。健康で幸 せな介護者は異常なほどのサポートが可能ですが、時には 思いやりのある関係は片方または両者にとって有難くない ものになることがあります。これは高齢者が虐待を受けや すくなる問題を引き起こします。虐待はネグレクト、身体 的な優位性（例えば、財政的に）もしくは身体的、精神的、 性的虐待の形をとることがあります。ネグレクトは無知や 介護者の技術不足もしくは外部の支援や監督の欠如から起 こることがあります。高齢者も介護者も医療従事者に虐待 について言及しないかもしれません。高齢者の態度や介護 者や親せきの態度、また身体的虐待のサインに基づいた観 察情報は潜在的虐待を認識するために使用する必要があり ます。（第1０章社会的ケアと支援を参照） 虐待関係の可能性を高める要因とは： •長期的関係がとぼしい •家庭内暴力の既往 •介護者が必要とされる介護を一貫して行うことが困難； さらに •介護者の身体的、精神的問題、特にうつ病、特に男性で 飲酒や薬物乱用 虐待の可能性は、認知症者の行為により起こる課題のよう に、提供される介護の特質や介護者のストレスに関連する 要因が単独で関係している訳ではありません。 もし、虐待関係が疑われるなら地域の紹介手順に沿い、よ り詳細な専門家の評価が必要です。 ＊これらの質問はPatient Health questionnaire（PHQ-9）（http://www.cqaimh.org/pdf/tool_phq9.pdf）にのっており、 うつ症状の評価を行うツールの1つです。または、mhGAPの介入ガイドのうつ分野を参照にしてください。 http://apps.who.int/iris/handle/10665/250239 75 11.1 介護者への質問 74ページの手順が介護者との話し合いを手引きします。 この手順では面談を受けた介護者は3つの領域について質 問されます。 1. 介護の負担（2つの質問）、もしかすると介護者を支援 する実用的な戦略につながります。 2. うつ病の２つの主な症状、もしかするとうつ病の完全 な評価を行うことになるかもしれません（9章 うつ症 状参照）。 3. 介護者の財務コスト、もしかすると利用できる地域の 財政支援や組織化された社会的ケアの源泉につなぐこ とができるかもしれません。 介護者と話をするとき、医療従事者は疲労、怒り、不満や 無関心のサインを探します。また、医療従事者は介護者に 社会的ケア提供者からのさらなる評価や支援を望むむかど うか尋ねることができます。時間と共に、介護者の負担は 積み重なっていきます。6 ヶ月ごとの再評価が適切です。 率直にまたすべて話すことに対する介護者の困惑やためら いを軽減するため、介護者の役割や効果の評価は高齢者と 離れて行うことが最も望ましいです。 高齢者の認知機能の問題も踏まえると、高齢者と介護者の 評価は様々な理由で異なる場合があります。従って、評価 は固有の能力から得られた知識に照らし合わせて検討する 必要があります。 11.2 介護者のための支援の提供 医療従事者や介護従事者による支援や監修により、適切な 研修をうけた専門家や報酬のある介護者が無報酬の介護者 を支援するべきです。地域において、医療従事者や社会福 祉従事者―専門家またボランティアとも―無報酬介護者の 支援のための利用可能な資源を振り分けるネットワークを 形成することができます。 iSupportはWHOのオンライントレーニングプログラムで、 認知症の介護者が良い世話をする助けや介護者自身のケア を行っています。 https://www.isupportfordementia.orgを参照 支援は家族の主要な介護者に焦点をあてています。介護者 のニーズを理解するため、支援者はアドバイスや実用的な 支援や革新的な支援技術により援助できるケアを念頭にお きながら、介護者にどのようなことが行われているか、方 法や頻度を尋ねることができます。（77ページのBOX参 照）支援は介護者の選択を尊重し、介護者のウェルビーイ ングを最適化することを重視すべきです。 11 介護者支援 介護者を支えるための ケア手順 76 11 介護者支援 介護者を支えるための ケア手順 医療従事者や介護従事者が可能な事項 ◦ 介護者に特殊なケアの技術の提供―例えば困難な行動 の対応； ◦ レスパイトケアのような実質的な支援の提供や手配の 検討；そして ◦ 機能性能力を喪失した人が社会的給付や政府や非政府 からの社会的もしくは財政支援を受けることができる かの検討 アドバイスを与える。 介護者はかなりのイライラやス トレスを感じることがあります。それはまた高齢者と介護 者との以前の関係が失われていくという悲しい気持ちによ り複雑になります。特に介護者が配偶者のときにはなおさ らです。 介護者には可能なかぎり高齢者本人の人生やケアの意思決 定に関与しながら高齢者の尊厳を尊重するように働きかけ ます。 レスパイトケアの手配。 介護が負担や疲弊してきた時、 別の人が一時的に高齢者を監督し介護を行うことができま すか？専門の人やボランティアにかかわらず、家族や家庭 の別の人や研修を受けた介護従事者が行うことができます。 デイケアのような、レスパイトケアでは主な介護者から解 放され、休息を取ったり、他の活動を行ったりすることが できます。デイケアは地域支援の１つの形で、1週間に数 日、1日数時間、個別のケア（入浴、食事、散髪、排泄） やリハビリテーション、レクリエーションや社会活動プロ グラム、食事、移送を提供します。また、デイケアは介護 者のための家庭訪問、家族活動、支援グループや研修など を介護者に提供することができます。介護から少しの期間 離れることは介護関係を健全で持続可能な状態を維持する 助けになるかもしれません、また、通常の介護者から離れ る期間は要介護者にとっても有害なことではありません。 精神的サポートの提案。 特に、介護が複雑で広範にわ たり介護者の負担が大きくなった時、介護者の精神的スト レスに対し支援や問題解決カウンセリングを試みて下さい。 革新的補助技術 遠隔モニタリングや介助ロボットのような革新的補助医療 技術は、介護者はもちろん高齢者のQOLを改善し、高齢者 の機能的能力を高め、選択肢、安全性を増し、自立や自制 感を増加し、住み慣れた地域での生活を可能にするための 手段となる可能性があります。これらの技術の使用は高齢 者や介護者のニーズや自分たちの選択に基づくべきで、ま た、使用者には適切なトレーニングが必要です。研究や発 展のために資金調達システムを充実させることや公正な履 行を確実にする為には慎重な注意が必要です。 革新的補助技術の例： ◦社会的支援ロボットPARO。このロボットペットは仲間 付き合いを提供します（22）。 http://www.parorobots.com ◦ハイブリッド補助肢（HAL）腰タイプ。これは要介護者 をベッドから椅子や浴槽に抱き上げて移す際に必要とす る介護者の筋機能を補助します。 https://www.cyberdyne.jp/english/products/Lumbar_ CareSupport.html 77 キーポイント パーソンセンタードケアとは包括的かつ個別 に調整されたケアで、医療従事者と高齢者、 および高齢者を支える家族や友人の協力的な 関係によって支えられる 多職種チームは、高齢者が自身の目標を設定 することを助けることができる パーソンセンタードケアを支える介入につい ては、高齢者において優先されるニーズや目 標に鑑みて、合意に至るべきである 目標を達成するためには、継続的で定期的な フォローアップが必須である 個別化されたケアプランの作成 高齢者個人のためのケアプランをたてることは、伝統的な 疾患中心の方法とは異なる方向性をもつ人間的なアプロー チであり、かわりに高齢者のニーズや価値観、嗜好に焦点 を当てます。ひとたびこれらが記載されれば、医療および 社会福祉ケアのすべての面において、パーソンセンタード ケアのプランが主導して、現実的なニーズにあった目標を サポートします。 個別化されたケアプランを作成する ステップ １． 機能的能力、健康、ウェルビーイングを 向上させる機会をみなおし、議論する 高齢者とその家族および/あるいは介護者（必要に応じて） とともに、多職種チームは、ケアの過程で提案されたパー ソンセンタードケアの評価と介入を今から見直しましょう。 パーソンセンタードケアの評価は、ケアプランに含まれ、 患者と話し合うべき介入案のリストの作成につながるで しょう。ICOPE アプローチは、この過程で医療従事者の 役に立つことが出来ます。多職種チームには、プライマ リーケア医、専門医、看護師、地域のケアワーカー、ソー シャルワーカー、セラピスト（理学療法、作業療法、言語 聴覚、心理療法）、有償あるいは無償の介護者、薬剤師、 およびボランティアなど、高齢者のケアに関わるすべての 人が含まれます。 2．パーソンセンタードケア目標の設定 目標を特定、設定し、優先順位をたてるための、パーソン センタードケアの目標の設定は、ケアプラン作成において 重要な要素です。多職種チームには、高齢者に自身のケア に関する意思決定に関わらせること、そして、そのニーズ、 価値観、嗜好、および優先順位を理解し尊重することが、 重要です。このことは、現在、医療従事者が患者と関わる 方法の大きな改革です。 ケアの目標は、医学的な問題による直接的な影響を軽減す るだけでなく、高齢者が自身が最も価値をおくこと、すな わち、介助されずに安全にエイジング・イン・プレイスを 実現することであったり、個人的な成長を継続することで あったり、自立性と健康を保てる間は地域に関わり貢献す ることにより焦点をおくことを可能にします。中期から長 期的な（６から12か月）の目標に加えて、高齢者がやる 気を維持し関わり続け、急な変化あるいは恩恵を得るため 短期的な（３か月）ゴールも含めることが推奨されます。 12 78 5．モニタリングとフォローアップ ケアプランの実施を定期的にフォローアップしモニターす ることは、合意された目標を達成するために必須です。こ れは、進捗状況をモニターする機会をつくり、介入に参加 することの困難、介入の悪影響、機能状態の変化を早期に 発見することを可能にします。それはまた、高齢者とその ケア提供者との間の良好な関係を維持することを手助けし ます。フォローアップのプロセスには、以下の内容、その 他が含まれます。 ◦ ひとつひとつケアプランがうまく実施されていること を確認する ◦ パーソンセンタードケアのアセスメントを繰り返し、 変化があれば記録する ◦ 医学的および社会的ケア介入の実施における結果、障 害、合併症をまとめる ◦ 変化や新しいニーズを同定する ◦ 必要なときには新しい介入を採用することや、必要に 応じてプランを改め発展させることを含め、変化やニー ズに対応をさらに深めることに合意する ◦ このサイクルを繰り返す 3．介入への同意 パーソンセンタードケアのアセスメントと経過の結果とし て、ケアプランに加える介入を提案するにあたっては、次 のことが必要です。 ａ） 高齢者からの同意 ｂ） 高齢者の目標、ニーズ、嗜好、および優先順位にあ わせること ｃ） 身体的状態や社会的状況を含めて考えること 続いて、ケアワーカーやソーシャルワーカーは高齢者とそ れぞれの介入について、ひとつひとつ、最終のケアプラン に残すものについて同意をえるための議論をすべきです。 4．ケアプランの決定と共有 ここまできたら、医療従事者はケアプランのなかに議論の 結果を記録し、その記録を高齢者やその家族、介護者、お よびそのケアに関わりうる他の人々と共有し、同意を得る 必要があります。ICOPE mobile app は、優先順位の高 い目標や、定められた条件を含む、ケアプランの要約に従 事するすべてのひとを補助することで、このプロセスをサ ポートします。 12 機能的能力の領域 1． 財産の保全、住居の維持、身の回りの安全の ような基本的なニーズに対応できる。 2． 学び、成長し、決断すること。それには、知 識を学び応用することや、問題の解決に従事 すること、個人の成長を維持することへの努 力、そして選択する力が含まれる。 3． 動けること。このことは、家のまわりのこと をしたり、お店や地域のサービスや施設を使 用したり、社会的、経済的、文化的な活動に 参加するために必要である。 4． 子供や他の家族との関係性、および友人や近 所の人たち、同僚との非公式の関係性、およ び、地域のケアワーカーとの公式の関係性を 幅広く築き維持すること。 5． 貢献すること。このことは、社会的、文化的 な活動に従事することと強く関係する。これ には、友人や近所の人たちを助けたり、仲間 や若い人たちを指導したり、家族や地域のひ とたちの介助をしたりすることが含まれる。 79 目標をさだめる： 高齢者やその家族、介護者とともに目標をさだめま す（23）。： ◦ 質問1 あなたの人生のすべてにおいて、もっとも大切な ものを説明してください。 ◦ 質問2 あなたの人生で、いくつかの具体的な目標は何で すか？ ◦ 質問3 あなたの健康に関して、いくつかの具体的な目標 は何ですか？ ◦ 質問4 さきほど議論した、人生および健康に関する目標 に基づいて、これからの3か月に、あなたが集中 したいと思う3つを選んでいただけませんか。こ れからの6から12か月では、どうですか？ 目標を設定する： 目標は高齢者のニーズやかれらが感じる問題の定義 にあわせることができます。 ◦ 質問5 それぞれの目標１、２、３について、これからの 3か月、具体的に何に従事したいですか。これか らの6から12か月ではどうですか？ ◦ 質問6 現時点で、あなたは目標に関連して何をしていま すか？ ◦ 質問7 この目標を達成するにあたって、あなたにとって 理想的な、しかし可能なターゲットは何ですか？ 目標に優先順位をつける： 高齢者とケア提供者の間で優先順位をたてた目標の 合意は、よりよい結果の実現につながります。 ◦ 質問8 これらの目標のなかで、これからの3か月、どれ にあなたは最も従事したいですか。あなた一人で しますか、それとも（医師のXやそのチームから） 助けてもらいたいですか。これからの6から12か 月ではどうですか？ どのようにしてパーソンセンタードケアの目標設定するか 出典：Health Tapestry （http://healthtapestry.ca）より引用 12 80 キーポイント ICOPEによるアプローチを効果的に実施す るには医療と社会福祉サービスをつなぐ包括 的なアプローチが必要です。 高齢者の内在的能力や機能を最適化すること は、地域社会や地域で働く医療従事者から始 まります。 健康および社会部門のシステム は、地域のレベルに焦点を合わせたケアをサ ポートする必要があります。 個別のケアプランは、ICOPEアプローチの 中心です。これらの計画を実行し管理するた めに、従事者はケースマネジメントの特定の トレーニングを必要とする場合があります。 高齢化と健康に関するWHO World report は、医療・介護 制度の新たな方向性を示しています(1)。この報告書では、 高齢者の機能的能力を維持・向上させることを目的として、 高齢者の内在的能力の最適化に焦点を当てるよう、これら の制度に求めています。2017年に発表された「内在的能 力の低下を管理するためのコミュニティレベルの介入に関 するWHOガイドライン」は、この新しい方向性を、地域 レベルでの評価とケアの実践的な取り組みとして具体化し たものです（2）。これらは共に、パーソンセンタードな、 包括的な医療・社会的ケアと支援を発展させるものです。 この取り組みは、地域の医療・ケア従事者が実行可能な、 パーソンセンタードな健康と社会的ケアのニーズの評価か ら始まります。 本章では、ICOPE の取り組みを実装する際に考慮すべき 重要な点に焦点を当てます。ICOPE アプローチを実施す るためのシステムとサービスのための WHO ICOPE ガイ ダンスでは、実装について詳しく説明しています。 （https://apps.who.int/iris/handle/10665/325669） 医療・介護制度はWHO ICOPEの実装に どのように寄与するのか？13 81 13.1 実施のための国の支援 最初のステップとして、WHOの推奨事項とこのハンドブッ クの両方を、介護福祉士、介護者、および高齢者自身の地 域の状況や文化、言語に適合させる必要があります。 適応 に関する包括的な進め方は、まずは新しい取り組みに対す る幅広い支援を構築することから始めます。 ICOPEの取り組みを実施するには、政策立案者、医療専門 家、社会福祉従事者、研究者、地域社会、高齢者などの関 係者が、あらゆるレベルや段階で継続的に協力する必要が あります。 地域の知恵により、世界的なガイダンスを実現 可能で受容可能なサービスに翻訳することが可能となりま す。 ヘルシーエージングを促進するためには、医療と社会的ケ アの両部門の関与が必要です。国の政策が医療と社会的ケ アの包括的アプローチを支援していれば、両部門はICOPE の取り組みを採用し適用することができます。従って政策 は医療と社会的ケアの間の連携が国、地域、およびコミュ ニティレベルでどのように機能するかを明記する必要があ ります。 インセンティブと報酬、資金調達方法、取り組みに関する モニタリングにより、内在的能力と機能的能力を最適化す る高齢者のケアの優先順位を上げることができます。情報 システムは、国や地域のレベルでこの変革をモニタリング することに向けられるべきです。 13.2 予算と人的資源の要件 ICOPEの取り組みの実装化による効果を分析して、どこに 追加投資が必要かを特定する必要があります。たとえば、 医療従事者のトレーニング、テクノロジーの使用、健康情 報システムの適用などです。特に、地域保健および社会福 祉従事者、プライマリーケアチームは、新しい取り組みを 理解し、適用するための支援が必要となります。国や地域 の職能団体は、すべての利害関係者が関与する参加型取り 組みの一環として重要な役割を果たします。 13 国内導入のための重要な検討事項 ICOPE の取り組みを医療・介護制度に統合するためには、以下を確認する必要があります。 ◦ 実現可能性 ― 財政的、組織的 ◦ 持続可能性 ― 効率性と労働力 ◦ 一 貫 性 ― ヘルシーエージングを支援する政策との整合性 ◦ 統 合 ― 医療と社会的ケアサービスの連携 82 13.3 医療・社会的サービス間のケアと 支援の統合 すべての包括的ケアによる介入は、2005年にWHOが「関 連する利害関係者による知識の統合、交換、適用により、 医療制度の強化と人々の健康の改善における世界および地 域における新たな考え方・取り組みのメリットを加速する」 と定義したknowledge translation（学術成果の実装化） の原則に従う必要があります。WHOが2012年に発表した 「高齢化と健康に関するknowledge translationの枠組み」 は、特に複数の併存疾患や医療サービスへのアクセスが困 難な高齢者のケアに適用するために開発されました（24）。 WHOが2016年に発表した「人を中心とした統合医療サー ビスに関する枠組み」では、質の高い包括的ケアを実現す るための主要なアプローチが提案されています（6）。包括 的ケアの重要な要素は、医療・社会的ケアの複数の領域に またがる可能性が高いケアプランの設計、調整、およびモ ニタリングを支援する強力なケースマネジメントです。健 康と社会的ケアワーカーは、ケースマネジメントおよび ICOPE勧告の臨床的側面において特定のトレーニングを必 要とする場合があります。 WHO の ICOPE 実装の枠組みでは、ICOPE を実施するた めのサービスおよびシステムレベルでの重要な行動が強調 されています（25）。ガイダンスでは、包括的ケアを提供 するためにサービスやシステムの管理者がとるべき行動 （84ページ）を取り上げています。この枠組みでは、既存 の健康・社会サービスの範囲に応じて、具体的な行動を推 奨しています。 13.4 実施を支援するための地域の健康と 社会的ケアサービスの調整 ICOPEの介入は、ageing in placeを支援するという観点 から実施されるべきです。つまり、高齢者が自分の家や地 域で安全に、自立して、快適に暮らせるように、健康と社 会的ケアサービスを提供する必要があります。介入は、プ ライマリーケアと地域を基盤としたケアを優先したケアモ デルを通じて提供されるように設計されています。これに は、在宅介入、地域社会への参加、完全に包括的な紹介シ ステムなどが重点的に含まれます。 この焦点は、プライマリヘルスケアと国民皆保険へのアク セスを増やす上で地域医療従事者・ケア従事者が果たす重 要な役割を認識し、支援することによってのみ達成できま す。地域に根ざしたヘルスワーカーのプログラムを最適化 するための健康指針とシステム支援に関するWHOガイド ラインでは、地域の医療・ケア従事者の選択、訓練、核と なる能力、監督、および報酬に関するエビデンスに基づい た提案と推奨を行っています（26）。 13 Guidance for systems and services Implementation framework INTEGRATED CARE FOR OLDER PEOPLE https://apps.who.int/iris/handle/10665/325669 83 専門的なケアが必要な場合は、二次・三次レベルの医療従 事者のネットワークが、地域の医療従事者の活動を支援す る必要があります。明確な紹介基準と経路は、業務レベル ですべての関係者の合意を通じて確立され、品質保証のた めにモニタリングされなければなりません。ケアプランが 適切に維持され、ヘルスケアと支援の提供が効果的である ことを保証するために、フォローアップのための取り決め を明確にする必要があります。フォローアップと支援は、 健康状態に大きな変化があった場合や、高齢者が転居や配 偶者・介護者の死などの大きなライフイベントを経験した 場合に特に重要となります。 13 ICOPE 実装の枠組みからの活動の概要 サービスのための行動 人々やコミュニティを巻き込み、力を与える。 高齢者、その家族、市民社会をサービス提供に 関与させ、介護者を支援・訓練する。 多職種チームによるサービスの調整を支援する。 地域社会でケアを必要とする高齢者を特定し、 総合的な評価を行い、総合的なケアプランを作 成する、医療・社会福祉従事者のネットワーク を構築する。 サービスを地域密着型のケアに向ける。十分な インフラに裏打ちされた地域密着型の従事者と サービスを通じて、機能的能力に焦点を当てた 効果的で納得のいくケアを提供する。 システムのための行動 ガバナンスと説明責任のシステムを強化する。 政策とサービスの開発に利害関係者を参加させ る。包括的ケアと高齢者虐待への対応を支援す るための政策と規制を策定する。継続的な品質 保証と品質改善に着手する。ケアを公平に提供 する能力を定期的に評価する。 システム強化を可能にする。労働者の能力、資 金調達、人的資源管理を開発する。サービス提 供者間の情報交換のためのテクノロジーの活用。 内在的能力と機能的能力に関するデータを収集 して報告する。自己管理を支援するためのデジ タル技術の活用。 84 13.5 コミュニティへの参加と 介護者への支援 介護従事者は、地域社会の追加の資源の助けを必要として います。高齢者のケアと支援に地域社会や近隣がより積極 的かつ直接的に関与するためには、地域の組織化と政治的 な高い意識の両方が必要であり、特にボランティア活動を 奨励し、高齢のコミュニティメンバーの貢献を促進するこ とが必要です。高齢者のクラブや協会は、この取り組みの 自然な味方です。 同時に、ヘルスケアシステムは、健康的な高齢社会をサ ポートするパートナー、コミュニティ組織、高齢者の家族 やその他の無償の介護者に対して責任を負っています。こ の責任には、第11章で述べたように、介護者の健康と福 祉への配慮や、ヘルシーエージングのための健全な環境を 作るための地域社会や地域組織との相互支援、協力、調整 が含まれます。 85 REFERENCES 9. painHEALTH. 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Orientamento per la valutazione centrata sulla persona e percorsi nelle cure primarie www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organiza on Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int Orientamento per la valutazione centrata sulla persona e percorsi nelle cure primarie MANUALE © Università degli Studi di Palermo 2024 This transla on was not created by the World Health Organiza on (WHO). WHO is not responsible for the content or accuracy of this transla on. The original English edi on Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. Geneva: World Health Organiza on; 2019. Licence: CC BY- NC-SA 3.0 IGO shall be the binding and authen c edi on. This translated work is available under the CC BY-NC-SA 3.0 CONTENUTI: Ringraziamen iv Abbreviazioni v 1. ASSISTENZA INTEGRATA PER GLI ANZIANI (ICOPE) 1 2. OTTIMIZZARE CAPACITÀ E ABILITÀ: 5 VERSO UN INVECCHIAMENTO SANO PER TUTTI 3. VALUTARE I BISOGNI DEGLI ANZIANI SVILUPPARE 9 UN PIANO ASSISTENZIALE PERSONALIZZATO 4. PERCORSI ASSISTENZIALI PER LA GESTIONE 19 DEL DECLINO COGNITIVO 5. PERCORSI ASSISTENZIALI PER LA GESTIONE 25 DELLE CAPACITA’ MOTORIE 6. PERCORSI ASSISTENZIALI PER LA GESTIONE 33 DELLA NUTRIZIONE 7. PERCORSI ASSISTENZIALI PER LA GESTIONE 41 DEI DEFICIT VISIVI 8. PERCORSI ASSISTENZIALI PER LA GESTIONE 51 DELLA PERDITA DELL’UDITO 9. PERCORSI ASSISTENZIALI PER LA GESTIONE 59 DEI SINTOMI DEPRESSIVI 10. PERCORSI ASSISTENZIALI PER LA GESTIONE 67 DELL’ASSISTENZA E DEL SUPPORTO SOCIALE 11. PERCORSI ASSISTENZIALI PER 75 IL SUPPORTO AL CAREGIVER 12. ELABORAZIONE DI UN PIANO PERSONALIZZATO 78 13. COME I SISTEMI SANITARI E DI CURA A LUNGO 81 TERMINE POSSONO SUPPORTARE LA REALIZZA- ZIONE DI UN APPROCCIO ICOPE DELL’OMS Referenze 86 III RINGRAZIAMENTI Questo opuscolo è stato realizzato grazie al lavoro di molte persone provenien da tu o il mondo e si focalizza su come prendersi cura e supportare le persone anziane. Islene Araujo de Carvalho e Yuka Sumi del Dipar mento dell’invecchiamento e del corso della vita dell’Organiz- zazione Mondiale della Sanità (OMS) hanno contribuito alla preparazione di questo opuscolo. Il gruppo di lavoro include Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Cur n University, Australia) e Finbarr Mar n (King’s College London, United Kingdom). Sarah Johnson e Ward Rinehart del Servizio editoriale di Jura sono responsabili della redazione del testo finale. Mol altri componen dell’OMS provenien dagli uffici regionali e dai dipar men , hanno contribuito in specifiche sezioni riguardan le loro aree di lavoro e nello sviluppo dei percorsi di cura: Shelly Chadha (Dipar - mento della ges one dei disturbi di comunicazione, disabilità violenza a prevenzione delle lesioni dell’OMS), Neerja Chowdhary Dipar mento della salute mentale e dell’abuso di sostanze dell’OMS), Tarun Dua (Dipar - mento di Sviluppo e Salute dell’OMS), Zee A Han (Dipar mento della ges one dei disturbi di comunica- zione, disabilità violenza a prevenzione delle lesioni), Dena Javadi (Dipar mento dell’alleanza per le Poli che di Salute e dei Sistemi di Ricerca dell’OMS), Silvio Paolo Mario (Dipar mento della ges one dei disturbi di comunicazione, disabilità violenza a prevenzione delle lesioni dell’OMS), Alarcos Cieza (Dipar mento della ges one dei disturbi di comunicazione, disabilità violenza a prevenzione delle lesioni dell’OMS), Alana Margaret Officer (OMS Dipar mento dell’invecchiamento e del corso della vita), Juan Pablo Peña-Rosas (Dipar mento della nutrizione per la Salute e lo Sviluppo dell’OMS), Taiwo Adedamola Oyelade (Unione Famiglia e Salute della riproduzione, dell’OMS, dipar mento dell’Africa), Ramez Mahaini (Salute Materna e della riproduzione, ufficio regionale per il Mediterraneo dell’est dell’OMS), Karen Reyes Castro (OMS Dipar mento della ges one dei disturbi di comunicazione, disabilità violenza a prevenzione delle lesioni), Enrique Vega Garcia (Vita salutare, Organizzazione della salute Pan America dell’OMS). Questa guida ha beneficiato di numerosi s moli provenien da numerosi esper accademici che hanno contribuito alla stesura di capitoli specifici: Ma eo Cesari (Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy), Jill Keeffe (OMS, Centro di colla- borazione per la Prevenzione della cecità India), Elsa Dent (The University of Queensland, Australia), Naoki Kondo (University of Tokyo, Japan), Arunee Laiteerapong (Chulalongkorn University, Thailand), Mikel Izquierdo (Universidad Pùblica de Navarra, Spain), Peter Lloyd- Sherlock (University of East Anglia, United Kingdom), Luis Miguel Gu errez Robledo (Ins tutos Nacionales de Salud de México, Mexico), Catherine McMahon (Macquarie University, Australia), Serah Ndegwa (University of Nairobi, Kenya), Hiroshi Ogawa (Niigata University, Japan), Hélène Paye e (Università de Sherbrooke, Canada), Ian Philp (University of S rling, United Kingdom), Leocadio Rodriguez-Mañas (University Hospital of Getafe, Spain), John Starr (University of Edinburgh, United Kingdom), Kelly Tremblay (University of Washington, United States of America), Michael Valenzuela (University of Sydney, Australia), Bruno Vellas (OMS, Centro di Collaborazione per la Fragilità Ricerca Clinica e Pra ca Geriatrica, Gérontopôle, Toulouse University Hospital, France), Marjolein Visser (Vrije Universiteit Amsterdam, the Netherlands), Kris na Zdanys (University of Connec cut, United States of America), e l’OMS Centro di collaborazione per la Fragilità la Ricerca Clinica e la pra ca geriatrica (Gérontopôle, Toulouse University Hospital, France) e per la Salute pubblica riguardan gli aspe della salute muscoloscheletrica e dell’invecchiamento (University of Liège, Belgium). Il concilio sulla salute nazionale australiana e della ricerca medica, alleanza globale per la salute muscolo-scheletrica e dell’Università di Chulalongkorn, Thailandia, hanno supportato lo sviluppo di questa guida, fornendo perso- nale per lo sviluppo di contenu e organizzando incontri tra gli esper . Inoltre sono sta presi in considerazione gli input provenien dai partecipan all’incontro annuale del Clinical Consor um on Healthy Ageing, tenutosi a Dicembre 2018. Il WHO Department Ageing and Life Course riceve il supporto finanziario dal Governo del Giappone, dal Governo tedesco e dal Kanagawa Prefectural Gover- nment in Japan. Scri o da Green Ink. IV ABBREVIAZIONI ADLs ac vi es of daily living [a vità della vita quo diana] BMI body mass index [indice massa di corporea] CBT cogni ve behavioural therapy [terapia cogni vo comportamentale] ICOPE integrated care for older people [assistenza integrata per gli anziani] MNA mini nutri onal assessment [valutazione nutrizionale] OSN oral supplemental nutri on [supplementazione nutrizionale orale] PTA pure tone audiometry [audiometria tonale] SPPB short physical performance ba ery [test di performance motoria] WHO World Health Organiza on [Organizzazione Mondiale della Sanità] Sono necessarie conoscenze e competenze specifiche per supportare le cure. V
SALUTE INTEGRATA PER LE PERSONE ANZIANE (ICOPE) Nel 2015, il World Report on Ageing and Health, ha definito gli obie vi per un invecchiamento in salute per aiutare le persone a sviluppare e a mantenere le abilità funzionali garantendo uno stato di benessere. Le capacità funzionali sono definite come “A ribu salute-correla che permet- tono alle persone di essere e svolgere quello che per loro ha valore”. Le abilità funzionali consistono nella capacità intrinsica dell’individuo, nell’ambiente, e dall'interazione fra i due. (1) La capacità intrinseca è “l’insieme delle capacità fisiche e mentali di cui la persona dispone nel corso di tu a la sua vita (1). Il conce o di invecchiamento in salute può guidare un nuovo focus sulle cure nell’età avanzata, un focus per o mizzare le capacità intrinseche e le abilità funzionali dell’anziano. Nell’O obre del 2017, l’Organizzazione Mondiale della Sanità (OMS) ha pubblicato le seguen linee guida per le persone anziane: Integrated care for older people: Guidelines on community-level interven ons to manage declines in intrinsic capacity (2). Queste linee guida includono 13 raccomandazioni basate sulle evidenze rivolte agli operatori sanitari, per aiutarli a sviluppare e me ere in pra ca cure integrate per le persone anziane in comunità. L’approccio di ICOPE costruisce un focus per o mizzare le capacità intrinseche e le abilità funzionali come chiave per invecchiare in salute. Queste raccomandazioni possono essere le basi su cui costruire le linee guida nazionali. Inoltre, possono essere usate per sostenere l’inclusione, con un programma di cure primarie ed un pacche o di cure essenziali per la ges one dei servizi di prevenzione per una copertura sanitaria universale, prevenendo la dipendenza dall'assistenza e dalle cure. 1 PUNTI CHIAVE 4 I sistemi sanitari possono promuovere un invec- chiamento in salute supportando le capacità intrinseche e le abilità funzionali che normalmente vengono meno con l’avanzare dell’età. 4 La dipendenza dalle cure può essere prevenuta se le condizioni associate al declino delle capacità intrinseche sono prontamente diagnos cate e ges te. 4 Seguendo le linee guida, gli operatori nell’ambito delle cure primarie, nei se ori sanitari e nel supporto sociale possono iden ficare gli anziani con perdita delle capacità e promuovere cure adeguate a inver re o rallentare questa perdita. Questo approccio è semplice ed economico. 4 Condizioni associate al declino della capacità intrinseca sono correlate e quindi richiedono un approccio integrato e centrato sulla persona. 1 I suggerimen da in questo manoscri o aiuteranno gli operatori nei se ori della salute e della cura a me ere in pra ca le raccomandazioni di ICOPE. Queste offrono percorsi di cura prioritari per la ges one di condizioni salute associate che determinano un deterioramento delle capacità funzionali: perdita delle funzioni motorie, malnutrizione, difficoltà visive, perdita dell’udito, declino cogni vo, sintomi depressivi. Ques percorsi iniziano con test di screening che interce ano la persona anziana che, in quel momento, e ̀ più ̀ probabilmente a rischio di perdere le capacità intrinseche. Gli operatori sociosanitari possono facilmente u lizzare ques screening nelle comunità̀ in cui operano. Questo è solo un primo passo per una conoscenza approfondita delle cure e del supporto sociale di cui hanno bisogno le persone anziane. Questa valutazione vuole fornire un piano di cure personalizzato che integra le strategie per rendere reversibile, rallentare o prevenire il declino delle capacità intrinseche e funzionali, tra are la mala a o andare incontro ai bisogni sociali. La valutazione incentrata sulla persona e lo sviluppo del piano di cura, generalmente richiedono operatori sanitari addestra in ambito delle cure primarie, come medici e infermieri delle cure primarie. In ogni caso, la perdita delle capacità funzionali può essere ges ta da un team mul disciplinare, sul territorio dove vivono gli anziani e il caregiver. PERCHÈ ABBIAMO BISOGNO DI CURE INTE- GRATE PER LE PERSONE ANZIANE (ICOPE)? Le persone anziane ormai cos tuiscono gran parte della popolazione mondiale. Nel 2017, si è s mato che 962 milioni di persone nel mondo avranno più di 60 anni, comprendendo il 13% della popolazione globale (3). Questa percentuale crescerà rapidamente nel giro di una decade sopra u o nei paesi a basso e medio reddito. A par re dal 2050, una persona su 5 avrà più di 60 anni. Questo trend è iniziato da circa 50 anni e rifle e la combinazione dei tassi di fer lità in rapida diminuzione e un aumento delle aspe a ve di vita nella maggior parte del mondo, spesso accompagnato dallo sviluppo socioeconomico. Mantenere in salute i nostri anziani deve essere visto come un inves mento in capitale umano e sociale, supportando le Nazioni Unite per obie vi di sviluppo sostenibile (4). Allo stesso tempo, prendersi cura della crescente popolazione anziana crea sfide per i sistemi sanitari. Le risorse economiche per la cura e la salute dovranno necessariamente essere ridistribuite tra i vari gruppi di età. È necessario un cambiamento nell’ap- proccio alla salute pubblica dell’anziano. Gli approcci convenzionali all'assistenza sanitaria degli anziani si sono concentra sulle condizioni mediche, me endo la diagnosi e la ges one di ques al centro. Affrontare queste mala e rimane importante, ma focalizzarsi troppo su questo obie vo può trascurare aspe fondamentali come l’udito, la vista, la memoria, il movimento, e la perdita delle capacità funzionali che comunemente vengono perse con l’avanzare dell’età. Il benessere di tu e le persone deriva allo stesso tempo dall’iden ficazione e dalla ges one di tu ques problemi. L’a enzione posta sulle capacità intrinseche degli anziani potrà contribuire, a raverso sistemi di Salute-Cura, in linea di massima al benessere di una larga e crescente parte della popolazione. A mol professionis del se ore salute manca la guida e la formazione per riconoscere e effe vamente ges re il declino delle capacità intrinseche. Si percepisce crescente pressione, dovuta anche al crescere della popolazione anziana, di sviluppare approcci globali community based che includano interven di pre- venzione del declino delle capacità intrinseche, per favorire un invecchiamento sano e supportare i caregiver. L’approccio su cui si basa ICOPE risponde a questa esigenza. A CHI È RIVOLTA QUESTA GUIDA? Questa guida si rivolge prima di tu o ai professionis della salute e ai lavoratori nell’ambito sociosanitario sia sul territorio che nell’ambito delle cure primarie.La guida ha lo scopo di informare i lavoratori del se ore che saranno chiama , a seconda delle necessità, ad assistere e programmare un piano di cure per tu e quelle persone che perdono le loro abilità funzionali e la capacità intrinseche. 2 COSA OFFRE? Questa guida si propone di supportare i lavoratori della sanità e del sociale che svolgono le loro a vità sul territorio per individuare e ges re il declino delle capacità funzionali nelle persone anziane basandosi sulle linee guida tracciate dall’Oms nel documento “Linee guida sui livelli di intervento per ges re il declino delle capacità intrinseche (2) e per indirizzare i bisogni clinici e sociali degli anziani in modo completo. Questa guida: • Fissa obie vi incentra sulla persona (Capitolo 2); • Supporta l’autoges one (Capitolo 2) • Sviluppa un piano che include mul pli interven di ges one delle condizioni associate alla perdita delle capacità intrinseche (Capitolo 3); • Protegge dalla perdita delle capacità intrinseche e valuta i bisogni sociali e clinici (capitolo 4–10); • Supporto del caregiver (capitolo 11); e • Sviluppo di un piano di cure personalizzato (capitolo 12). L’approccio ICOPE Questa guida si propone di supportare i lavoratori della sanità e del sociale che svolgono le loro a vità sul territorio per individuare e ges re il declino delle capacità funzionali nelle persone anziane basandosi sulle linee guida tracciate dall’Oms nel documento “Linee guida sui livelli di intervento per ges re il declino delle capacità intrinseche (2) e per indirizzare i bisogni clinici e sociali degli anziani in modo completo. La copertura sanitaria universale è basata sul raggiungi- mento dell'obie vo sanitario per lo sviluppo sostenibile (4). Per il raggiungimento di ques ul mi, la salute e l’assistenza sociale delle persone anziane necessita di essere indirizzata nel giusto modo e con con nuità di cure nel lungo periodo. La strategia dell’organizzazione mondiale della sanità e il proge o sull’invecchiamento e sulla salute (5) so olinea il ruolo dei sistemi sanitari nella promozione di un invecchiamento in buona salute o mizzando le capacità intrinseche. Le raccomandazioni di ICOPE (2) e questa guida contri- buisce a porre le basi per il raggiungimento di ques obie vi. Questa guida è anche uno strumento per implementare la rete dei servizi di salute incentra sulla persona (6). La stru ura richiede di cambiare il modo in cui i servizi sanitari vengono ges ed eroga , a raverso un approccio integrato, incentrato sulla persona. In questo contesto, ICOPE, propone una sanità basata su: ● La valutazione dei bisogni, preferenze ed obie vi; ● Lo sviluppo di un piano di cure personalizzato; ● Una rete di servizi coordina , guida a raverso l’obie vo di mantenere le capacità intrinseche e le abilità funzionali e salvaguardare il più possibile a raverso cure primarie e di comunità. Inoltre, i professionis responsabili della formazione nei campi della medicina, dell'assistenza infermieris ca e della salute e della sanità pubblica possono a ngere sia ai conce che agli approcci pra ci qui di seguito descri . Altro pubblico a cui è rivolto questo lavoro è sicuramente quello dei managers della salute pubblica e dei servizi della salute, come le is tuzioni nazionali, regionali o locali che programmano piani organizza vi dei servizi pubblici, così come le agenzie che finanziano e/o realizzano programmi di salute pubblica o le organizzazioni non governa ve e gli en di beneficenza che servono gli anziani in contes comunitari PRINCIPI GUIDA Alla base di questa guida vi sono i seguen principi: 4 Gli anziani hanno diri o alla migliore salute possibile. 4 Gli anziani dovrebbero avere pari opportunità di accedere ai determinan dell’invecchia- mento in buona salute, indipendentemente dallo status sociale o economico, dal luogo di nascita o residenza o altri fa ori sociali. 4 L'assistenza dovrebbe essere fornita equa- mente a tu , senza discriminazione, soprat- tu o senza discriminazione basata sul sesso o sull’età. 3 4 OTTIMIZZARE CAPACITÀ E ABILITÀ ATTRAVERSO UN INVECCHIAMENTO SALUTARE PER TUTTI.2 Il report mondiale dell’OMS sull’invecchiamento e la salute, definisce un invecchiamento in salute come il mantenimento e lo sviluppo di abilità funzionali che favoriscono il benessere. Questa guida supporta l’invecchiamento in salute interce ando prima di tu o le condizioni associate con il declino delle capacità intrinseche (figura 1), i bisogni delle persone anziane e il supporto al caregivers. • Declino cogni vo (capitolo 4) • Rido a mobilità (capitolo 5) • Malnutrizione (capitolo 6) • Deficit visivi (capitolo 7) • Perdita dell’udito (capitolo 8) • Sintomi depressivi (capitolo 9) • Assistenza sociale (capitolo 10) • Supporto al caregiver (capitolo 11) "COME LA PERDITA DELLE CAPACITÀ INTRINSECHE PUÒ CAMBIARE IL CORSO DELLA VITA?” La Figura 2 mostra il pico pa ern delle capacità intrinseche e funzionali della vita adulta. Entrambe vanno incontro ad un declino con l’avanzare dell’età, come risultato di un processo di invecchiamento che si rende evidente sopra u o durante la mala a. Questo pa ern pico può essere diviso in tre fasi: un periodo di rela va alta stabilità, un periodo in cui vi è un iniziale declino delle capacità intrinseche e un periodo di significa va perdita delle capacità, cara erizzato dalla dipendenza dalle cure. FIGURA 1. PRINCIPALI DOMINI DELLA CAPACITA’ INTRINSECA Capacità motoria Capacità psicologica Capacità cogni va Vitalità Capacità visiva Capacità udi va 5 INTERVENTI PER OTTIMIZZARE LE CAPACITÀ INTRINSECHE Iden ficare le condizioni associate alla perdita delle capacità intrinseche può offrire l’opportunità ̀ di intervenire per rallentare, stoppare o ribaltare il declino (Figura 2). I professionis della sanità nei diversi se ng clinici e sul territorio possono cercare segni dis n vi dell’invecchiamento associato con il declino delle capacità intrinseche. Ripetere questa valutazione nel tempo può garan re il monitoraggio dei cambiamen così da offrire prontamente interven mira alla perdita delle abilità perse. In questo modo gli interven che vengono eroga nei diversi se ng possono evitare che una persona diven fragile o dipendente dall’assistenza. Gli interven mul disciplinari sembrano essere i più efficaci. Differenze nelle capacità intrinseche sono presen all'interno dello stesso Paese e fra i paesi. Questo si rifle e ampiamente nelle aspe a ve di vita, dove a raggiungere un’età uguale o maggiore di 82 anni sono Paesi quali l’Australia, il Giappone e la Svizzera, minore di 55 anni sono invece Nazioni come quelle delle Repubbliche centro-africane, Chad e Somalia. La variazione della capacità intrinseca è di gran lunga maggiore tra le persone in età avanzata rispe o alle più giovani, uno dei segni dis n vi dell’invecchiamento. Un individuo può avere un’età maggiore di dieci anni rispe o ̣ ad un’altro individuo, ma avere simili abilità intrinseche e/o abilità funzionali. Questo è il mo vo per cui l'età cronologica non è indica va dello stato di salute. CAPACITÀ INTRINSECA E ABILITÀ FUNZIONALE L’OMS definisce la capacità intrinseca come la combinazione delle capacità fisiche e mentali (inclusa quella psicologica) di un individuo. Le abilità funzionali sono la combinazione e l’interazione della capacità intrinseca con l’ambiente in cui l’individuo è inserito. ...[ ] 6 Molte delle cara eris che che determinano la capacità intrinseca sono modificabili. Ciò include i comportamen rela vi alla salute e la presenza di mala e. Pertanto, vi è un forte mo vo per a uare interven efficaci vol all'o mizzazione capacità intrinseca. Questa è la logica fondamentale dell'approccio ICOPE e di questa linea guida. I diversi problemi di salute associa alla perdita di capacità intrinseca interagiscono su più livelli. La perdita dell'udito, ad esempio, è associata al declino cogni vo, la nutrizione aumenta l'effe o dell'esercizio e ha un impat- to dire o sull'aumento della massa muscolare e della forza. Queste interazioni richiedono un approccio integrato allo screening, alla valutazione e alla ges one della perdita di capacità intrinseca. SERVIZI DELLA SALUTE: CURE A LUNGO TERMINE: AMBIENTE: FIGURA 2. UNA STRUTTURA DI SANITA’ PUBBLICA PER UN INVECCHIAMENTO IN SALUTE APPROCCIO ICOPE Rimuovere le barriere compensare la perdita delle capacità Capacità elevata e stabile Capacità in declino Perdita significa va della capacità Abilità funzionale Capacità intrinseca Prevenire condizioni di cri cità o garan re la sua iden ficazione e controllo precoce Inver re o rallentare la perdita di capacità Ges one delle condizioni croniche avanzate Supportare i comportamen che migliorano le capacità Garan re una vita dignitosa a fine vita Promuovere i comportamen che migliorano le capacità Fonte Organizzazione mondiale della sanità, 2015 (1) 7 8 La cura basata sulla persona si basa sul principio che le persone anziane sono molto di più delle loro mala e o delle condizioni di salute associate; tu e le persone, a prescindere dall’età, sono individui unici nelle loro esperienze, bisogni e preferenze. La cura basata sulla persona si rivolge ai bisogni di cura e di supporto sociale piu osto che ad una mala a isolata o ad un sintomo. Un approccio integrato inoltre considera l’individuo nelle sue a vità quo diane, incluso l’impa o sulla salute e le necessità non solo sue ma anche di chi lo circonda o della comunità stessa. Ci sono cinque steps che dovrebbero essere considera in un approccio di cure integrato basato sui bisogni e sulla cura del sociale delle persone anziane, come dimostrato nella figura seguente. VALUTAZIONE DEI BISOGNI DELLE PERSONE ANZIANE E SVILUPPO DI UN PIANO PERSONALIZZATO.3 PUNTI CHIAVE 4 L’iden ficazione di persone anziane nelle co- ̀munità con condizioni preesisten associate ̀con il declino delle capacità intrinseche può essere effe uata a raverso l’integrazione tra la cura della persona (ICOPE) e gli strumen di screening. 4 ICOPE ha iden ficato come queste condizioni si riferiscano sopra u o agli ambulatori di cure primarie per una valutazione approfon- dita che aiu nello sviluppo di un piano di cure personalizzato. 4 ̀ Il piano di cure può includere mul pli inter- ven per ges re il declino delle capacità intrinseche e o mizzare le abilità funzionali, come per esempio l’esercizio fisico, la sup- plementazione orale di nutrien , la s mola- zione cogni va e la prevenzione domes ca delle cadute. 9 Manuale di cura generico Valutazione incentrata sulla persona e percorso per le cure primarie 3 ORGANIZZAZIONE DALLA PERDITA DELE CAPACITÀ INTRÍNSECA IN COMUNITÀ FASE 1 ORGANIZZAZIONE FASE 2 VALUTAZIONE INCENTRATA SULLA PERSONA NELLE CURE PRIMARIE SI SI SI Perdita della capacità intrinseca Rinforzare l’orientamento generico sulla salute, sugli s li di vita o cure abituali VALUTARE IN MODO DETTAGLIATO VALUTARE PIÙ IN PROFONDITÀ LE CONDIZIONI ASSOCIATE ALLA PERDITA DELLE CAPACITÀ INTRINSECHE Comprendere la vita, i valori, le priorità o contesto sociale dell’anziano VALUTAZIONE E GESTIONE DELLE MALATTIE SOTTOSTANTI VALUTAZIONE E GESTIONE DELL’AMBIENTE SOCIALE E FISICO Interven a livello comunitario per la ges one della perdita delle capacità intrinseche l Ges one integrata della mala a l Riabilitazione l Cure pallia ve e di fine vita l Piano di assistenza e cure sociali l Rimuovere le barriere l Ada amento ambientale l VALUTARE LA NECESSITÀ DEI SERVIZI DI ASSISTENZA SOCIALE (domiciliare, is tuzionali) 10 FASE 3 ELABORAZIONE DI UN PIANO DI CURE PERSONALIZZATO l Definire gli obie vi centra sulla persona Equipe mul disciplinarel Elaborare un piano di cure che includal interven mul disciplinari, ges re le mala e so ostan , cura di sè e autoges one, assistenza e cura FASE 4 GARANTIRE IL MONITORAGGIO DEL PIANO DI CURE CON COLLEGAMENTO ALL’ASSISTENZA GERIATRICA SPECIALIZZATA FASE 5 COINVOLGERE LA COMUNITÀ E SOSTENERE IL CAREGIVER 11 TABELLA 1. STRUMENTI DI SCREENING ICOPE Condizioni prioritarie associate Test/esami Valutare tu i domini segnando i cerchi alla perita della capacità intrinseca DECLINO COGNITIVO 1. Ripetere le tre parole: cane, casa, ga o (per esempio) (Capitolo 4) 2.Orientamento nel tempo e nello spazio: Errore o non sa rispondere Qual é la data completa di oggi? Dove si trova (casa, clinica, etc.)? a nessuna delle domande 3.Ricorda le tre parole? Non è in grado di ricordare le tre parole RIDUZIONE DELLA MOBILITÀ Test della sedia: Alzarsi dalla sedia 5 volte senza l’uso delle braccia. NO (Capitolo 5) La persona riesce a farlo 5 volte in meno di 14 secondi? MALNUTRIZIONE 1. Perdita di peso: Ha perso più di 3 kg senza volerlo negli ul mi 3 mesi? SI (Capitolo 6) 2.Perdita di appe to: ha riscontrato una perdita di appe to? SI DEFICIT VISIVO Ha problemi di vista? Difficoltà nella visione da lontano (Capitolo 7) difficoltà nella le ura, mala e della vista o è a ualmente SI in tra amento medico (esempio, per il diabete o pressione alta)? PERDITA DELL’UDITO Sente i sussurri (test del sussurro) o (Capitolo 8) L’Audiometria di screening ha riscontrato 35 dB o meno o TEST FALLITO Supera il test automa co (in app) digitale dei rumori SINTOMI DEPRESSIVI Nelle ul me due se mane ha provato (Capitolo 9) Umore deflesso, depresso o si è sen to senza speranze? SI Poco interesse o piacere nel fare qualcosa? SI 12 FASE 1 VALUTAZIONE DELLA CAPACITÀ INTRINSECA U lizzando il processo e gli strumen contenu in questa guida, gli operatori sanitari qualifica possono eseguire l'iden ficazione iniziale delle persone con perdita delle capacità intrinseche nella comunità o a casa. Basta u lizzare gli strumen di screening ICOPE (Tabella 1). Lo strumento di screening ICOPE è il primo passo in ciascuno dei percorsi assistenziali presenta nei capitoli 4-9 e considera sei condizioni rela ve ai domini delle capacità intrinseche (Figura 1, pagina 5). Le strategie di sensibilizzazione della comunità, come le visite domiciliari da parte degli operatori sanitari della comunità e l'autovalutazione supportata dalle tecnologie dei telefoni cellulari, possono essere u lizzate per la ricerca a va dei casi. Chi mostra segni della perdita di capacità già in questo primo passaggio deve so oporsi ad una valutazione completa. È probabile che una valutazione completa richieda operatori sanitari con una formazione specifica, di solito, ma non necessariamente, di un medico. Gli operatori sanitari e sociali dovrebbero garan re che l’iden ficazione dei limi della capacità intrinseca siano segui da un'ulteriore valutazione. I risulta di questa valutazione dovrebbero servire come contributo all'elaborazione del piano di assistenza personalizzato. La diagnosi di qualsiasi mala a di base, come il morbo diAlzheimer, la depressione, l'artrosi, l'osteoporosi, la catara a, il diabete e l'ipertensione, è essenziale per la valutazione incentrata sulla persona. Queste diagnosi possono richiedere esami complessi non sempre disponibili presso i servizi sanitaria di base. A seconda del contesto, può essere necessario indirizzare il paziente a un servizio geriatrico specialis co di livello secondario o terziario. 2D. Valutazione dell’ambiente sociale e fisico e delle necessità di assistenza sociosanitaria Valutare gli ambien sociali e fisici e iden ficare qualsiasi esigenza di servizi sociali e di supporto è fondamentale per le persone con perdita di capacità intrinseca. Questa è una parte essenziale della valutazione centrata sulla persona nelle cure primarie. Per individuare i bisogni di assistenza sociale, si può chiedere all'anziano se può svolgere le diverse a vità della vita quo diana senza l'aiuto di altri. La tabella presentata nel capitolo 10 include una serie di domande per valutare e determinare i bisogni dell'assistenza sociale in genere. Inoltre, ogni guida all'assistenza presentata nei capitoli 4-9 indica possibili esigenze di assistenza sociale specifiche per ciascuna condizione di salute associata. FASE 2 REALIZZAZIONE DI UNA VALUTAZIONE INCENTRATA SULLA PERSONA NELL’ASSISTENZA PRIMARIA La valutazione dei bisogni assistenziali sociosanitari incentra sull'anziano, effe uata nelle cure primarie, è essenziale per o mizzare le capacità intrinseche. 2A. Comprendere la vita degli anziani Una valutazione dell'anziano inizia non solo con un'anamnesi convenzionale, ma con una comprensione completa della vita, dei valori, delle priorità e delle preferenze della persona in relazione alla sua salute e alla ges one di questa 2B. Valutazione de agliata delle condizioni associate alla perdita della capacità intrinseca La valutazione si occupa più da vicino di condizioni associate alla perdita delle capacità intrinseche. Inoltre, a enziona le condizioni chiave che interessano i diversi domini delle capacità stesse. I percorsi assistenziali, presen nei capitoli 4-9, sono generalmente organizzate in tre componen : screening comunitario iniziale, valutazione delle cure primarie nel mezzo e un piano di assistenza personalizzata alla fine. 2C. Valutazione e ges one delle mala e di base Dovrebbero essere studiate possibili mala e croniche so ostan , così come la polifarmacoterapia (uso di più farmaci). La polifarmacoterapia ed eventuali effe avversi che ne derivano, possono causare la perdita in diversi domini della capacità intrinseca e pertanto meri- tano sempre un'indagine (vedi riquadro Polifarma- coterapia, pagina 18). 13 3 Il sostegno alla cura di sé consiste nel fornire agli anziani le informazioni, le competenze e gli strumen necessari per ges re le loro condizioni di salute, evitare complicazioni, massimizzare le loro capacità intrinseche e mantenere la qualità della vita. Questo non significa che le persone anziane dovranno "fare tu o da soli" o che verranno loro poste richieste irragionevoli o eccessive. Invece, riconoscere la loro autonomia e capacità di dirigere la propria cura, con il consiglio e la collaborazione degli operatori sanitari, le loro famiglie e altri caregiver. L'inizia va mHealth for Aging (mAgeing) dell'OMS può integrare l'assistenza di rou ne per gli operatori sanitari sostenendo l'auto-cura e l'autoges one. Fornendo informazioni sulla salute, consigli e promemoria tramite telefoni cellulari, l'inizia va incoraggia comportamen sani e aiuta gli anziani a migliorare e mantenere le loro capacità intrinseche. Per ulteriori informazioni sull'impostazione di un programma di mAgeing e suggerimen per i messaggi di texto, vedere h ps://www.who. Int/invecchiamento/sistemi-sanitari/mAgeing. Disponibile in lingua inglese FASE 3 DEFINIRE GLI OBIETTIVI DI CURA ED ELABORARE UN PIANO DI CURE PERSONALIZZATO 3A. Definire gli obie vi di cura insieme agli anziani. Gli obie vi necessari per o mizzare la capacità intrinseca e l'abilità funzionale aiutano a garan re l'integrazione delle cure, oltre a fornire l'opportunità di monitorare l'evoluzione dell'anziano e l'impa o degli interven . È essenziale che gli anziani e i caregiver siano coinvol nel processo decisionale e nella definizione degli obie vi fin dall'inizio, e gli obie vi sono defini e ordina in ordine di priorità in base alle priorità, ai bisogni e alle preferenze della persona. 3B. Elaborare un piano di cura. La valutazione incentrata sulla persona serve come contributo allo sviluppo di un piano di assistenza personalizzato. Il piano di assistenza personalizzato u lizza un approccio integrato per implementare interven che affrontano la perdita in più domini di capacità intrinseca. Tu gli interven devono essere considera e applica insieme. 14 3 Questo approccio integrato è importante perché la maggior parte delle condizioni di salute prioritarie associate alla perdita della capacità intrinseca condividono gli stessi determinan fisiologici e comportamentali so ostan . Pertanto, gli interven hanno benefici in diversi domini. Ad esempio, l'esercizio intensivo di resistenza è l'intervento principale per prevenire la perdita di mobilità. Allo stesso tempo, l'esercizio di resistenza protegge indire amente il cervello dalla depressione e dal declino cogni vo e aiuta a prevenire le cadute. La nutrizione potenzia gli effe dell'esercizio e contemporaneamente aumenta la massa muscolare e la forza. A raverso un approccio integrato e unificato, potrebbe essere possibile modificare l'insieme dei fa ori che aumentano il rischio di dipendenza assistenziale. Il piano di assistenza personalizzato avrà diversi componen , che possono includere: • Un pacche o mul componente di interven per ges re la perdita di capacità intrinseca. La maggior parte dei piani di assistenza include interven per migliorare la nutrizione e incoraggiare l'esercizio fisico; • Ges one e tra amento delle patologie di base, mul morbilità e sindromi geriatriche. L’OMS ha sviluppato linee guida cliniche che affrontano la maggior parte delle condizioni croniche rilevan che possono contribuire alla perdita di capacità intrinseca (2). Ogni operatore sanitario dovrebbe avere accesso a queste linee guida; • Sostegno alla cura di sé e all'autoges one; • Ges one delle mala e croniche avanzate (cure pallia ve, riabilitazione) per garan re che le persone anziane possano con nuare a vivere una vita con scopo e dignità; • Assistenza e sostegno sociale, compresi gli ada a- men dell'ambiente circostante per compensare eventuali perdite funzionali; • Un piano per soddisfare i bisogni di assistenza sociale con l'aiuto della famiglia, degli amici e dei servizi comunitari. • Gli operatori sanitari e sociali possono supportare l’a uazione del piano di assistenza nella comunità o nell’assistenza primaria. L’autoges one, supportata dall’orientamento, dall’edu- cazione e dall’incoraggiamento di un professionista sanitario nella comunità, può modificare alcuni dei fa ori responsabili della perdita di capacità intrinseca. Una partnership che coinvolge gli anziani, i professionis dell'assistenza primaria, le famiglie e la comunità aiuterà a preservare il benessere delle persone che invecchiano. Valutazione incentrata sulla persona e percorsi per le cure primarie Percorso generico di cure 15 3 Valutazione incentrata sulla persona e percorsi per le cure primarie Percorso generico di cure FASE 4 GARANTIRE PERCORSI DI CURE SPECIALIZZATI E IL FOLLOW UP DEL PIANO COLLEGATO AI SERVIZI DI ASSISTENZA GERIATRICA SPECIALISTICA Un follow-up periodico e regolare, con integrazione tra i diversi livelli e pologie di servizi, è essenziale per l'a uazione degli interven raccomanda in questa guida. Questo approccio promuove la diagnosi precoce di complicanze o cambiamen nello stato funzionale, prevenendo emergenze non necessarie e risparmiando sui cos a raverso un intervento precoce. Il follow-up regolare fornisce inoltre l’opportunità di monitorare l’evoluzione del piano di assistenza, nonché un mezzo per l’anziano per o enere ulteriore supporto quando necessario. Il follow-up e il supporto possono essere par colarmente importan dopo cambiamen nello stato di salute, nel piano di assistenza, nel ruolo o nella situazione sociale della persona (ad es. trasloco o morte del coniuge). È importante disporre di solidi percorsi di riferimento per garan re un rapido accesso alle cure urgen e di emergenza in caso di even acu e imprevis , come le cadute, nonché alle cure pallia ve di fine vita o dopo la dimissione ospedaliera. È inoltre essenziale che esista un collegamento con un servizio specializzato di assistenza geriatrica. I sistemi sanitari devono garan re che le persone abbiano accesso tempes vo a servizi specializza , urgen e di emergenza quando necessario. Esistono prove eviden del fa o che le unità geriatriche specialis che per acu offrono cure di qualità superiore con degenze più brevi e cos inferiori rispe o alle unità ospedaliere generali. IL RUOLO DELL'ASSISTENZA GERIATRICA SPECIALIZZATA I geriatri concentrano le loro conoscenze sugli anziani con condizioni complesse a lungo termine, come le sindromi geriatriche (incon nenza, cadute, delirium, ecc.), la polifarmacoterapia, mala e come la demenza e la cura di persone con limitazioni nelle a vità della vita quo diana. La mul morbilità aumenta con l'avanzare dell'età, determinando quadri clinici complessi; in ques casi il medico di base dovrebbe chiedere consiglio al geriatra. Nell'approccio ICOPE, i geriatri fanno parte di un team mul disciplinare, che si prende cura cura degli anziani, assistendoli nella supervisione del team di assistenza primaria e intervenendo quando sono necessarie cure specialis che. 16 FASE 5 COINVOLGERE LA COMUNITÀ PER AIUTARE I CAREGIVERS Prendersi cura delle persone anziane può essere este- nuante. Coloro che si prendono cura di anziani con perdita di capacità spesso, si sentono isola e sono ad alto rischio di disagio psicologico e depressione. Il piano di assistenza personalizzato dovrebbe includere interven basa sull’evidenza per supportare i caregiver. Gli operatori sanitari necessitano inoltre di informazioni di base sulle condizioni di salute della persona anziana e di formazione per sviluppare varie abilità pra che, come trasferire la persona da una sedia a le o in modo sicuro o aiutarla con il bagno. Gli anziani e i caregiver dovrebbero ricevere informazioni sulle risorse comunitarie a loro disposizione. Dovrebbero esserci opportunità per coinvolgere le comunità e i quar eri più dire amente a sostegno dell’assistenza, in par colare incoraggiando il volontariato e consentendo agli anziani della comunità di contribuire. Spesso tali a vità possono svolgersi in associazioni e gruppi che a raggono e riuniscono gli anziani. Il capitolo 11 presenta una tabella di marcia per valutare il carico del caregiver e soddisfare le esigenze dei caregiver informali (non retribui ) di prendersi cura di se’ stessi e sostenersi. L'approccio ICOPE si basa a livello di comunità o di assistenza primaria, dove può essere accessibile al maggior numero di persone. Allo stesso tempo, l’approccio richiede for collegamen con livelli specializza di assistenza (secondario e terziario), come nutrizionis e farmacis , per coloro che ne hanno bisogno. APP DEL MANUALE ICOPE Saranno disponibili app mobili per guidare gli operatori sanitari e sociali a raverso tu i passaggi da seguire, dallo screening e valutazione, alla creazione del piano di assistenza personalizzato. L'app genererà anche un riepilogo dei risulta della valutazione e degli interven da inserire nel piano assistenziale in formato PDF stampabile. 3 Valutazione incentrata sulla persona e percorsi per le cure primarie Percorso generico di cure 17 3 Valutazione incentrata sulla persona e percorsi di cura Percorsi generali di cura POLIFARMACOTERAPIA La polifarmacoterapia è solitamente descri a come l’uso di cinque o più farmaci contemporaneamente ed è spesso associata a reazioni avverse ai farmaci. L’uso di più farmaci aumenta il rischio di conseguenze nega ve per salute, può comportare un’inu le perdita di capacità intrinseca ed è una causa comune di ricoveri ospedalieri acu . Le persone anziane che vedono più operatori sanitari o che sono state recentemente ricoverate in ospedale corrono un rischio maggiore di polifarmacoterapia. È probabile che una persona anziana con mul morbilità sia maggiormente colpita dai cambiamen fisiologici lega all’età che possono alterare la farmacocine ca e la farmacodinamica. Poiché la polifarmacoterapia può contribuire a perdite in diversi ambi delle capacità intrinseche, le valutazioni centrate sulla persona dovrebbero includere una revisione dei farmaci che l’anziano sta assumendo. Per ridurre la polifarmacoterapia, è possibile interrompere la som- ministrazione di farmaci non necessari e inefficaci, nonché di farmaci con doppio effe o. Come prescrivere adeguatamente e ridurre gli errori nella prescrizione: • O enere uno storico completo dei medicinali usa ; • Valutare se alcuni farmaci possono inficiare le capacità; • Evitare prescrizioni prima della diagnosi, ecce o nei casi acu e gravi; • Revisionare i medicinali regolarmente e sempre prima di prescrivere un farmaco nuovo; • Conoscere le azioni, effe avversi, le interazioni farmacologiche, i requisi di monitoraggio e la tossicità dei farmaci prescri ; • Cercare di usare un solo farmaco per tra are due o più condizioni cliniche; • Creare un piano di controllo dei medicinali per il paziente • Educare il paziente o il caregiver al rispe o di ogni medicinale Se si hanno dubbi sulla sospensione di un medicinale, rivolgersi allo specialista adeguato. 18 Il declino cogni vo si presenta come una diminuzione della capacità di ricordare, perdita dell’a enzione, riduzione delle abilità di risolvere i problemi. Mentre la causa esa a non è conosciuta, il declino cogni vo può essere correlato all’invecchiamento dell’encefalo, alle mala e (per esempio mala e cardiovascolari come l’ipertensione, l’ictus oppure la mala a di Alzheimer) o anche a fa ori ambientali come la mancanza di esercizio fisico, isolamento sociale e basso livello di scolarità. Il declino cogni vo diventa maggiormente preoccupante quando inizia ad interferire con le abilità di “funzionare” efficacemente nell’ambiente in cui la persona vive (abilità di vita quo diana), questo succede per esempio, quando una persona è affe a da demenza. Questo percorso è des nato agli anziani affe da diversi gradi di declino cogni vo ma non des nato alle persone con demenza. Gli operatori sanitari devono essere capaci di valutare i bisogni di assistenza e sostegno (vedi Capitolo 10). PUNTI-CHIAVE Il declino delle capacità cogni ve può essere minimizzato e in alcuni casi regredire a raverso la conduzione di un corre o s le di vita, l’uso di interven di s molazione cogni va e il coinvolgimento sociale. Il tra amento di condizioni come il diabete, l’iper- tensione può prevenire il declino delle capacità cogni ve. Il declino negli altri domini che riguardano le capacità intrinseche come l’udito e le capacità motorie, possono comprome ere la cognizione, e dovrebbero essere valutate e tra ate con terapie mirate. Cure geriatriche, in pazien affe da demenza, sono necessarie per pianificare e a uare interven complessi. 4 CAPACITÀ COGNITIVA Percorso di cura e ges one del declino cogni vo 19 4 CAPACITÀ COGNITIVA Percorso di cura per la ges one del declino cogni vo * Deficit vitamínici, squilíbrio ele rolí co, disidratazione grave ** Fa ori di rischio cardiovascolari: ipertensione, dilipidemia, diabete, fumo, obesità, mala e cariache, stroke, TIA. Risk reduc on of cogni ve decline and demen a: WHO Guidelines h ps://apps.who.int/iris/handle/10665/312180 DOMANDARE SCREENING DEL DECLINO COGNITIVO declino cognitivo improbabile declino cognitivo improbabiledeclino cognitivo probabile Test esa o Test esa o Test fallito Test fallito Supportare la salute e consigliare su salute e s li di vita Ri ene di avere problemi di memoria o i come non ricordarsi che giorno è o dove si trova)? SI VALUTARE LE CAPACITÀ COGNITIVE Consultare percorso di cure sulla malnutrizione Iden ficare la causa (condizioni mediche, intossicazioni esogene, uso di sostanze) e tra arla Revisione dei farmaci e sospensione di quelli inappropria Valutare la storia cerebrovascolare (acciden vascolari cerebrali/a acchi ischemici transitori) e prevenire gli altri even Consultare il percorso per i sintomi depressivi VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE - MALNUTRIZIONE* - DELIRIUM - POLIFARMACOTERAPIA - ACCIDENTI CEREBROVASCOLARI - SINTOMI DEPRESSIVI Valutare la necessità di un’assistenza sociale Se il declino cogni vo comprome e l’autonomia e l’indipendenza, consultare la sezione della guida di intervento sulla demenza mhGAP h ps://apps.who.int/iris/handle/10665/25023 Fornire cure e supporto alle a vità di vita quo diana Dare consigli su come mantenere la con nenza Valutazione del caregiver (vedi percorso) Sviluppare un piano di assistenza sociale che includa anche il supporto al caregiver VALUTAZIONE E GE S T IONE DEGLI AMBIENTI SOCIALI E FISICI VALUTAZIONE E GESTIONE DELLE PROBLEMATICHE CARDIOVASCOLARI E DEI FATTORI DI RISCHIO ** PREVENIRE ULTERIORI CALI DELLE CAPACITÀ COGNITIVE SI Fornire la ges one integrale delle mala e Ridurre i rischi cardiovascolari: - Suggerire la sospensione del fumo - tra are ipertensione e diabete - fornire una dieta e dei consigli per il controllo del peso corporeo Esercizi mul modali Fornire una s molazione cogni va Semplice test di orientamento e memoria Ripetere tre parole: chiedere di ricordare tre semplici parole di significato concreto: casa, pane, ga o Orientamento nel tempo e nello spazio: Domandare: Qual é a data completa di oggi? E dove siamo? (in casa, ospedale etc.)? Ricordare le tre parole: chiedere di ripetere nuovamente le tre parole Passato o fallito? Se la persona non risponde ad almeno una domanda di orientamento o non ricorda le tre parole è probabile che abbia una perdita della capacità cogni va. Necessita dunque di ulteriori valutazioni 20 VALUTAZIONE DEGLI ASPETTI COGNITIVI Se possibile u lizzare una valutazione approfondita delle abilità cogni ve. In basso a destra è stata s lata una lista di opzioni per la valutazione delle abilità cogni ve degli anziani da u lizzare in un se ng di cure primarie. Mancanza di scolarità. Molte delle valutazioni cogni ve necessitano di un certo grado di educazione scolas ca. Se una persona ha solo 5-6 anni di scolarità o non ne ha affa o, la valutazione cogni va può risultare inficiata perciò si dovrebbe fare affidamento solo sulle informazioni cliniche riportate nell’ana- mnesi o sul giudizio clinico. Per ques individui è fortemente raccomandata l’iscrizione al programma di alfabe zzazione (se possibile) per promuovere le funzioni cogni ve. Se uno strumento di valutazione non è disponibile o non appropriato, il sanitario può chiedere alla persona o a chi se ne occupata se ha notato problemi di memoria, orientamento, linguag- gio o difficoltà nello svolgimento delle a vità quo diane. Fallire un test di valutazione cogni va o lamentare problemi di memoria o orientamento suggerisce un decadimento cogni vo. Alcune persone possono anche riscontrare problemi nello svolgimento delle a vità quo diane non strumentali (ADL) o strumentali (IADL) Queste informazioni sono necessarie per sviluppare un piano di cure personalizzato. Se il declino cogni vo diminuisce ci sono maggiori probabilità che dimi- nuisca la capacità dell’anziano di funzionare bene nel suo ambiente. È necessaria quindi una valutazione specialis ca per far diagnosi di demenza o mala a di Alzheimer (la forma più frequente). Il protocollo per la valutazione e la ges one della demenza è possibile trovare il percorso di cure e la guida di Intervento su mhGAP da OMS: h ps://apps.who.int/iris/handle/10665/250239 QUANDO È NECESSARIO L’INTERVENTO DELLO SPECIALISTA GERIATRA • Diagnosi e tra amento della demenza. • Ges one delle condizioni associate, come delirium, acciden cerebrovascolari e cardiologici. ESEMPI DI STRUMENTI PER LA VALUTAZIONE COGNITIVA NELLE CURE PRIMARIE Cos’è la demenza? La demenza è una sindrome cronica e progressiva che porta a diversi cambiamen nel cervello. La demenza porta al declino delle funzioni cogni ve e interferisce con le a vità̀ della vita quo diana come lavarsi, mangiare, mantenere l’igiene personale. Maggiori informazioni: linee guida mhGAP da OMS (h ps://apps.who.int/iris/handle/10665/250239) 4 CAPACITÀ COGNITIVA Percorso di cura per la ges one del declino cogni vo STRUMENTO/TEST VANTAGGI SVANTAGGI DURATA Mini-Cog Rapido; valuta il linguaggio, L’uso di liste di parole 2-4 min h p://mini-cog.com/wp-content/uploads/2015/ bias etnici e di scolarità differen può influire 12/Universal-Mini-Cog-Form-011916.pdf minimo sul test Montreal cogni ve assessment (MoCA) Capacità di iden ficare Bias culturali e di scolarità; 10-15 min h ps://www.mocatest.org/ la compromissione cogni va pochi da di pubblicazione lieve; disponibile in varie lingue disponibili Mini mental state examina on (MMSE) Largamente u lizzato Bias culturali e di scolarità, 7-10 min h ps://www.parinc.com/products/pkey/237 e studiato effe o te o General prac oner assessment of Bias culturale e di scolarità Può essere difficile 5-6 min cogni on (GPCOG) mínimo; disponibile in varie o enere informazioni sugli h p://gpcog.com.au/index/downloads lingue. anziani valuta 21 Un passaggio importante, prima di qualsiasi processo diagnos co è valutare la presenza di condizioni associate, tra ando queste, per prime. 4.1 CONDIZIONI CHE PROVOCANO SINTOMI COGNITIVI Le più comuni condizioni a cara ere reversibile a causa il declino cogni vo includono la disidratazione, la malnutrizione, le infezioni e problemi con le terapie. Con un tempes vo tra amento di queste condizioni, i sintomi cogni vi associa possono scomparire. Disidratazione severa. La disidratazione severa e altri problemi nutrizionali possono essere causa di delirium (con similitudini con le demenze) e, in mol casi, anche di morte. Delirium. Il delirium è un’improvvisa e dras ca perdita dell’abilità di focalizzare l’a enzione. Le persone non riescono ad orientarsi nel tempo e nello spazio. Il delirium evolve dopo un breve periodo di tempo e tende a perdurare nel corso del giorno. Può essere il risultato di cause organiche acute come le infezioni, i farmaci, anomalie metaboliche (ipoglicemia o iponatriemia), intossicazione da farmaci/sostanze o sovradosaggio di farmaci. Polifarmacoterapia. Due o più farmaci possono interagire e causare effe collaterali (vedi box nel Capitolo 3). I seda vi e gli ipno ci sono i farmaci maggiormente responsabili di disordini cogni vi tra gli anziani. Chirurgia Maggiore e anestesia generale. La chirurgia generale e l’anestesia generale sono riconosciute come rischi di declino cogni vo. Bisognerebbe sempre domandare se il declino cogni vo è la conseguenza di una chirurgia maggiore. Se così fosse, queste persone saran- no ad alto rischio di declino cogni vo futuro a seguito di ogni chirurgia maggiore. Questo alto rischio dovrà essere iden ficato e discusso con il chirurgo e l’anestesista prima di qualsiasi futura chirurgia e anestesia. Mala a cerebrovascolare. La mala a vascolare dell’encefalo è associata stre amente al declino cogni vo. Se il paziente ha una storia di ictus/minor stroke/TIA (a acco ischemico transitorio), la preven- zione per even futuri è il primo approccio per fermare il declino cogni vo futuro. La scoperta di una causa medica di declino cogni vo reversibile implica un lavoro diagno- s co completo. Potrebbe essere necessario esplorare diverse potenziali cause di sintomi per arrivare a un approccio accurato per il piano di cura. 4 CAPACITÀ COGNITIVA Percorso di cura per la ges one del declino cogni vo VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE 22 4 CAPACITÀ COGNITIVA Percorso di cura per la ges one del declino cogni vo • Persone con declino cogni vo possono beneficiare della s molazione cogni va. • Altri interven di ICOPE, come gli esercizi mul - modali (vedi il capitolo 5, Mobilità limitata), possono contribuire alla salute mentale. • Le perdite in altri domini della capacità intrinseca, in par colare l'udito, la vista e l'umore, possono influ- enzare la cognizione. Per o enere i migliori risulta , potrebbe essere necessario valutarli. La perdita di una o più funzioni cogni ve non riguarda tu gli individui allo stesso modo. 4.2 STIMOLAZIONE COGNITIVA La s molazione cogni va può rallentare il declino delle capacità cogni ve (7). Questa s molazione cogni va mira a s molare i partecipan a raverso a vità cogni- ve, potenziamento della memoria, s molazione mul sensoriale e a vità sociali. La s molazione cogni va può essere proposta come a vità individuale o di gruppo. L’inserimento in un gruppo può essere vantaggioso per alcune persone; il conta o sociale può favorire il miglioramento delle abilità cogni ve. I gruppi possono essere più ada ed efficaci se i membri del gruppo condividono uno scopo comune, come migliorare l'alfabe zzazione sanitaria. L'approccio di gruppo standard prevede fino a 14 sessioni a tema di circa 45 minu ciascuna, che si tengono due volte a se mana. Un facilitatore conduce queste sessioni. In genere, una sessione potrebbe iniziare con un'a vità ̀ di riscaldamento non cogni va, e per poi passare a vari compi cogni vi, incluso l'orientamento alla realtà ̀ (ad esempio, una lavagna che mostra informazioni come luogo, data e ora). Le sessioni si concentrano su diversi temi, tra cui, ad esempio, l'infanzia, l'uso del denaro, i vol o le scene. Queste a vità generalmente evitano il richiamo di episodi/fa accadu , ma si concentrano invece su domande come: "Che cosa hanno in comune queste/i [parole o ogge ]?" Chi può condurre la s molazione cogni va? Nei paesi ad alto reddito, di solito sono gli psicologi a condurre la terapia di s molazione cogni va. Con degli adeguamen , potrebbe essere condo o da non specialis adeguatamente forma e supporta . Tu avia, proge are e fornire un intervento personalizzato per una persona con deficit significa vi può richiedere valutazioni e una pianificazione più de agliata, richiedendo competenze geriatriche. Pertanto, i protocolli locali dovrebbero includere criteri per l’invio a specialis della salute mentale e di terapia di s molazione cogni va. I familiari e gli operatori sanitari possono svolgere un ruolo importante nella s molazione cogni va. È importante incoraggiare i familiari e gli operatori sanitari a fornire regolarmente agli anziani informazioni quali giorno, data, tempo, ora, nomi delle persone e così via. Queste informazioni li aiutano a rimanere orienta nel tempo e nello spazio. Inoltre, esporli a materiali come giornali, programmi radiofonici e televisivi, album di famiglia e ar coli per la casa può promuovere la comunicazione, orientare una persona anziana agli even a uali, s molare i ricordi e consen re alla persona di condividere e valorizzare le proprie esperienze. GESTIONE DECLINO COGNITIVO 5 23 La scoperta di una causa medica di declino cogni vo reversibile implica un lavoro diagnos co completo. Potrebbe essere necessario esplorare diverse potenziali cause di sintomi per arrivare a un approccio accurato per il piano di cura. 4 CAPACITÀ COGNITIVA Percorso di cura per la ges one del declino cogni vo VALUTAZIONE E GESTIONE AMBIENTI SOCIALI E FISICI Se il declino cogni vo limita l'autonomia e l'indipendenza di una persona, è probabile che quella persona abbia maggiore necessità di assistenza sociale. Un operatore sanitario può aiutare il caregiver a personalizzare un programma di a vità della vita quo diana che mas- simizza l'indipendenza, migliora le funzioni cogni ve, aiuta ad ada arsi e sviluppare le abilità necessarie a svolgere a vità di vita quo diana riducendo al minimo la necessità di supporto. I familiari e caregivers possono: • dare informazioni per restare orienta nello spazio e nel tempo, come la data, circa gli even che accadono nella società e in famiglia, o l'iden tà di coloro che fanno loro visita; • incoraggiare e organizzare incontri con familiari e amici; • rendere e mantenere la casa sicura per ridurre il rischio di cadute e lesioni; • posizionare cartelli in casa - ad esempio per il bagno, la camera da le o, la porta dell'esterno - per aiutare la persona a orientarsi; ed infine • organizzare e partecipare ad a vità occupazionali (a seconda delle capacità della persona). 11 I Caregivers delle persone con gravi deficit cogni vi devono affrontare situazioni pesan . Lo stress può me ere a rischio la loro salute fisica e psicologica. (Vedere il Capitolo 11 su come affrontare i bisogni dei caregiver). 24 5 CAPACITÀ MOTORIA Percorso di cura per migliorare la capacità motoria La mobilità è un fa ore determinante per un invec- chiamento in salute. La mobilità è importante per mantenere l'autonomia e prevenire la dipendenza dalle cure. La capacità fisica di una persona di spostarsi da un luogo all'altro è definita capacità motoria. Molte persone anziane e le loro famiglie acce ano come inevitabili la perdita della capacità locomotoria e il dolore a esso associato. Non lo sono. Esistono infa strategie efficaci per migliorare e mantenere la mobilità in età avanzata. PUNTI-CHIAVE • La perdita della capacità motoria è comune negli anziani ma evitabile • Gli operatori sanitari a livello comunitario possono valutare la mobilità grazie a semplici test. • Un programma di esercizio fisico regolare, ada o alle capacità e ai bisogni individuali, è l’approccio più importante per migliorare o mantenere la capacità motoria • Ada are il proprio ambiente e u lizzare gli ausili sono modi adegua a mantenere la mobilità nonostante la rido a capacità motoria 25 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria ESERCIZI MULTIMODALI Un programma di esercizi mul modali per persone con mobilità rido a combinano esercizi e tra amento funzionale con enfasi principalmente su gruppi muscolari come i glutei, coxofemorali, addominali e parte inferiore del corpo. Un programma di esercizi mul modali deve essere ada ato alle capacità e necessità individuali. Un proge o Vivifrail offre una guida pra ca per elaborare un programma di esercizi personalizzato. h p://www.vivifrail.com/resources Per le raccomandazioni globali di OMS sul- l’a vità fisica, consulta il riquadro a pagina 30. Consiste nell’alzarsi e sedersi senza usare le braccia 5 volte consecu ve in meno di 14 sec SCREENING PERDITA DELLA MOBILITA’ Test di sollevamento dalla sedia SI Rinforzare l’orientamento generico sulla salute e s li di vita o sulle abitudini Mobilità rido a (punteggio SPPB da 0 a 9) Mobilità normale (ponteggio SPPB da 10 a 12) VALUTAZIONE DELLA MOBILITÀ (SPPB o altro test di valutazione sica) Prescrivere esercizi mul modali con supervisione Considerare l’invio alla riabilitazione Considerare l’aumento dell’intake proteico Considerare e procurare disposi vi di assistenza per aiutare la mobilità Raccomandare esercizi mul modali a casa Supportare l’autoges one per favorirne l’aderenza NO per tu o VALUTAZIONE E GESTIONE DEGLI AMBIENTI SOCIALI E FÍSICI Valutazione dell’ambiente fisico per ridurre il rischio caduta Includere interven di prevenzione delle cadute, come l’ada amento domes co Considerare e fornire un disposi vo di assistenza per aiutare nel movimento Fornire spazi sicuri per camminare VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE - POLIFARMACOTERAPIA - ARTROSI, OSTEOPOROSI E ALTRE LIMITAZIONI OSTEOMUSCULARI - FRAGILITÀ E SARCOPENIA - DOLORE SI Revisione dei farmaci ridurre se possibile Ges one integrata del dolore Considerare la ges one del dolore 26 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria SHORT PERFORMANCE PHISICAL BATTERY (SPPB) Sebbene sia disponibile un ampia gamma di test di performace fisica, si raccomanda l’SPPB, per la gamma di abilità fisiche testate. L’SPPB misura le prestazioni fisiche con tre compi ognuna composta di 4 pun . Il punteggio finale varia da zero (presta- zione peggiore) a 12 (prestazione migliore). Prima di tu o, descrivere ogni test e domandare se la persona si sente capace di eseguirli. In caso contrario, vai al prossimo passaggio. 1. Test dell’equilibrio: Stare in piedi per 10 secondi in ciascuna delle posizioni seguen . Usa la somma dei tre punteggi nelle tre posizioni 2. Test della velocità di marcia: Tempo per sollevarsi dalla sedia cinque volte Tempo per percorrere qua ro metri: <4,82 secondi 4 pun 4,82 – 6,20 secondi 3 pun 6,21 – 8,70 secondi 2 pun >8,70 secondi 1 pun impossibile da completare 0 pun 3. Test di sollevamento dalla sedia: Tempo per sollevarsi dalla sedia cinque volte <11,19 secondi 4 pun 11,2 – 13,69 secondi 3 pun 13,7 – 16,69 secondi 2 pun 16,7 – 59,9 secondi 1 pun >60 secondi o incapace di completare 0 pun Ponteggio finale del’SPPB = somma dei punteggi dei test. Maggiori de agli sopra l’SPPB: h p://hdcs.fullerton.edu/csa/research/documents /sppbinstruc ons_scoresheet.pdf 2 1 TEST DI SOLLEVAMENTO DALLA SEDIA Un semplice test può decidere se un anziano necessita di un ulteriore valutazione sulla mobilità limitata. Istruzioni: Domandare alla persona. “Pensi che sarebbe sicuro sollevarsi dalla sedia cinque volte senza l’uso delle braccia?” (Dimostrare alla persona.) Se SI, chiedi di: - Sedersi al centro della sedia - Braccia incrociate sul pe o - Sollevarsi completamente e sedersi nuovamente - Ripetere cinque volte più rapidamente possibile senza fermarsi. Cronometrare i test. Se la persona non riesce a sollevarsi 5 volte in 14 secondi, necessita di un'ulte- riore rivalutazione. QUANDO È NECESSARIO L’INTERVENTO DELLO SPECIALISTA GERIATRA La capacità motoria dovrebbe essere valutata anche in base ad altri aspe come la cogni vità, la vitalità, gli organi di senso e il programma di esercizi. Può anche essere preso in considerazione l’invio in riabilitazione. A. Piedi uni Mantenere la posizione 1 punto per10 secondi Mantenere la posizione 0 pun per meno di 10 secondi Non man ene 0 pun Se il paziente non man ene, terminare il test dell’equilíbrio. B. Posizione di semi-tandem Mantenere la posizione 1 punto per 10 secondi Man ene per meno 0 pun di 10 secondi Non man ene 0 pun C. Posizione di tandem Mantenere la posizione 2 pun per 10 secondi Mantenere la posizione 1 punto per 3 a 9,99 secondi Mantenere la posizione 0 pun per meno di 3 secondi Non man ene 0 pun Se il paziente non man ene, terminare il test dell’equilibrio. 27 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria VALUTAZIONE DELLA MOBILITÀ La mobilità può essere valutata in modo più completo esaminando le prestazioni di una persona in tre semplici test. Insieme, ques test sono no come Short Physical Performance Ba ery (SPPB). Il Chair stand test (test di sollevamento dalla sedia) è uno di ques test. Va ripetuto dopo le altre due prove: • il test dell’equilibrio: in piedi per dieci secondi in ciascuna delle tre posizioni • il test di velocità del cammino: quanto tempo è necessario per coprire qua ro metri camminando. I punteggi di ogni prova vengono somma . Punteggi totali più bassi significano mobilità rido a. Il percorso delinea due diversi approcci di ges one, a seconda del punteggio totale. Maggiori informazioni sui test e su come valutarli sono disponibili nella pagina precedente. QUANDO È NECESSARIO L’INTERVENTO DELLO SPECIALISTA GERIATRA (PIU’INFORMAZIONI) Potrebbero essere necessarie cure specialis che anche per una persona che ha: • dolore persistente che modifica l'umore o altre aree di funzionamento • significa vo indebolimento delle funzioni ar colari • fra ura • rischi per la sicurezza (vedi box nella pagina a fianco) • la necessità di aiuto nella scelta di un ausilio adeguato alla mobilità. 28 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria GESTIONE DELLA RIDOTTA MOBILITÀ 5.1 PROGRAMMA DI ESERCIZI MULTIMODALI Per persone con mobilità rido a, un programma di esercizi mul modali deve essere ada ato alle sue capacità e necessità individuali. Un programma di esercizi mul modali per persone con mobilità rido a può includere: • allenamento della forza/resistenza, che richiede lavoro dei muscoli so o carico, u lizzando pesi, bande di resistenza o esercizi a corpo libero come squat (accovacciarsi, accosciarsi), affondi ed esercizi sit-to- stand (da seduto a in piedi e viceversa); • allenamento aerobico/cardiovascolare, come la cam- minata veloce o il ciclismo che aumenta la frequenza cardiaca fino a quando la persona è leggermente senza fiato ma riesce a mantenere una conversazione • allenamento dell'equilibrio, che valu il sistema del- l'equilibrio, includendo esercizi sta ci e dinamici; può essere eseguito su superfici diverse e con gli occhi aper e chiusi; alcuni esempi sono: stare in piedi su una gamba alla volta e camminare dal tallone alla punta dei piedi (tacco - punta) in linea re a • allenamento della flessibilità, che migliora l'estensi- bilità dei tessu molli, come i muscoli, e la gamma dei movimen ar colari; esempi sono lo stretching (allun- gamen ) e altri esercizi di yoga e pilates (ginnas ca posturale). 6 Sicurezza degli esercizi. Prima di consigliare degli esercizi o pianificare un programma di esercizi, domandare le condizioni di salute che potrebbero intaccare il tempo e l’intensità degli esercizi. Se la persona risponde si a qualunque delle seguen domande, un professionista qualificato deve elaborare un programma di esercizi su misura • Ha avuto dolore al pe o a riposo? • Ha avuto un infarto negli ul mi sei mesi? • È svenuto o ha perso conoscenza? • È caduto negli ul mi 12 mesi? • Ha avuto fra ure negli ul mi mesi? • È mai mancato il fiato per a vità quo diane come il ves rsi? • Ha una mala a ossea o muscolare che limita l’a vità? • Un operatore sanitario ha de o di limitare l’a vità fisica? Nutrizione. L’aumento dell’apporto proteico o altri interven nutrizionali possono aumentare i benefici di un programma di esercizi. Consulta il Capitolo 6 sulla nutrizione. Il proge o Vivifrail offre una guida pra ca per l’ela- borazione di un programma di esercizi personalizza . h p://www.vivifrail.com/resources 29 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria Ges one delle limitazioni. Nei casi in cui il dolore limi la mobilita,̀ si può s molare l'a vità̀ fisica in periodi di tempo adegua . Aumentare lentamente le a vità fisiche aiuta a costruire la resilienza del corpo e a ges re il dolore. Per le persone con mobilità gravemente rido a, l'allenamento fisico a le o o da sedu su una sedia può essere un punto di partenza. Per le persone con limitazioni cogni ve, come la demenza, un programma di esercizi semplice e meno stru urato può essere piu ̀ ada o. 5.2 SOSTEGNO ALL’AUTOGESTIONE Il sostegno all'autoges one aumenta l'aderenza e i vantaggi di un programma di esercizi mul modale. Le persone i cui punteggi SPPB sono compresi tra 10 e 12 possono allenarsi a casa e nella comunità. Le persone con limitazioni motorie più gravi possono aver bisogno di supervisione e guida durante l'esercizio. Il manuale dell'OMS sulla salute mobile per l'invec- chiamento (mAgeing) spiega come una app per telefoni cellulari può integrare l'assistenza di rou ne degli operatori sanitari supportando l'auto-cura e l'auto- ges one. Maggiori informazioni: h p://www.who.int/ageing/health-systems/mAgeing RACCOMANDAZIONI GLOBALI DI OMS SULL’ATTIVITÀ FISICA Tu gli anziani possono beneficiare di consigli sull'a vità fisica consigliata per la loro età, tenendo conto delle loro condizioni di salute. Questo riquadro riassume le raccomandazioni globali dell'OMS sull'a vità fisica per le persone di età pari o superiore a 65 anni. 4 Ogni se mana, fare almeno 150 minu di a vità fisica aerobica di intensità moderata o almeno 75 minu di a vità aerobica intensiva, o una combi- nazione equivalente. 4 Fare sessioni di esercizio di almeno 10 minu alla volta. 4 Per o enere ulteriori benefici, fare 300 minu (5 ore) di esercizio aerobico di intensità moderata a set- mana o 150 minu di a vità aerobica intensiva a se mana, o una combinazione equivalente. 4 Fare a vità di potenziamento muscolare due o più giorni alla se mana. 4 Se la mobilità è scarsa, svolgere a vità fisica tre giorni a se mana o più per migliorarla. 4 Se non puoi allenar tanto quanto raccomandato, sii il più possibile fisicamente a vo. Maggiori informazioni: h p://www.who.int/dietphysicalac vity/pa/en/index.html 30 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE 5.2 POLIFARMACOTERAPIA Alcuni farmaci possono comprome ere la mobilità o interferire con l’equilibrio; inoltre, a volte sono inu li o inefficaci per una persona specifica (8). Ques includono, ma non sono limita a: • an convulsivan • benzodiazepine • ipno ci non benzodiazepinici • an depressivi triciclici • inibitori sele vi della ricaptazione della serotonina (SSRI) • an psico ci • oppioidi L'eliminazione dei farmaci non necessari o inefficaci e dei farmaci con effe o ridondante riduce la polifarmaco- terapia. In caso di dubbi sull'interruzione sicura di un farmaco, rivolgersi al geriatra o al medico di medicina generale. 5.4 DOLORE Valutare il dolore. Il forte dolore associato al movimento può limitare o addiri ura impedire l'esercizio. È u le valutare la gravità del dolore correlato alla mobilità, sia per aiutare a proge are un programma di esercizi che per ges re il dolore. Puoi u lizzare il ques onario breve del dolore: h ps://www.aci.health.nsw.gov.au/__data/assets/ pdf_file/0015/212910/Brief_Pain_Inventory_Final.pdf. Ges one del dolore (9). Le condizioni muscolo- scheletriche che comprome ono la mobilità spesso comportano dolore persistente. Tu avia, raramente si può trovare una causa biologica specifica del dolore persistente. Un approccio basato sulle migliori pra che per la ges one del dolore affronta quindi i molteplici fa ori che possono essere associa al dolore: fa ori fisici (come forza muscolare, di movimento e resistenza), benessere psicologico, alimentazione e sonno. Quando il dolore è una barriera significa va al movimento e all'a vità,̀ un operatore sanitario con conoscenze specialis che nella ges one del dolore dovrebbe sviluppare un piano di ges one del dolore. Gli interven per il dolore includono: - autoges one 5.2 - esercizi e altre a vità fisiche - farmaci che vanno dal paracetamolo a farmaci an n- fiammatori non steroidei, al gabapen n e agli oppioidi - terapia manuale come massaggio, manipolazione ar colare e mobilizzazione ar colare - terapia psicologica e terapia cogni vocomporta- mentale (vedi Capitolo 9 sui sintomi depressivi) - agopuntura - iniezioni spinali/epidurali - denervazione a radiofrequenza. 9 Alcuni di ques interven possono essere resi disponibili dire amente a domicilio. Altri probabilmente richiederebbero il rinvio presso stru ure specializzate. 31 5 CAPACITÀ MOTORIA Percorso di cure per migliorare la capacità motoria VALUTAZIONE E GESTIONE AMBIENTI SOCIALI E FISICI Chi ha una mobilità rido a potrebbe aver bisogno di aiuto per far fronte alle a vità quo diane. Il primo passo consiste nel valutare i bisogni di assistenza sociale (vedi capitolo 10). Bisogni di assistenza sociale specifici per le persone anziane con perdita di mobilità possono includere quelli che si manifestano durante una valutazione dell’ambiente fisico o in relazione al bisogno di ausili. Un programma di esercizi può aiutare a prevenire il rischio cadute. 5.5 VALUTARE L'AMBIENTE FISICO PER RIDURRE IL RISCHIO DI CADUTE Una valutazione dell'ambiente fisico implica guardarsi intorno in casa per trovare possibili pericoli e offrire suggerimen . Gli esempi potrebbero includere ridurre il disordine, rimuovere i tappe larghi, appianare le irregolarità del pavimento e dei gradini, spostare i mobili per creare un percorso ampio e senza ostacoli, migliorare l'illuminazione e migliorare l'accesso al bagno, soprat- tu o di no e (aggiungendo maniglie al muro, per esempio). Una rampa per la porta principale renderà più facile per le persone che usano sedie a rotelle e altre persone con difficoltà a salire i gradini. I limi di mobilità specifici di una persona faranno da guida per realizzare gli ada amen ambientali più importan . Chi fornisce cure primarie al domicilio o presso stru ure assistenziali e possiede una formazione specifica può valutare la casa di una persona. Se non è possibile una visita a domicilio, un operatore sanitario di base può invece dare istruzioni generali alla persona o al caregiver su come creare un ambiente domes co più sicuro. Una valutazione e una ges one completa del rischio di cadute di una persona richiedono conoscenze speciali- s che. 5.6 CONSIDERARE E FORNIRE AUSILI Le persone con limitazioni della mobilità potrebbero aver bisogno di ausili per spostarsi. Lo scopo principale degli ausili è mantenere o migliorare la capacità funzionale e l'indipendenza di un individuo per facilitare la parteci- pazione e migliorare il benessere generale (10). Ques includono bastoni, stampelle, deambulatori, sedie a rotelle e disposi vi protesici o ortesici. Le scelte possono essere limitate dalla disponibilità e dal costo, ma un professionista sanitario con conoscenze di terapia fisica, se disponibile, può dare i migliori consigli sulla scelta di un ausilio adeguato e le istruzioni su come u lizzarlo in sicurezza. Il calo di qualsiasi capacità intrinseca può aumen- tare il rischio di cadute. Anche l'ambiente fisico e il modo in cui viene eseguita l'a vità, possono essere fa ori di rischio. Oltre alla valutazione dell'ambiente fisico, una valutazione completa del rischio di caduta comprende: • raccogliere uno storico delle cadute, compresi i de agli delle a vità̀ svolte; • valutazione dell'andatura, dell'equilibrio, della mobilita,̀ della funzionalità e flessibilità musco- lare e ar colare; • Valutazione della paura di cadere, della vista, della cognizione, dello stato cardiovascolare e neurologico e dell'urgenza o nicturia (risveglio per urinare di no e) • revisione dei farmaci per la polifarmacoterapia (vedi Capitolo 3 sulla valutazione e lo sviluppo di un piano). Alcune persone avranno bisogno di un'ulteriore valutazione e ges one di problemi come la sincope, l'epilessia e i disturbi neurodegenera vi come il morbo di Parkinson. 32 6 VITALITÀ Percorso di cure per la ges one della malnutrizione L'OMS usa il termine vitalità per descrivere i fa ori fisiologici che contribuiscono alla capacità intrinseca di un individuo. Ques possono includere il bilancio energe co e il metabolismo. Questa guida si concentra su una delle ragioni principali della diminuzione della vitalità in età avanzata: la mal- nutrizione. PUNTI-CHIAVE • Gli operatori sanitari di base possono facilmente fare una valutazione iniziale dello stato nutrizionale. Que- sto dovrebbe far parte di qualsiasi valutazione della salute di una persona anziana. Una valutazione com- pleta dello stato nutrizionale richiede conoscenze specialis che e talvolta esami del sangue. • Sia un'alimentazione inadeguata che una minor reat- vità fisica portano alla perdita di massa muscolare e forza. • Una dieta equilibrata e l’assunzione di cibo in quan tà adeguate di solito forniscono le vitamine e i minerali necessari per le persone anziane, ma sono comuni carenze di vitamine D e B12. • La malnutrizione in alcuni casi porta alla perdita di peso. La massa grassa può sos tuire la massa musco- lare, lasciando il peso invariato. • Un altro aspe o della malnutrizione è l'obesità, pro- blema non affrontato in questa guida. 33 Percorso di cure per la ges one della malnutrizione VITALITÀ 6 DOMANDARE SCREENING SULLA MALNUTRIZIONE IN COMUNITÀ Ha notato una perdita di peso di più di 3 kg involontaria negli ul mi mesi? Ha notato una perdita di appe to? Rinforzare l’orientamento generale sulla salute, gli s li di vita e le abitudini SI (per una qualsiasi delle domande) Malnutrito (punteggio MNA<17) Stato nutrizionale normale Punteggio MNA 24-30) Rischio di malnutrizione (punteggio MNA 17-23.5) VALUTAZIONE DELLO STATO NUTRIZIONALE Esemplo: Mini Nutri onal Assessment (MNA) Intervento nutrizionale necessario Prescrivere un supplemento nutrizionale con aumento di inges one di proteine (400-600 kcal/dia) Offrire consigli diete ci 1 Monitorare a entamente il peso Offrire consigli nutrizionali Considerare supplementazione orale se incapace di migliorare l’inges one degli alimen Monitorare a entamente il peso Considerare gli esercizi mul modali RIVALUTAZIONE… - Dopo mala e o even acu - Una volta l’anno negli anziani che vivono in comunità - Ogni tre mesi negli anziani con al bisogni sociali Rafforzare la salute e lo s le di vita generici consigli o cure abituali Ges one integrata delle mala e di base: Considerare la riabilitazione per migliorare la funzione muscolare VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE - FRAGILITÀ - SARCOPENIA VALUTAZIONE E GESTIONE DEGLI AMBIENTI SOCIALI E FISICI Superare le barriere della salute nutrizionale Incen vare pas in famiglia o fuori dalla residenza Organizzare assistenza nella preparazione dei pas Supplementazione nutrizionale orale Una supplementazione nutrizionale orale fornisce un giusto apporto proteico e calorico e un adeguato supporto di vitamine e minerali a seconda dei bisogni individuali del gusto e limitazione fisica. 34 Percorso di cure per la ges one della malnutrizione VITALITÀ 6 ORIENTAMENTO NUTRIZIONALE • Gli operatori sanitari di base possono fornire assistenza agli anziani e incoraggiare un'alimentazione sana. Tu gli anziani possono beneficiare di queste linee guida, siano essi a rischio o già affe da malnutrizione, indi- pendentemente dal fa o che necessi no o meno di cure specialis che. Seguire una dieta sana è più facile per le persone che registrano ogni giorno ciò che mangiano su un foglio di calcolo, durante i pas e tra i pas . • Aiutare l'anziano a iden ficare gli alimen specifici disponibili localmente e che forniscono energia ade- guata (carboidra ), proteine e micronutrien come vitamine e minerali. Fornire indicazioni sulle quan tà adeguate di ques alimen . • Poiché l'assorbimento delle proteine d iminuisce con l'età, consigliare agli anziani di assumere un'adeguata quan tà di proteine. Per gli anziani sani si consiglia l'assunzione di 1,0-1,2 g di proteine p er kg di peso corporeo. Gli anziani che si stanno riprendendo da una perdita di peso o da una mala a acuta o da un infortunio possono necessitare fino a 1,5 g per kg di peso corporeo. La funzione renale deve essere monitorata, poiché un elevato apporto proteico può portare ad un aumento della pressione intraglomerulare e all’iper- filtrazione glomerulare. • Consigliare l'a vità fisica, che perme e l'incorpo- razione delle proteine da parte dei muscoli e aumenta l'appe to. • Incoraggiare l'esposizione alla luce solare per indurre la pelle a produrre vitamine D. La vitamina D contenuta negli alimen non è sufficiente affinché gli anziani mantengano livelli o mali. È necessario un esame del sangue per misurare se il livello di vitamina D di una persona è adeguato • Le persone anziane spesso non mangiano abbastanza. Per aiutare una persona anziana a mangiare di più, suggerire pas in famiglia e fuori casa, sopra u o per gli anziani che vivono soli o sono socialmente isola . RICORDA! L’operatore sanitario deve informare i familiari e gli altri operatori sanitari, non solo la persona anziana. VALUTAZIONE DELLO STATO NUTRIZIONALE Sono disponibili strumen validi per aiutare a valutare lo stato nutrizionale (11). Per esempio: Mini Nutri onal Assessment (MNA) (8) Determinare il rischio di malnutrizione h ps://www.bapen.org.uk/pdfs/must/must_full.pdf Malnutri on Universal Screening Tool h ps://www.bapen.org.uk/pdfs/must/must_full.pdf Ques onario per la valutazione del rischio nutrizio- nale nell’anziano h ps://www.flintbox.com/public/project/2750/ Short nutri onal assessment ques onnaire 65+ (SNAQ65+) h p://www.fightmalnutri on.eu/toolkits/summary- 1 2 QUANDO È NECESSARIO RIVOLGERSI AD UNO SPECIALISTA Gli operatori sanitari di base e delle stru ure possono offrire consigli e supporto per aiutare tu e le persone anziane a seguire una dieta sana. Le persone malnutrite o ad alto rischio di malnu- trizione hanno bisogno di un nutrizionista per iden ficare le cause e i fa ori di rischio e per prescrivere un piano nutrizionale personalizzato. Se indicato, effe uare o richiedere un'ulteriore valutazione delle possibili condizioni che potreb- bero essere alla base o portare alla malnutrizione, anche se lo stato nutrizionale a uale sembra adeguato. I segni di queste possibili condizioni includono deperimento, rapida perdita di peso, disturbi del cavo orale, dolore o difficoltà a deglu- re, vomito cronico o diarrea e dolore addominale. Il percorso di cura nella pagina successiva è basato sul Mini Nutri onal Assessment (MNA). 35 Percorso di cure per la ges one della malnutrizione VITALITÀ 6 VALUTAZIONE DELLO STATO NUTRIZIONALE La maggior parte degli strumen di valutazione nutri- zionale richiedono: • assunzione di cibo e liquidi • perdita di peso recente (come nella valutazione iniziale) • mobilità • recente stress psicologico o mala a acuta • problemi psicologici • situazione abita va. Inoltre, viene registrato: • il peso • altezza • indice di massa corporea (BMI - peso in kg/altezza in m2) • circonferenza del braccio e del polpaccio COMPOSIZIONE DELLA MASSA CORPOREA E INVECCHIAMENTO Tipicamente dopo circa i 70 anni di età, la massa musco- lare può diminuire, con effe importan e potenzial- mente dannosi sulla vitalità ̀. Sia un'alimentazione inadeguata che un esercizio fisico inadeguato portano alla perdita di massa muscolare e della forza. Allo stesso tempo, la massa grassa può aumentare. Il peso corporeo pụ diminuire o rimanere lo stesso, mascherando ques possibili cambiamen dannosi. Una persona malnutrita potrebbe, quindi, aver perso il tessuto corporeo magro e avere ancora un BMI nel range di normalità̀ o addiri ura essere sovrappeso. Un operatore sanitario preparato, anche se non specia- lista, può valutare in modo affidabile la funzione muscolare e quindi la malnutrizione proteica, con uno strumento come un dinamometro manuale per misurare la forza di presa. Questo strumento misura quanto forte è una persona stringendo lo strumento con una mano. Una bassa forza di presa della mano indica la necessità di esercizio e di una dieta che includa più proteine. 36 6.2 PER GLI ANZIANI CON MALNUTRIZIONE Per una persona malnutrita (ad esempio, un punteggio MNA inferiore a 17), un intervento nutrizionale dovrebbe iniziare immediatamente. L'operatore sanitario di base può dare immediatamente consigli diete ci standard (vedi riquadro a pagina 35). Non appena possibile, un operatore sanitario con conoscenze specialis che dovrebbe anche offrire consigli diete ci e, se necessario, prescrivere una nutrizione supplementare orale (vedi so o). L'intervento dovrebbe essere parte di un piano di assistenza completo che affron i fa ori so ostan che contribuiscono a una ca va alimentazione, insieme ad altri interven che affrontano altri domini della capacità intrinseca, come la mobilità limitata. In par colare, un'adeguata assunzione di energia e proteine renderà ̀ piu ̀efficaci i programmi di esercizio fisico mul modale (vedi Capitolo 5 sulla mobilità rido a). Supplementazione nutrizione orale La supplementazione nutrizionale orale (SNO) fornisce proteine aggiun ve di alta qualità, calorie e quan tà adeguate di vitamine e minerali. Sono necessarie conoscenze geriatriche per sviluppare un piano per OSN su misura per le esigenze, i gus e le limitazioni fisiche del singolo individuo. Percorso di cure per la ges one della malnutrizione VITALITÀ 6 GESTIONE DELLA NUTRIZIONE NELL’ETÀ AVANZATA Le menomazioni sensoriali (una diminuzione del senso del gusto e dell'olfa o), la scarsa salute orale come problemi di mas cazione e difficoltà di deglu zione, isolamento, solitudine, basso reddito e condizioni cro- niche complesse aumentano il rischio di malnutrizione in età avanzata. 6.1 PER GLI ANZIANI A RISCHIO DI MALNUTRIZIONE Una persona anziana a rischio di malnutrizione (ad esempio, un punteggio MNA compreso tra 17 e 23,5) può beneficiare di consigli sull'alimentazione (vedere riquadro pagina successiva). A una persona a rischio di malnutrizione dovrebbe anche consigliata una dieta adeguata, per prevenire lo stato di malnutrizione. 5 37 Percorso di cure per la ges one della malnutrizione VITALITÀ 6 La valutazione consente di scegliere il miglior metodo di integrazione, sia a raverso cibi ricchi di sostanze nutri- ve, sia a raverso l’assunzione di integratori vitaminici o minerali, sia a raverso prodo commerciali specializza o formulazioni nutrizionali non commerciali. L'operatore sanitario può supportare e monitorare la persona che assume SNO (vedi riquadro). La supplementazione nutrizionale orale deve essere prescri a quando il paziente non riesce ad avere un’alimentazione normale con introito adeguato di calorie e nutrien o come strategia temporale, per aumentare l’apporto calorico. Esami del sangue Gli esami del sangue producono informazioni per elaborare un piano nutrizionale personalizzato. Un esame del sangue può iden ficare specifiche carenze vitamine e minerali. La supplementazione orale o la somministrazione specifica di nutrien mancan può tra are la specifica deficienza. Per esempio, se neces- sario compresse o iniezioni per tra are la deficienza di vitamine D e B12, che sono le più comuni. PUNTI CHIAVE SULLA SUPPLEMENTAZIONE NUTRI- ZIONALE ORALE 4 La naturale alimentazione viene prima, a meno che la necessità di SNO non sia urgente, si dovrebbe prima cercare di migliorare la dieta, se possibile, e mangiare più frequentemente. 4 Gli SNO integrano la normale dieta, non dovrebbero sos tuire il cibo. 4 Una persona che assume SNO dovrebbe capire che bisogna mangiare nel miglior modo possibile 4 Gli SNO dovrebbero essere assunto lontano dai pas , non durante i pas . 4 Le persone spesso necessitano di sostegno e incorag- giamento con nui (da parte di familiari, operatori sanitari e operatori sanitari) per con nuare ad assu- mere SNO e con nuare a mangiare nel miglior modo possibile. 4 Dopo un po', una persona potrebbe stancarsi del gusto e della consistenza di un po di ONS. È necessario allora variare i gus e cambiare periodicamente gli integratori può aiutare. 4 Il peso deve essere monitorato e registrato regolarmente. 4 L'obie vo ideale è fermare l'ONS quanto prima il rischio di scarsi la nutrizione è passata e la dieta fornisce un'alimentazione adeguata. 38 Percorso di cure per la ges one della malnutrizione VITALITÀ 6 VALUTAZIONE E GESTIONE CONDIZIONE ASSOCIATA VALUTAZIONE E GESTIONE AMBIENTI SOCIALI E FISICI 6.1 SARCOPENIA E FRAGILITÀ Sarcopenia e fragilità sono condizioni che possono essere associate a malnutrizione. Intervenire sugli s li di vita, incluso il miglioramento sull’alimentazione e sull’eser- cizio fisico, può aiutare a migliorare o evitare entrambe. Sarcopenia. Il termine sarcopenia descrive una perdita generale e progressiva della massa, forza e funzione muscolare. Può essere il risultato di una mala a, della malnutrizione o mancanza di esercizio sico, o senza causa ogge va ed essere associato ad un processo di invecchiamento Il caregiver e la comunità possono aiutare a superare barriere sanitarie nutrizionali degli anziani. Per esempio, l’organizzazione comunitaria può organizzare even sociali che promuovano pas per gli anziani. Fragilità. La fragilità può determinare la perdita di peso, forza muscolare, bassi livelli di a vità fisica, fa cabilità e lentezza (camminare lentamente, per esempio). La fragilità può risultare da stress fisico o psicologico, come un trauma, una mala a o perdita di una persona cara. Persone con fragilità possono perdere abilità funzionali e essere dipenden da un caregiver. I professionis sanitari della comunità possono facilitare l’accesso agli alimen , aiutare come la ges one delle finanze accesso a fon di accesso al reddito, facilitando l’assistenza a preparare gli alimen o ricevendo alimen già prepara , come avviene nei servizi di consegna dei pas . 39 40 7 La visione è una componente fondamentale della capacità intrinseca, che consente alle persone di essere mobili e di interagire in sicurezza con i propri coetanei e con l'ambiente. Alcune cause di disabilità visiva diventano più comuni con l'invecchiamento: miopia, ipermetropia, catara a, glaucoma e degenerazione maculare. La disabilità visiva può causare difficoltà nel manteni- mento delle relazioni familiari e sociali, nell'accesso alle informazioni, nel movimento sicuro (sopra u o in un contesto di equilibrio e rischio di cadute) e nello svolgimento di a vità manuali. Tali difficoltà possono portare ad ansia e depressione. Una valutazione della vista è una componente cri ca di una valutazione centrata sulla persona. PUNTI CHIAVE l Con una semplice tabella o almica, gli operatori sanitari delle cure primarie e di comunità̀ possono testare una significa va perdita della vista. l Molte persone con riduzione dell’acuità visiva pos- sono o enere delle cure per la propria condizione. È importante chiedere informazioni, valutare o verifica- re la presenza di una mala a oculare accertata. l Spesso, gli occhiali possono correggere la riduzione la vista da vicino o da lontano. l Gli ausili (len d'ingrandimento) possono facilitare chi ha una riduzione della vista che non può essere corre a con gli occhiali. l In casa e in comunità, semplici inizia ve come miglio- rare l’illuminazione possono aumentare le capacità funzionali delle persone anziane con riduzione della vista. CAPACITÀ VISIVA Percorso di cure per la ges one del deficit visivo 41 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista DOMANDARE Hai mai avuto problemi di vista: difficoltà nella visione da lontano, leggere, mala e oculari o ha tra amen in a o? (Diabete, ipertensione) TEST DI ACUITÀ VISIVA SI SI SI Usare i semplici grafici OMS: - Test della visione distante prima della visione da vicino - Test senza occhiali se normalmente indossa - Test prima a singolo occhio poi insieme VISIONE DA LONTANO VISIONE DA VICINO Rinforzare la salute degli occhi e lo s le di vita, promuovere i consigli su igiene della vista e per la persona e l’ambiente RIVALUTARE… Una volta l’anno, in assenza di deficit visivi Fornire occhiali da le ura VALUTARE IL DEFICIT VISIVO E LE MALATTIE OCULARI Tra are le mala e oculari Ges re il deficit visivo Revisione e prescrizione di occhiali gradua o offrire nuovi occhiali Considerare la riabilitazione della vista, introdurre strumen di assistenza, come schermi e len di ingrandimento VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE - IPERTENSIONE - DIABETE - USO DI STEROIDI Ges one dei fa ori di rischio cardiovascolari Rivolgersi all’oculista per lo screening annuale della re na Revisionare i farmaci potenzialmente dannosi per gli occhi VALUTAZIONE E GESTIONE DELL’AMBIENTE SOCIALE E FISICO Dare consigli sulla vita quo diana con visione limitata Introdurre strumen di ada amento di casa (luce, contras di colori) per prevenire le cadute Rimuovere gli ostacoli dai percorsi a piedi usuali La perdita della visione da lontano deve sempre richiedere l’invio allo specialista DEFICIT VISIVO (14) Deficit della visione da lontano: - Lieve acuità visiva rido a a 6/12 - Moderata: visione rido a a 6/18 - Severa: acuità visiva rido a a 6/60 - Cecità: acuità visiva rido a a 3/60 Deficit della visione da vicino: - Acuità Visiva da vicino meno di N.6 o M.08 con correzione FALLITO FALLITO Gli occhiali risolvono il problema? 42 7 QUANDO È NECESSARIO RIVOLGERSI ALLO SPECIALISTA Se una persona ha una mala a agli occhi accertata o viene iden ficata come affe a da una mala a agli occhi, uno specialista in oculis ca decide la frequenza e il po di esame. TEST DI ACUITA’ VISIVA NELLE CURE PRIMARIE • Il semplice screening per la della vista dovrebbe essere effe uato almeno una volta all'anno per le persone di età pari o superiore a 50 anni. • Lo screening può essere eseguito u lizzando l’app dell'OMS per testare sia la visione da lontano che quella da vicino. Le istruzioni vengono visualizzate vedi TEST DELLE E. • Eseguire lo screening non richiede una formazione formale nella valutazione della cura degli occhi (13). • Se gli occhiali da le ura disponibili in commercio risolvono il problema della vista, non sarà necessario ulteriore esami de aglia IGIENE DELLA VISTA L’igiene della vista coinvolge l’ambiente e la persona. Fa ori e comportamen ambientali possono facilitare la funzione della vista (per esempio, illuminazione, ostacoli, uso di colori) o possono peggiorarla (per esempio, osservazione prolungata di schermi elet- tronici, uso prolungato della visione da vicino). L’igiene personale include tu i comportamen di igiene della vista come lavare le mani frequentemente, non sfregare gli occhi, usare un sapone neutro per le palpebre ed evitare l’ uso di cosme ci intorno agli occhi ESAME DELLA VISTA DA LONTANO CON LA TABELLA VISIVA DELL’ OMS Lascia che la persona tenga la scheda del test per la visione il più vicino possibile. 1. Test con 4 E piccole a 3 metri. 7.1 L’ acuità visiva é 6/18 o maggiore se la persona iden fica le direzioni di almeno tre su qua ro E tra le più grandi, supera il test di screening per la visione da vicino. (SUPERATO l’esame di screening per la visione da lontano). In caso contrario, controlla se gli occhiali da le ura disponibili in commercio possono essere d'aiuto. Con gli occhiali da le ura, se non si è in grado di vedere almeno tre delle E più grandi (il test di screening della visione da vicino è da considerarsi FALLITO), si richiede la valutazione della disabilità visiva e delle patologie oculari. La dimensione media è simile alla stampa nei libri. La dimensione più piccola è simile alla stampa su libri e riviste (non è necessario che sia vista). 2. Test con le E grandi a 3 metri. 7.2 Se la persona riesce a vedere le E, l’acuità visiva é di 6/60. Se non riesce a vedere almeno 3 E grandi a 3 metri 3. Test con le E grandi a 1,5 metri. 7.2 Se la persona riesce a vedere almeno 3delle 4 E, la visione é 3/60 ESAME DELLA VISTA DA VICINO CON UNA TABELLA VISIVA SEMPLICE DELL’ OMS 7.3 Lascia che la persona tenga la scheda per il test della vista il più vicino possibile. Test dalla più grande alla più piccola “E”: Se la persona riesce a discernere l’orientamento di almeno 3 di 4 “E” più grandi, ha superato l’esame di screening della vista da parte di un esperto. Caso contrario, verificare se gli occhiali da le ura disponibili in commercio, sono capaci di aiutare. Se riesce a dis nguere meno di tre “E” più grandi usando gli occhiali da le ura (FALLITO lo screening della visione da vicino), é necessario valutare il deficit visivo e le possibili patologie oculari. La dimensione media è simile a quella usata nei libri La dimensione piccola è simile ai cara eri piccoli usa nelle riviste o sui libri (non è necessario da vedere). 1 2 4 3 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista 43 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista 7.1 TABELLA VISIVA SEMPLICE DELL’OMS (QUATTRO “E” PICCOLE, VISIONE DA LONNTANO) • Ogni “E” misura 1,3 cm x 1,3 cm ed è posizionata a 1,3 cm di distanza dall’altra. • “E” nera su fondo bianco. 44 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista 7.2 TABELLA DELLA VISIONE SEMPLICE DI OMS (QUATTRO “E” GRANDI, VISIONE DA LONTANO) • Ogni E misura 4,2 cm x 4,2 cm ed è posta a 4,5 cm di distanza dall’altra • “E” nera su fondo bianco. 45 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista 7.3 TABELLA DELLA VISIONE SEMPLICE DI OMS (VISIONE DA VICINO) 46 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista VALUTAZIONE DEL DEFICIT VISIVO E DELLE MALATTIE OCULARI 7.4 VALUTARE IL DEFICIT VISIVO E LE MALATTIE OCULARI • La perdita della vista rapidamente progressiva, a uno o ambo gli occhi, richiede un esame o almologico base e oltre che la valutazione da parte di uno specialista oculista. • Un professionista delle cure primarie può esaminare gli occhi e ricercare segni di mala e oculari comuni. Questo esame generalmente non è completo e richiede quindi uno specialista. Se la condizione oculare sopra elencata persiste, si raccomanda una visita oculis ca specialis ca. • Un professionista delle cure primarie può esaminare gli occhi di una persona. Se ci sono cambiamen come occhi rossi, secrezioni, cicatrici, dolore con nuo, intol- leranza alla luce solare o catara a, allora, un oculista (o almologo, optometrista) dovrebbe esaminare la persona. • Gli occhiali da le ura aiutano molte persone anziane a vedere da vicino. Per alcune persone, tu avia, gli occhiali da le ura non sono la risposta. Ad esempio, le persone che sono presbi o che hanno l'as gma smo hanno bisogno di occhiali prescri da un oculista dopo l'esame. • Un esame diagnos co standard richiede un profes- sionista qualificato che u lizza una lampada a fessura per esaminare l'occhio in de aglio. Questo strumento può essere u lizzato, ad esempio, per rilevare una catara a e puo ̀ aiutare a decidere l’opportunità̀ di un intervento chirurgico. L'esame della re na e del nervo o co richiede l'uso di altri strumen e talvolta l'acquisizione di immagini per rilevare i cambiamen precoci e guidare il tra amento per prevenire la perdita della vista. L'esame della re na a intervalli regolari è par colarmente importante per le persone con diabete. Catara a La catara a è l'opacamento del cristallino oculare, che impedisce una visione chiara, spesso correlata al processo di invecchiamento. La catara a rimane la principale causa di cecità. La riduzione del fumo e dell'esposizione alla luce ultraviole a può prevenire o ritardare lo sviluppo della catara a. Il diabete e l'obesità sono ulteriori fa ori di rischio. La compromis- sione della vista e la cecità da catara a sono evitabili perché la chirurgia della catara a è sicura e può res tuire la vista. 47 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista 7.5 OCCHIALI DA LETTURA Molte persone di età pari o superiore a 50 anni hanno difficoltà a vedere o leggere a breve distanza. Spesso possono trarre vantaggio dall'uso di occhiali da le ura. Gli occhiali da le ura semplici sono disponibili a basso costo. Sono spesso disponibili in varie gradazioni di ingrandimento, infa fanno semplicemente apparire gli ogge vicini più grandi. Quando i semplici occhiali da le ura non risolvono il problema, è consigliabile un esame completo della vista e dell’occhio. Se possibile, tu e le persone di età pari o superiore a 50 anni dovrebbero essere esaminate da un oculista a intervalli regolari. I semplici test di visione e le ura non sos tuiscono un esame completo effe uato da un oculista. 7.6 IPOVISUS IRREVERSIBILE Molte persone hanno problemi di vista per i quali gli occhiali da vista non possono correggere sufficiente- mente la visione. Per queste persone, gli strumen di visione assis ta - len di ingrandimento da scrivania o mobili - forniscono un ingrandimento maggiore rispe o agli occhiali. Possono rendere possibili compi che coinvolgono la visione da vicino, come leggere un libro o un giornale, dis nguere banconote, leggere e che e e ispezionare piccoli ogge o par di ogge di grandi dimensioni. Gli operatori sanitari o di riabilitazione a livello comuni- tario possono aiutare le persone a o enere ques disposi vi. GESTIONE DEI DEFICIT VISIVI 48 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista7.7 IPERTENSIONE L’ ipertensione é un importante fa ore di rischio per le mala e della re na e glaucoma. 7.8 DIABETE Persone con diabete devono passare per un esame o almologico annuale per verificare se ha una re nopa a diabe ca. 7.9 USO DI CORTICOSTEROIDI In alcune persone, la terapia con steroidi a lungo termine può aumentare la pressione nel bulbo oculare (pressione intraoculare) o portare alla catara a. Questa maggiore pressione può portare alla perdita della vista, che comporta danni al nervo o co e che può portare alla cecità se non tra ata. Chiunque riceva una terapia steroidea a lungo termine ha bisogno di visite oculis che regolari e controlli della pressione oculare. Ci sono mol modi per aiutare le persone ipoveden a godere di una migliore funzionalità. I familiari e gli operatori sanitari possono fornire supporto. Sono necessari ada amen locali di questa guida in funzione dei diversi modelli organizza vi che specifichino dove o enere ausili per la visione assis ta e i servizi a essi connessi. VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE 49 7 CAPACITÀ VISIVA Percorso di cura per la ges one del deficit della vista VALUTAZIONE E GESTIONE DEGLI AMBIENTI FISICI E SOCIALI 7.10 IPOVISUS: ACCORGIMENTI Oltre alla fornitura di disposi vi per la visione assis ta, semplici accorgimen possono consen re alle persone ipoveden di mantenere le loro a vità e, quindi, conservare la loro qualità di vita. È possibile apportare modifiche alla casa e alle aree di movimento abituali di una persona per rendere più sicure e facili le a vità consuete e le a vità del tempo libero. Di seguito alcuni esempi. Migliorare l'illuminazione. Una buona illuminazione è par colarmente importante per la visione da vicino. È meglio che la luce provenga dal lato della persona (senza creare ombre). Ridurre l'abbagliamento. La luce più intensa è solita- mente migliore. Ma il bagliore del sole o le luci intense possono infas dire alcune persone. Spostare gli ostacoli. Ogge pericolosi come mobili e altri ogge duri possono essere sposta fuori dal percorso abituale della persona o, se necessario, dovreb- bero essere lascia sempre nello stesso posto. Creare contrasto. Un buon contrasto all'interno e tra gli ogge li rende più facili da vedere, trovare o evitare. Esempi sono la marcatura ad alto contrasto sui bordi dei gradini (in par colare per chi vede da un occhio solo), le e che e colorate in modo che il cibo risul in contrasto e l’uso di una penna nera per scrivere. Le persone ipove- den , i familiari e gli operatori sanitari possono colorare i manici degli utensili domes ci e da cucina per renderli più visibili e più sicuri, ad esempio avvolgendo il manico di un coltello con nastro adesivo dai colori vivaci o dipingerlo. Usare il cara ere più leggibile. Per i materiali stampa e gli schermi ele ronici di computer e telefoni, i cara eri sans serif grandi (come quelli in questo manuale) che si dis nguono chiaramente da un colore di fondo uniforme sono i più facili da leggere. Scegliere ogge domes ci con cara eri più grandi e buon contrasto. Spesso nei negozi sono disponibili prodo che u lizzano le ere e numeri più grandi o un buon contrasto. Esempi di prodo disponibili con queste cara eris che sono: sveglie, orologi e libri a cara eri grandi. Per il tempo libero, per esempio, è possibile acquistare o realizzare grandi tabelloni e pezzi di gioco e carte da gioco con cara eri e simboli grandi. Usare strumen per l'udito e per la vista. Mol ar coli nei negozi ora hanno la capacità di parlare, come orologi parlan , termometri e bilance. Mol telefoni cellulari e programmi per computer dispongono ora di funzioni di sintesi vocale. 50 8 La perdita dell'udito legata all'età è una delle meno- mazioni sensoriali più comuni nelle persone anziane. Non tra ata, la perdita dell'udito interferisce con la comunicazione e può portare all'isolamento sociale. Le limitazioni di altre capacità, come il declino cogni vo, possono peggiorare l’isolamento sociale. La perdita dell'udito è legata a mol altri problemi di salute, tra cui il declino cogni vo e il rischio di demenza, depressione e ansia, scarso equilibrio, cadute, ricoveri e morte prematura. La valutazione dell'udito è quindi una parte fondamentale del monitoraggio della capacità intrinseca delle persone anziane. Valutare l'udito in modo più approfondito è fondamentale nella valutazione della persona anziana. PUNTI-CHIAVE • Gli operatori di assistenza primaria sul territorio e delle stru ure residenziali possono eseguire lo screening per la perdita dell'udito con semplici apparecchiature porta li o con il whisper voice test (test della voce sussurrata). • Semplici azioni in casa possono ridurre l'impa o della perdita dell'udito. Le strategie di comunicazione per facilitare l'udito includono parlare chiaramente, me ersi di fronte la persona con perdita dell'udito quando si parla e ridurre il rumore di fondo. • Migliorare l'udito stesso con apparecchi acus ci e impian cocleari, rivolgendosi a fornitori del se ore e a rezzature specializzate. CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito 51 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito - Test della voce sussurrata: in grado di sen re i sussurri - Audiometria di screening: 35 dB o meno (RIUSCITO) - test automa co (basato sulle app) digitale del rumore Rinforzare l’orientamento generico sulla cura dell’udito o sulle cure abituali Sordità (Audiometria: ≥ 81 dB) TEST FALLITO PASSATO Perdita dell’udito da moderata a grave (Audiometria: 36–80 dBB) Udito normale (Audiometria: ≤ 35 dB) VALUTAZIONE DELLA CAPACITÀ UDITIVA (Audiometria diagnos ca) Fare riferimento all’a enzione fonologica specializzata - Valutare e organizzare disposi vi di assistenza (protesi acus che o impian cocleari) (a tu e) SI DOMANDARE: - FATTORI DI RISCHIO (come l’esposizione a farmaci ototossici) - MAL D’ORECCHIE - STORIA di secrezioni stagionali - VERTIGINI - OTITE MEDIA CRONICA - PERDITA UNILATERALE DELL’UDITO Rinforzare l’orientamento generico sulla cura dell’udito o sulle cure abituali RIVALUTARE una volta l’anno Fornire protesi acus che. Se non disponibili apparecchi acus ci, informare sulla le ura labiale e lingua dei segni, o su altre strategie di comunicazione (a tu o) Fornire supporto emo vo e aiuto per la ges one dello stress Fornire un’assistenza tecnologica in casa (telefono, campanello) VALUTAZIONE E GESTIONE DEGLI AMBIENTI SOCIALI E FISICI Fornire alla persona come perdita udi va e alla sua famiglia strategie di relazione TEST dell’UDITO 52 CONSIGLI GENERICI PER LA CURA DELL’UDITO • NON me ere le dita sporche nelle orecchie e non dimen care di lavarsi le mani prima di toccare il cibo e non mangiare con le mani sporche lavarsi SEMPRE le mani dopo essere anda in bagno • NON nuotare o lavarsi con acqua sporca • NON me ere nulla nelle orecchie: - olio caldo o freddo - rimedi alle erbe - liquidi come il cherosene. 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito TEST AUDIOMETRICI Per la valutazione iniziale si può usare uno dei tre test che seguono PROVA DELLA VOCE SUSSURRATA Il test della voce sussurrata è uno strumento di screening che può aiutare a determinare se una persona ha un udito normale o necessita di audiometria diagnos ca. AUDIOMETRIA DI SCREENING (15) U lizzare lo screening audiometrico se si dispone dell'a rezzatura. L'audiometria di screening presenta i toni a raverso lo spe ro del parlato (da 500 a 4000 Hz) ai limi superiori dell'udito normale. I risulta vengono registra come presenza o assenza. Sen re i suoni di 35 dB o meno indica un udito normale. Con una breve forma- zione specifica, un non specialista può testare accurata- mente l'udito con questa apparecchiatura. Test audiometrici con l’u lizzo di app (digits-in-noise (DIN) test). È inoltre possibile u lizzare il DIN test usando app per determinare se è necessaria l'audiometria dia- gnos ca. Disponibile come app per telefoni cellulari, ad esempio: listenWHO: hearWHO: h ps://www.who.int/deafness/hearWHO (gratuito, In inglese) hearZA: (gratuito in inglese).h ps://www.hearza.co.za/ uHear:h p://unitron.com/content/unitron/nz/en/profes- sional/prac ce-support/uhear.html (gratuito per iPhone, In inglese, francese,tedesco e spagnolo). Disponibile come applica vo online - ad esempio: da HearCom: h p://hearcom.eu/prof/DiagnosingHearingLoss/SelfScre enTests/ThressDigitTest/en.html (gratuito, in olandese, inglese, tedesco, polacco e svedese. TEST DELLA VOCE SUSSURRATA Stare a circa un braccio di distanza dietro e di lato alla persona. Chiedere alla persona o ad un assistente di chiudere l'orecchio opposto premendo sul trago. ( Il trago è la protezione di fronte e parzialmente coperta dall’apertura dell’orecchio). Espira e poi sussurra dolcemente 4 parole. Usa parole comuni e non correlate. Chiedi alla persona di ripetere le parole. Le parole dovrebbero essere pronunciate una per volte e aspe are la risposta per ognuna delle parole. Se la persona ripete più di tre parole e sei sicuro che possa sen r chiaramente, è probabile che la persona abbia un udito normale. Sposta dall'altra parte della persona e testare l’altro orecchio Sussurra parole familiari per la persona. Alcuni esempi: – fabbrica – cielo – fuoco – numero QUANDO È NECESSARIO RIVOLGERSI ALLO SPECIALISTA • Valutazione di una persona con grave ipoacusia/sordità. • Applicazione di un apparecchio acus co. • Ges one di un problema so ostante che causa o contribuisce alla perdita dell'udito. – pesce – bicicle a – giardino – giallo 2 3 1 53 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito 8.1 TRE PROVE PER UNA VALUTAZIONE APPROFONDITA Per la valutazione dell'udito si possono usare tre prove con l’u lizzo di apparecchiature specializzate: l’audiometria tonale, audiometria vocale e l’impedenzo- metria. Ques test possono aiutare a iden ficare la necessità di iniziare un percorso di riabilitazione udi va. Fare ques test richiede una formazione specifica. L’audiometria tonale (PTA) viene eseguita valutando la percezione del suono per via aerea, usando suoni che possiedono una frequenza pura, prive di armoniche. Consiste nel riprodurre suoni preregistra sempre più for finché la persona non riesce a sen rli individuando la soglia udi va della persona. Si impiegano suoni con frequenze che variano da 125 Hz (molto basse) a 8000 Hz (molto alte), Inoltre viene eseguita la soglia udi va per via ossea. Tramite questo test si è in grado di determinare il grado e il po di perdita dell’udito. Audiometria vocale. Per gli anziani viene usata anche l'audiometria vocale. In questo test paziente ascolta una serie di parole pre registrate, riprodo e a volume crescente, che deve ripetere all’esaminatore, il quale trascrive quante parole vengono comprese corre a- mente. Questo test incrocia i risulta del PTA. Aiuta a determinare se il riconoscimento vocale è coerente con i risulta PTA, se c'è un'asimmetria della percezione del parlato che non emerge dal PTA, o iden fica per quale orecchio usare l’apparecchio acus co. Timpanometria. Infine, la mpanometria testa la com- pliance (o mobilità) del mpano. La mpanometria è un test per valutare la funzione/ condizione dell’orecchio medio e la mobilità del mpano (membrana mpanica). Questo test può supportare i risulta dell'audiometria tonale e vocale per determinare il po di problema udi vo. VALUTAZIONE DELLA CAPACITÀ UDITIVA 54 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito GESTIONE DELLA PERDITA DELL’UDITO Sia le strategie di comunicazione che i disposi vi acus ci dovrebbero essere presi in considerazione per affrontare la perdita dell'udito. L'approccio migliore per ges re la perdita dell'udito dovrebbe essere deciso alla luce della valutazione completa delle capacità intrinseche della persona, compreso il declino cogni vo, la perdita di capacità locomotoria o perdita di destrezza nelle braccia o nelle mani, e il la capacità di supporto della famiglia e dell’ambiente in cui la persona vive. 8.2 ANZIANI CON PERDITA DELL’UDITO DA MODERATA A GRAVE • Spiegare alle persone con ipoacusia e alle loro famiglie i vantaggi dell’uso degli apparecchi acus ci, dove trovarli e come usarli. Una volta che una persona ha un apparecchio acus co, l'operatore sanitario può soste- nere e incoraggiare l'uso. • L'audiometria da sola non dovrebbe determinare se una persona ha bisogno di un apparecchio acus co, ma vanno prese in considerazione anche le esigen- ze/bisogni generali della persona. La maggior parte delle persone con ipoacusia lamentano difficoltà a comunicare quando è presente rumore di fondo. • Fornire indicazioni chiare alle persone con ipoacusia, alle loro famiglie e agli operatori sanitari sulle strategie di comunicazione che possono migliorare la capacità funzionale della persona stessa. • Alcuni farmaci possono causare danni all' orecchio interno, con conseguente perdita dell'udito e/o perdita dell'equilibrio. Ques includono an bio ci come streptomicina e gentamicina e an malarici come chinino e clorochina. Anche altri farmaci possono influenzare l'udito. La riduzione di ques farmaci, se possibile, può prevenire un'ulteriore perdita dell'udito 8.3 PERSONE CON PERDITA DELL’UDITO Una persona anziana con un alto grado di ipoacusia (grave o profonda) o che non beneficia degli interven sopra menziona avrà̀ bisogno di cure udi ve specializ- zate come l'applicazione di un apparecchio acus co. Solo persone con competenze specialis che possono fornire apparecchi acus ci (test, prescrizione e ada amento dell’apparecchio acus co) richiede competenze specia- lis che. Altri segnali che evidenziano la necessità di cure/assistenza specialis ca. Le condizioni che possono essere alla base della perdita dell'udito richiedono una diagnosi e una ges one specialis ca. Queste includono: • Mal d’orecchio • O te media cronica (infezione dell’orecchio medio) • Perdita dell’udito improvvisa o rapida- mente progressiva • Ver gini con perdita dell’udito da moderata a grave • Secrezioni a ve dell’orecchio/i • Presenza di fa ori di rischio, come l’esposi- zione a rumori e uso di medicinali che possono pregiudicare l’udito 8.5 55 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito 8.4 DISPOSITIVI UDITIVI Apparecchi acus ci. Gli apparecchi acus ci sono la migliore tecnologia disponibile per le persone anziane con perdita dell’udito. Gli apparecchi acus ci rendono i suoni più udibili. Possono essere efficaci per la maggior parte delle persone e sono convenien perché vengono indossa dentro o sopra l'orecchio. È importante spie- gare alle persone che gli apparecchi acus ci non curano la perdita dell'udito. Impian cocleari. Gli impian cocleari sono u li a perso- ne con un alto grado di ipoacusia che non beneficiano dell'uso di apparecchi acus ci. Un impianto cocleare vie- ne inserito chirurgicamente nell'orecchio. Trasforma i suoni in impulsi ele rici e li invia ai nervi dell'orecchio. È necessaria un’a enta valutazione per verificare se un impianto cocleare può essere u le. Se l'impianto cocleare non può essere u lizzato perché non disponibile o ada o alla persona anziana, quest’ul ma e la sua famiglia dovrebbero essere informa circa la possibilità dell’u lizzo per comunicare sia della le ura del labiale sia del linguaggio dei segni. Sistemi ad induzione magne ca e amplificatori sonori personali. Anche l’uso di sistemi ad induzione magne ca gli amplificatori sonori è considerato efficace. Essi sono cos tui da un amplificatore che riceve il segnale, per esempio, da un microfono e uno o più cavi posiziona nel perimetro dell’ambiente, i quali ricevendo il segnale dall’amplificatore lo trasformano in campo magne co, coprendo l’intera superficie delimitata dal cavo. Il campo magne co che viene interce ato dall’ausilio udi vo annulla la distanza dalla fonte sonora e favorisce un ascolto chiaro e non disturbato dai rumori ambientali. Le linee guida dell’OMS per gli apparecchi acus ci e i servizi di sviluppo dei vari Paesi offrono ulteriori indicazioni: h p://apps.who.int/iris/handle/10665/43066 56 8 CAPACITÀ UDITIVA Percorso di cura per la ges one della perdita dell’udito VALUTAZIONE E GESTIONE DEGLI AMBIENTI SOCIALI E FISICI Ridurre al minimo l'impa o della perdita dell'udito può aiutare a preservare l'indipendenza e ridurre la necessità per le persone anziane di fare affidamento sui servizi offer dal sistema sanitario quando risiedono nella loro dimora per far fronte ai bisogni della vita quo diana. I membri della famiglia, gli altri operatori sanitari e l’ambiente in cui la persona vive possono essere di supporto. La perdita dell'udito porta spesso a disagio psicologico e isolamento sociale. Per questo mo vo, la riabilitazione audiologica sta ora ponendo maggiore enfasi su consi- derazioni psicosociali, ada ate agli obie vi della perso- na anziana e dei suoi caregivers. • La regolarità delle interazioni sociali può ridurre il rischio di declino cogni vo, depressione e altre conseguenze emo ve e comportamentali della perdita dell'udito. In tempi di par colare difficoltà, le re di sostegno sociale possono aiutare. • Amici e familiari possono aiutare a prevenire la solitudine e l'isolamento. Essi potrebbero aver bisogno di consigli su come farlo. Ad esempio, dovrebbero con nuare a comunicare con la persona che ha una perdita dell’udito e organizzare a vità che coinvolgano la persona, mante- nendo la sua rete sociale. Vedere il riquadro per consigli su come parlare con una persona ipoacusica. • Le soluzioni nell’ambiente domes co possono includere la collocazione di campanelli e telefoni che possono essere udi in tu a la casa 8. 5 STRATEGIE DI COMUNICAZIONE PER FAMILIARI E CAREGIVERS Gli operatori sanitari possono consigliare ai familiari e ai caregivers di seguire alcune semplici indicazioni pra - che quando si parla con una persona ipoacusica (14). 4 Lasciare che la persona veda il viso quando si parla. 4 Assicurarsi che ci sia una buona luce sul viso per aiutare l'ascoltatore a vedere le labbra. 4 A rare l'a enzione della persona prima di parlare. 4 Cercare di evitare le distrazioni, in par colare i rumori for e i rumori di so ofondo. 4 Parlare chiaramente e più lentamente. Non gridare. 4 Non rinunciare a parlare con persone che hanno problemi di udito. Questo li isolerebbe e potrebbe portare a conseguenze come la depressione. Queste strategie sono u li indipendentemente dal fa o che una persona indossi un apparecchio acus co.8.5 57 58 9 “Il termine "sintomi depressivi" (o umore deflesso) si applica alle persone anziane che hanno due o più sintomi simultanei di depressione per la maggior parte del tempo o per tu o il tempo da almeno due se mane, ma che non soddisfano i criteri per una diagnosi di depressione maggiore. I sintomi depressivi sono più comuni nelle persone anziane con condizioni invalidan a lungo termine, in isolamento sociale o che prestano assistenza a loro volta con responsabilità assistenziali gravose. Ques problemi dovrebbero essere considera come parte di un approccio globale alla ges one dei sintomi depressivi. I sintomi depressivi sono un aspe o importante della capacità psicologica, ma rappresentano solo uno degli aspe . Ce ne sono altri come l'ansia, le cara eris che di personalità, la capacità di coping (fronteggiamento delle avversità) e il senso di padro- nanza, che richiedono misure complesse. Questo capitolo fornisce indicazioni sulla prevenzione e la ges one dei sintomi depressivi nelle persone anziane. Ulteriori indicazioni sugli interven per la depressione sono disponibili nella Guida agli interven mhGAP dell'OMS, all'indirizzo: h p://iris.paho.org/xmlui/handle/123456789/34071 PUNTI-CHIAVE • Ponendo una serie di domande, l'operatore di assistenza primaria nella comunità può iden ficare coloro che presentano sintomi depressivi e dis ngue- re i sintomi depressivi dalla depressione. • U lizzando brevi interven psicologici stru ura , operatori sanitari adeguatamente addestra e supervisiona anche se non specializza possono aiutare le persone con sintomi depressivi nella comunità e in altri contes di assistenza primaria. • La depressione richiede un approccio al tra amento completo e solitamente specialis co. • Il declino in altri domini delle capacità intrinseche, come l'udito o la mobilità, può comprome ere le capacità funzionali, ridurre la partecipazione sociale e contribuire ai sintomi depressivi. CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi 59 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi DOMANDA Nelle ul me due se mane hai avuto/sen to SCREENING DEI SINTOMI DEPRESSIVI Umore basso, depresso, senza speranza? * Hai poco interesse o mancanza di piacere nel fare le cose? Rinforzare l’orientamento generico sulla salute o s li di vita o abitudini SI SINTOMI DEPRESSIVI (0-2 sintomi addizionali) DEPRESSIONE (>3 sintomi) VALUTAZIONE DELL’UMORE Offrire interven psicologici brevi e stru ura - Terapia cogni vo comportamentale - counselling di risoluzione dei problemi o terapia - A vazione comportamentale - Terapia della reminiscenza Esercizi mul modali Pra ca di consapevolezza(mindfulness) (ad una qualsiasi delle domande) TRATTAMENTO DELLA DEPRESSIONE Gli anziani che hanno diagnosi di depressione maggiore necessitano di cure specializzate. Dovrebbero essere valuta e tra a come consigliato dall’OMS nella guida mhGAP h ps://apps.who.int/iris/handle/10665/2502 VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE - Grave perdita negli ul mi 6 mesi - Storia di mania - Decadimento cogni vo - deficit visivi - Invalidità per mala a o lesioni Rivedere i tra amen come gli an depressivi, an staminici, an psico ci Integrare la ges one delle condizioni associate Valutare e ges re il dolore - POLIFARMACOTERAPIA - ANEMIA MALNUTRIZIONE IPOTIROIDISMO - DOLORE VALUTAZIONE E GESTIONE DI AMBIENTI SOCIALI E FISICI Ridurre lo stress e il peso del supporto sociale Mo vare socialmente Promuovere il funzionamento nelle a vità quo diane Incoraggiare la partecipazione basata su esercizi programma e sviluppo delle abilità Iden ficare e affrontare solitudine e isolamento sociale (considerare anche l’intervento della tecnologia) (a tu e) 60 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi VALUTAZIONE DELL’ UMORE Se una persona riferisce almeno uno dei seguen sintomi principali: • sen rsi giù, depresso o senza speranza e avere poco interesse o piacere nel fare le cose • fai un'ulteriore valutazione dell'umore. È possibile u lizzare parole alterna ve se una persona non ha familiarità con una delle due domande filtro. DOMANDA: “Nelle ul me due se mane sei stato disturbato o hai avuto uno qualsiasi dei seguen sintomi??”* • Difficoltà ad addormentarsi o mantenere il sonno o dormire troppo. • Sensazione di stanchezza o poca energia. • Scarso appe to o eccesso di cibo. • Sen rsi male con sé stessi o pensare di essere un fallimento o di aver deluso sé stessi o la propria famiglia. • Difficoltà a concentrarsi su cose come leggere il giornale o guardare la televisione. • Muoversi o parlare così lentamente che altre persone potrebbero notarlo. • Essere così irrequieto o muoversi molto più del solito. • Avere pensieri quali: meglio morire o di farsi del male in qualche modo. * Queste domande possono essere trovate nel Pa ent Health Ques onnaire (PHQ-9) h p://www.cqaimh.org/pdf/tool_phq9.pdf), che è uno strumento per la valutazione dei sintomi depres- sivi. Oppure vedi la sezione sulla depressione della guida all’intervento mhGAP, su h ps://apps.who.int/iris/handle/10665/250239. SINTOMI DEPRESSIVI Se una persona avesse almeno uno dei sintomi princi- pale o due sintomi addizionali potrebbe soffrire/avere sintomi depressivi. Se una persona avesse più di due sintomi, potrebbe avere una diagnosi di depressione. È importante dis nguere tra sintomi depressivi e depressione perché il loro tra amento è differente. • Il declino cogni vo e la demenza possono essere associa a sintomi depressivi e devono essere valuta nel migliore dei modi. Le persone con demenza spesso arrivano dai sanitari con lamentele o problemi comportamentali come apa a, perdita del controllo sulle emozioni o difficoltà a svolgere il lavoro o a vità domes che e sociali. • Allo stesso tempo il declino in altri domini della capacità intrinseca come il sensorio o la mobilità possono ridurre le abilità funzionali e la partecipazio- ne sociale e contribuire quindi ai sintomi depressivi. • Gli interven per il declino in altri domini della capacità intrinseca come la capacità cogni va, l’udito possono essere più efficaci se i sintomi depressivi sono guida allo stesso tempo. Possono essere considera al momento di sviluppare il piano di cure personalizzate. QUANDO SONO NECESSARIE CURE GERIATRICHE • La ges one della depressione necessita di un approccio più completo e solitamente geriatrico per sviluppare un piano di cura personalizzato. • Per ges re i sintomi depressivi, gli operatori sanitari hanno bisogno di una formazione specifica in brevi interven psicologici stru ura . • Alcune condizioni associate, come l'ipo roidismo, possono richiedere una diagnosi e una ges one geriatrica. 61 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi APPROCCIO AI SINTOMI DEPRESSIVI 9.2 BREVI INTERVENTI PSICOLOGICI STRUTTURATI Interven psicologici stru ura come la terapia cogni vo- comportamentale, approcci di problem-solving (risoluzione dei problemi), la behavioral ac va on (a vazione comportamentale), la life review therapy (terapia della reminiscenza) posso ridurre considerevolmente i sintomi depressivi degli anziani. Esercizi mul modali e pra ca di consapevolezza possono ridurre i sintomi depressivi. Possono essere u lizza mol interven psicologici con il consenso e l’accordo delle persone anziane in modo da prendere consapevolezza sulle difficoltà e sulla risoluzione del problema. L’esercizio fisico può essere considerato, in aggiunta ai tra amen psicologici stru ura , per gli effe posi vi dell’esercizio fisico nel miglioramento dell’umore. (Vedi capitolo 5 sulla mobilità limitata). La prescrizione di an depressivi come primo approccio, senza uno specialista con conoscenze in salute mentale non è raccomandato. Terapia cogni vo-comportamentale La terapia cogni vo-comportamentale (TCC) si basa sull’idea che i sen men sono influenza da credenze e comportamen . Le persone con sintomi depressivi (o diagnosi di disordini mentali) possono avere pensieri distor in maniera irreale e nega va che, se non riconosciu , possono portare a comportamen dannosi. Così, la TCC picamente ha una componente cogni va aiutare le persone a sviluppare abilità per iden ficare e cambiare pensieri irrealis camente nega vi così come una componente comportamentale aumentare i comporta- men posi vi e diminuire quelli nega vi. Le tappe possono includere 1) iden ficazione dei comportamen nella vita 2) diventare consapevole dei pensieri, delle emozioni e credenze riguardan i problemi, 3) iden ficare pensieri nega vi e inaccura 4) e rielaborare ques pensieri in maniera più realis ca. Counselling o terapia di problem solving (risoluzione dei problemi) Un approccio di problem solving può essere considerato per le persone con sintomi depressivi che sono so oposte a stress o che hanno qualche difficoltà nelle funzioni sociali (in assenza di diagnosi di episodi depressivi o disordini). La terapia di problem solving offre alla persona supporto dire o e pra co. I sanitari, agendo come terapis , lavorano insieme alla persona anziana per iden ficare e isolare l’area chiave del problema che può contribuire ai sintomi depressivi. Insieme, possono segmentare il problema in par ges bili e risolvibili e sviluppare strategie per far fronte a specifici problemi. I sanitari con formazione sulla salute mentale possono general- mente ges re ques interven . Gli operatori sanitari di comunità possono anche fornire assistenza se hanno le competenze e sono addestra sui problemi di salute mentale delle persone anziane. Nessun danno è associato a ques interven . 5 62 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressiviBehavioral ac va on (A vazione comportamentale) La Behavioral ac va on implica di incoraggiare la persona a partecipare in a vità appagan per ridurre i sintomi depressivi. Questo approccio può essere imparato più rapidamente di mol altri tra amen psicologici basa sulle evidenze. Questo può essere insegnato da persone non specializzate cosicché l’accesso alle cure dei sintomi depressivi può essere incrementato. Questo intervento è stato studiato principalmente come un intervento in sessioni mul ple condo e da geriatri. È possibile, comunque, che l'inter- vento possa essere modificato come intervento breve e fornito da professioni della salute addestrate come aggiunta al tra amento o come primo livello di un approccio di cure comprensive nelle cure primarie. Life Review Therapy (Terapia della Reminiscenza) La Terapia della Reminiscenza coinvolge un terapista che guida una persona nel ricordare e valutare il passato in modo da raggiungere un senso di pace e di acce azione della sua vita. Questo po di terapia può aiutare a vedere la vita in prospe va ma anche a recuperare memoria degli amici e delle persone amate. La Terapia della Reminiscenza può aiutare a tra are la depressione nelle persone anziane e può aiutare ad affrontare il tema del fine vita. I terapis concentrano la Terapia della Reminiscenza sui temi della vita o ricordando episodi passa come l’infanzia, la genitorialità, diventare nonni o gli anni del lavoro. 9.2 ESERCIZI MULTIMODALI Un programma di esercizi adeguato alle abilità fisiche della persona può ridurre i sintomi depressivi a breve termine e forse anche a lungo termine. Vedi capitolo 5 sulla limitazione della mobilità. 9.3 PRATICA DEL MINDFULNESS La pra ca del Mindfulness (consapevolezza) consente di porre a enzione su cosa sta accadendo nel presente piu osto che essere focalizza su treni di pensiero rela vi al passato, al futuro, ai desideri, alle responsabilità o ai rimpian . Ques pensieri appena descri possono diventare una spirale discendente per una persona con sintomi depressivi. Ci sono mol pi di pra ca di mind- fulness. Un approccio frequentemente usato è sedere o stendersi in maniera calma e focalizzare l’a enzione sulle sensazioni provocate dalla respirazione. Il Mindfulness dei movimen fisici - per esempio, durante lo yoga o le camminate - è anche d’aiuto per alcune persone. 5 63 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi VALUTAZIONE E GESTIONE DELLE CONDIZIONI ASSOCIATE La presenza delle seguen condizioni associate vuole suggerire il bisogno di un differente approccio nel tra amento della depressione. • Grande perdita negli ul mi sei mesi. • Storia di disturbi maniacali. Mania Il disturbo maniacale è un episodio di aumento del tono dell’umore e di aumentata energia e a vità. Le persone che hanno episodi maniacali sono classificate come bipolari. Una storia di mania può essere iden ficata verificando le presenze di più sintomi simultanei, della durata di almeno una se mana, tale da interferire significa va- mente con il lavoro e le a vità sociali o che richiedono l’ospedalizzazione o la reclusione. (vedi il mhGAP interven on guide h ps://www.paho.org/mhgap/en/bipolar_flowchart. html). • Declino cogni vo. La relazione tra la depressione e il deterioramento cogni vo è complessa. Gli studi epidemiologici hanno associato la depressione allo sviluppo del disturbo di Alzheimer. Le funzioni cogni ve influenzate nella depressione sono l’a enzione, l’apprendimento e la memoria visiva come anche le funzioni esecu ve. La depressione può essere una risposta psicologica all’insorgenza del declino cogni vo che non è ancora tale da interferire con le funzioni quo diane. • Perdita dell’udito. Gli anziani con perdita dell’udito possono riportare imbarazzo, ansia e perdita del senso di auto-efficacia, e diminuire la probabilità di parte- cipare alle a vità sociali e fisiche, l’isolamento sociale, tristezza ed eventualmente depressione. (15). • Deficit della vista e la presenza di disturbi oculari maggiori correla con l’età come la degenerazione maculare e il glaucoma sono associa con l'aumento della depressione (16). Le persone con funzioni visive diminuite spesso riportano sen men come l’infeli- cità, la tristezza e la perdita della speranza. • Reazione alla disabilità, alla mala a e al deficit. La depressione è comunemente secondaria a condi- zioni di disabilità. Le persone con esperienza di disabilità di fronte alla mala a e al deficit manifestano stress; dovendo anche fronteggiare affrontare i cambiamen che intervengono nell’arco della vita. Le fasi di ada amento ad una nuova forma di disabilità includono shock, negazione, rabbia/depressione, ada amento/acce azione. Gli anziani con nuove disabilità sono a rischio di sviluppare ansia e depressione. 64 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi9.1 POLIFARMACOTERAPIA La polifarmacoterapia può generare sintomi depressivi, e sintomi depressivi possono generare polifarmacoterapia. Indirizzare la polifarmacoterapia così come i sintomi depressivi è importante per rompere il circolo vizioso. Farmaci addizionali che agiscono primariamente sul sistema nervoso, farmaci con pro- prietà psicotrope come gli an staminici, gli an psico ci e i miorilassan e altri farmaci non psicotropi con proprietà an colinergiche possono essere associa a sintomi depressivi. Eliminare quelli non necessari, inefficaci come principi a vi con effe duplica , riduce la polifarma- coterapia. 9.2 ANEMIA, MALNUTRIZIONE Anemia e malnutrizione possono manifestare sintomi depressivi sopra u o se si tra a di deficit di ferro, vitamine come i fola e le vitamine B6 e B12. Sintomi depressivi possono giocare un ruolo nello sviluppo di anemia. La perdita di appe to e la mancanza di interesse nelle a vità quo diane (come fare acquis o cucinare) può ridurre la qualità e la quan tà della nutrizione degli anziani, facilitandone lo sviluppo di anemia e malnu- trizione. Per ges re i sintomi depressivi è cruciale la ges one dell’anemia e migliorare lo stato nutrizionale. (vedi capitolo 6 sulla malnutrizione). 9.3 IPOTIROIDISMO L’ipo roidismo è un disordine comune degli anziani, specialmente nelle donne. I sintomi dell’ipo roidismo possono essere aspecifici e variare da persona a persona ma possono includere sintomi depressivi. L’ipo roidismo può essere valutato e ges to dai sanitari con specifiche competenze. 9.4 DOLORE Gli individui affli da dolore cronico molto spesso possono essere affe da sintomi depressivi. È impor- tante valutare e ges re il dolore. (Vedi capitolo 5 sulla limitazione della mobilità 6 5 65 9 CAPACITÀ PSICOLOGICA Percorso di cura per la ges one dei sintomi depressivi VALUTAZIONE E GESTIONE AMBIENTE SOCIALE E FISICO È pica della depressione la perdita d’interesse in a vità usualmente pra cate che solitamente risultano interes- san o piacevoli. I membri della famiglia e i caregivers possono incoraggiare gen lmente e supportare un aumento dell’a vità fisica e del coinvolgimento sociale e a raverso programmi di esercizi da fare in comunità e di sviluppo di abilità. Se una persona anziana sperimenta una perdita delle capacità come perdita dell’udito o limitazione delle capacità motorie, familiari e caregivers devono prestare a enzione all’isolamento sociale. L’isolamento sociale può portare a sintomi depressivi. Si consideri il ricorso alle tecnologie usando telefono o internet per affrontare la solitudine. 66 10 Per le persone con significa va perdita della capacità intrinseca, conservare la dignità è spesso possibile solo con la cura, il sostegno e l'assistenza degli altri. La disponibilità di assistenza e sostegno sociale è fonda- mentale per garan re una vita dignitosa e piena di significato. L'assistenza e il sostegno sociale compren- dono non solo l'aiuto nelle a vità della vita quo diana (ADL) e la cura della persona, ma anche l'agevolazione dell'accesso alle stru ure territoriali e ai servizi pubblici, la riduzione dell'isolamento e della solitudine, il sostegno finanziario, luoghi ada in cui vivere, sicurezza personale proteggendo le persone anziane da moles e e abusi e la partecipazione e il coinvolgimento in a vità che danno senso alla loro vita. In alcuni casi è necessario chiedere informazioni a un proxy (familiare o caregiver) rela vamente ai bisogni della persona anziana. Nel caso in cui si è in presenza di declino cogni vo è necessario porre domande ad un familiare, un caregiver o un amico su come la persona svolge a vità di vita quo diana non strumentali (IADL), o strumentali come la ges one delle finanze. PUNTI-CHIAVE • La rido a capacità funzionale è comune tra le persone anziane, specialmente tra quelle con rido a capacità intrinseca, ma non è inevitabile. • Gli operatori sanitari sul territorio possono eseguire lo screening per la perdita delle capacità funzionali con un semplice ques onario. • Interven incentra sulle priorità di ogni singola persona anziana possono migliorare la sua capacità funzionale. • Gli interven efficaci includono quelli per migliorare la capacità intrinseca, l'abilità funzionale e la fornitura di servizi di assistenza e supporto sociale. ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto sociale 67 10 ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto sociale VALUTAZIONE DELLA NECESSITÀ DI ASSISTENZA E SUPPORTO SOCIALE DOMANDA AIUTO CON IL SUPPORTO SOCIALE (AUSILIO ALLA PERSONA) Valutare e modificare ausili fisici per compensare capacità intrinseche, migliorare la mobilità e prevenire le cadute. Considerare l’uso di tecnologie, aiuto e ada amento Valutare supporto del coniuge, della famiglia o di altri caregiver informali e includere una valutazione dei bisogni del caregivers Revisionare i bisogni per supportare i lavoratori delle cure a pagamento Caregivers e servizi dovrebbero essere disponibili come cure domiciliari, cure giornaliere, infermiere a domicilio. SI SI SI SI SI Considerare: - Ada amento domiciliare - Sistemazioni alterna ve - far riferimento a benessere sociale o programmi di housing di comunità o re sociali esisten FARE DOMANDE SUPPLEMENTARI Ha alcune preoccupazioni a causa di: 1. La sua sicurezza e la sicurezza del posto dove vive? 2. Le condizioni della sua casa? 3. La località della sua casa? 4. I cos della sua casa? 5. La riparazione o manutenzione della sua casa? 6. Ges one della sua vita nel luogo dove vive? FARE DOMANDE SUPPLEMENTARI 1. In generale come vanno le finanze a fine mese? 2. Sei capace di ges re i tuoi affari monetari? 3. Ti piacerebbe ricevere suggerimen su benefit e indennizzi finanziari? Considerare: - un consulente finanziario - consigli su come delegare le decisioni finanziarie con la protezione contro gli abusi finanziari 1. Ha difficoltà a muover in casa? 2. Ha difficoltà nell’uso del bagno (o dei sanitari)? 3. Ha difficoltà nel ves rsi? 4. Ha difficoltà nell’uso della vasca o della doccia? 5. Ha difficoltà nel curare il suo aspe o? 6. Ha difficoltà nell’alimentarsi? 7. Ha problemi con il posto dove vive? (nella sua sistemazione) 8. Ha problemi finanziari? 9. Vive solo? 10. È capace di perseguire i suoi interessi, hobbies, lavori, volontariato, supportare la sua famiglia, a vità di educazione, o a vità spirituali importan per lei? 11. Valutare il rischio dell’abuso sugli anziani. Analizzare come migliorarsi: - connessioni sociali vicine (coniuge, famiglia, amici;animali) - uso di risorse locali comunitarie (clubs, gruppi di fede, centri diurni) - opportunità di contribuire (volontariato, impieghi) - conne ere usando la tecnologia FAR DOMANDE AGGIUNTIVE PER IDENTIFICARE LE BARRIERE: Non è in grado di fare. a causa di: 1.cos 2. Distanze 3. traspor 4. Mancanza di opportunità̀ 5. Altro? Fornire una lista dei servizi offer dalla comunità̀ locale per le persone anziane come stru ure per il tempo libero, clubs, stru ure di educazione per adul , a vità̀ di volontariato o di impiego. Incoraggiare gli anziani ad usare ques servizi e incrementarne la partecipazione Informazioni basate sui comportamen degli anziani, i comportamen dei caregivers o dei familiari, o segni di abuso fisico possono essere usa per iden ficare potenziali abusi. Se nessun tra amento immediato, far riferimento a valutazioni specialis che a raverso i servizi sociali, protezione per adul o sistemi giudiziari 68 Gli operatori sanitari dovrebbero sapere a chi indirizzare le persone anziane per una valutazione geriatrica. I protocolli ̀u lizza variano anche a seconda della disponibilità del territorio in cui si vive. A volte in alcuni contes alcune persone svolgono funzioni di supporto al posto degli assisten sociali, come ad esempio il preside di una scuola, un sacerdote. Dato che l'assistenza e il sostegno sociale usando un approccio integrato richiedono di creare dei legami e delle interazioni tra persona e ambiente sociale, è molto importante l’organiz- zazione di mee ng tra gli specialis e i servizi sociali. Vengono riportate le aree di competenza geriatrica: • Condizione abita va: per i servizi abita vi lo specialista coinvolto può essere l’assistente sociale o il terapista occupazionale. • Ges one delle finanze: lo specialista coinvolto può essere l’assistente sociale • Solitudine: le figure coinvolte possono essere l’assistente sociale, volontari di organizzazioni di volontariato, il medico di base. • Partecipazione: le figure coinvolte possono essere l’assistente sociale, che ingaggia la persona in a vità di tempo libero, in lavori socialmente u li o a vità di volontariato. • Abuso: può essere l’assistente sociale, l’autorità di protezione e contrasto dall’abuso degli adul . • A vità della vita quo diana: il personale coinvolto può essere il terapista occupazionale, l’assistente sociale, l’infermiere o il team mul disciplinare geriatrico. • Mobilità indoor: le figure coinvolte possono essere il fisioterapista, il terapista occupazionale, l’assistente sociale o il team mul disciplinare geriatrico • Mobilità all'aperto:le figure coinvolte possono essere il fisioterapista, l’assistente sociale, o i volontari del servizi di trasporto sanitario ed di assistenza. IL COMPORTAMENTO DEGLI ANZIANI • Sembra aver paura di un parente o del/della badante. • Non risponde quando gli viene chiesto qualcosa, o guarda con ansia il caregiver/ parente prima di rispondere. • Il comportamento cambia quando il caregiver/ parente entra o lascia la stanza. • Si riferisce al caregiver in termini di "volontà forte" o spesso "stanco" o "di ca vo umore", o come diven- tare irritabile/molto ansioso/molto stressato/perdere la calma molto facilmente. • Mostra rispe o esagerato o estrema deferenza per il caregiver POSSIBILI SEGNI DI ABUSI SUGLI ANZIANI COMPORTAMENTO DEL CAREGIVER/PARENTE • Ostacola o impedisce al professionista e la persona di parlare in privato, o ha mo vi per interrompere il colloquio di valutazione (entrando ripetutamente nella stanza, per esempio). • Insiste a rispondere a domande che sono invece indirizzate alla persona più anziana. • Pone ostacoli alla fornitura di assistenza a casa per la persona più anziana. • Dimostra un alto livello di insoddisfazione circa il prendersi cura della persona anziana. • Tenta vi di convincere il professionista che la persona anziana è "pazza" o demente, o che la persona non sa cosa dicono a causa di confusione, quando questo non è il caso. • E’ os le, stanco o impaziente durante l'intervista, e la persona anziana è molto inquieta alla sua presenza ABUSO FISICO • Tagli, us oni, lividi e graffi. • Lesioni che non corrispondono a una spiegazione plausibile. • Lesioni che difficilmente si sono verificate accidentalmente. • Ferite e ferite in luoghi nascos . • Lividi che hanno la forma delle dita (spesso braccia superiori). • Lesioni in aree prote e, ad es. ascelle. • Lesioni non tra ate. • Lesioni mul ple a diversi stadi di guarigione. • Farmaci non eroga o uso eccessivo 10 ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto sociale QUANDO È NECESSARIA L’ASSISTENZA GERIATRICA 69 10 ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto sociale VALUTAZIONE E GESTIONE NECESSITÀ DI SUPPORTO SOCIALE 10.1 VALUTARE E GESTIRE I BISOGNI RELA- TIVI ALLA CURA PERSONALE E ALL’AS- SISTENZA NELLE ATTIVITÀ DI VITA QUOTI- DIANE (SEZIONE “A” DEL PERCORSO) Sei domande (ADL)servono a valutare se una persona anziana è in grado di prendersi cura di sé senza l'aiuto degli altri. Questo po di valutazione è u le per una persona anziana con una significa va perdita delle capacità intrinseche. Muoversi in casa comprende una serie di a vità, come spostarsi dal le o alla sedia, camminare, andare in bagno e usare i servizi igienici e salire e scendere le scale. La mobilità limitata porta a maggiori rischi fisici per la persona anziana e alla necessità di cure ad hoc. Ves rsi, nutrirsi, fare il bagno e pe narsi sono a vità non strumentali di vita quo diana (ADL). Non essere in grado di svolgere a vità di vita quo diana porta alla necessità di supporto nelle cure. Molte persone anziane non vogliono affidarsi ad altri per avere aiuto nelle a vità di vita quo diana, preferendo essere in grado di cavarsela da sole. Persone anziane che hanno difficoltà nelle a vità di vita quo diana e/o problemi di mobilità beneficiano dell’uso di programmi di riabilitazione. I programmi di riabilita- zione possono essere focalizza sul miglioramento delle capacità, ma possono essere anche incluse tecnologie assis ve e ada amen ambientali per o mizzare la capacità funzionale nonostante i limi della capacità intrinseca. I servizi di trasporto possono essere forni per migliorare la mobilità all'aperto. Se le difficoltà persistono, il sostegno del coniuge, della famiglia e di altri prestatori di assistenza non retribui dovrebbe essere riesaminato, tenendo conto anche delle loro esigenze. Se è necessario ulteriore sostegno, dovrebbero essere forni servizi di assistenza domiciliare volontari, priva o pubblici. 10.2 VALUTARE E GESTIRE I BISOGNI DI SUP- PORTO SOCIALE (SEZIONE “B” DEL PER- CORSO) Indipendentemente dal livello di capacità intrinseca e abilità funzionali, la persona anziana può beneficiare della valutazione dei bisogni di supporto sociale. Fornire supporto sociale consente a una persona anziana di fare le cose che sono importan per lei, tra cui il sostegno per le sue condizioni di vita, la sicurezza finanziaria, evitamento della solitudine, l'accesso alle stru ure territoriali e ai servizi pubblici e il sostegno contro gli abusi. B7 CONDIZIONI DI VITA. Il luogo in cui vive una persona anziana può influire sulla sua salute, indipendenza e benessere. I problemi possono riguardare molte cose, tra cui le dimensioni, l'accesso, le condizioni e la sicurezza del luogo fisico. Domande supplementari possono aiutare l’analisi delle condizioni di vita. 70 I problemi rela vi alle condizioni di vita possono essere mi ga introducendo nuove misure di sicurezza, avendo un numero da chiamare in caso di emergenza e apportando ada amen per mantenere condizioni di vita indipendente. Potrebbe essere u le avere accesso a aiu finanziari a supporto dei cos di alloggio, o per la riparazione e manutenzione dell'abitazione. Se questo non è possibile, dovrebbe essere preso in considerazione un trasferimento in una sistemazione più ada a. B 8 RISORSE ECONOMICHE Le risorse finanziarie sono fortemente associate alla salute, all'indipendenza e al benessere in età avanzata. I problemi possono includere: mancanza di denaro per soddisfare i bisogni di base o per partecipare pienamente alle a vità sociali. Le persone anziane possono temere che il denaro finisca o che non siano in grado di ges re le proprie finanze. Ulteriori domande possono aiutare a iden ficare aree specifiche che devono essere affrontate. I problemi finanziari possono essere mi ga a raverso una consulenza indipendente sulla pianificazione finanziaria e sulla ges one finanziaria. La ges one delle finanze può essere delegata a terzi, a condizione che sia in a o una protezione legale per prevenire gli abusi finanziari. ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto socialeB9 SOLITUDINE Sperimentare senso di solitudine è comune in età avanzata ed è associata a una maggiore probabilità di depressione e morte prematura. (Vedere il Capitolo 9 per una guida sullo screening dei sintomi depressivi). Essere soli non è la stessa cosa che sen rsi soli: una persona anziana può essere sola anche quando è circondata da altre persone, se la qualità delle relazioni è scarsa. È u le chiedere ad una persona anziana sola se un mag- giore conta o sociale con la famiglia e con gli amici, o l'incontro con altri con interessi simili, aiuterebbe a ridurre il suo senso di solitudine. Ma quando si chiede ad una persona anziana se un maggiore conta o può aiuta- re, bisogna rassicurare l’interessato che è una domanda privata, per aiutare a superare qualsiasi paura di rivelare la natura delle relazioni personali. Per molte persone anziane avere un animale da compa- gnia riduce la solitudine. Frequentare circoli, gruppi reli- giosi, centri diurni e servizi spor vi, ricrea vi o educa vi dovrebbe essere incoraggiato e potrebbero esserci opportunità di svolgere a vità di volontariato o lavori retribui sentendosi meno soli. Le relazioni sociali pos- sono essere aumentate a raverso l’uso della tecnologia. Dovrebbe essere intrapresa una revisione generale di queste misure per comba ere la solitudine. Chi valuta deve essere consapevole delle risorse disponibili sul territorio. 10 71 10 ASSISTENZA E SUPPORTO SOCIALE Percorso di cura per l’assistenza e il supporto sociale B 10 IMPEGNO E PARTECIPAZIONE SOCIALE L'obie vo dell'approccio ICOPE è quello di aiutare le persone anziane a fare le cose che per loro sono importan . È u le scoprire cosa è importante per la persona anziana, a raverso la comprensione della sua vita, delle priorità e delle sue preferenze, in quanto potrebbe essere possibile trovare modi per aumentare la partecipazione sociale. Le a vità del tempo libero, gli hobby, il lavoro, l'apprendimento e le a vità spirituali sono esempi di partecipazione alla vita a va della società. Ogni persona anziana è unica e avrà priorità diverse, spesso molto specifiche. Al fine di creare un piano di assistenza personalizzato sarebbe bene chiedere tu e queste informazioni e usarle come guida. Ulteriori domande dovrebbero essere poste per iden ficare eventuali ostacoli come cos , accessibilità e opportunità. Chi fa la valutazione dovrebbe essere a conoscenza della disponibilità sul territorio di I stru ure ricrea ve, club, centri di formazione permanente per adul , associazioni di volontariato e servizi di consulenza del lavoro, e discutere con la persona anziana se ques potrebbero essere di interesse per lei. L’accesso ai mezzi di trasporto potrebbe essere un problema importante e sarebbe bene informarsi sulla presenza di eventuali servizi disponibili. Potrebbero essere erogate sovven- zioni per coprire i cos di alcuni di ques servizi per consen re agli anziani e a coloro che hanno un reddito basso di parteciparvi. B 11 ABUSO E MALTRATTAMENTI Molte persone anziane non autosufficien sono vulne- rabili agli abusi e circa un anziano su sei subisce una qualche forma di abuso, una cifra superiore a quanto s mato in precedenza (20). L'abuso può assumere molte forme, tra cui negligenza, abuso psicologico, abuso fisico, abuso sessuale e abuso finanziario. Informazioni basate sul comportamento della persona anziana, sul comportamento dei suoi caregivers o paren , o segni di abuso fisico dovrebbero essere usate per iden ficare potenziali abusi. Se c'è qualche segno di abuso, sarà necessaria una valutazione e una ges one specialis ca. In tal caso bisognerà informare l’anziano della necessità di un approfondimento specialis co. In caso di rischio immediato, rivolgersi ai servizi sociali territoriali prepos e alla polizia/carabinieri. 1 72 11 Quando il declino delle capacità intrinseche e delle capacità funzionali rende una persona dipendente dalla assistenza di un caregiver, come il coniuge un altro membro della famiglia o altri membri della famiglia, che si fanno carico della persona anziana. A seconda delle esigenze della persona anziana, l'onere di fornire assistenza può me ere a rischio il benessere del caregiver. Il benessere del caregiver può essere monitorato da un operatore sanitario, intervenendo quando necessario. PUNTI-CHIAVE • Prendersi cura di una persona anziana in alcuni casi può diventare un peso e procurare stress nella persona che se ne occupa. Tale impegno a volte comporta il lasciare il lavoro, sopra u o nel caso delle donne. • Iden ficare i bisogni di aiuto del caregiver è una parte importante delle azioni a supporto della persona anziana con deficit nelle capacità intriseche. • Una serie di interven - come la terapia di sollievo, il supporto, la formazione, il sostegno finanziario e gli Interven psicologici possono aiutare il caregiver a sostenere una relazione di assistenza soddisfacente e sana. • Occasionalmente, la relazione di cura diventa violenta. Nel caso in cui un operatore sanitario dovesse riconoscere i segni di abuso durante la valutazione di una persona anziana o di un caregiver, allora si renderà necessaria una consulenza specialis ca. SUPPORTO AL CAREGIVER Percorso di cura per il supporto al caregiver 73 11 Percorso di cure per il supporto al caregiver SUPPORTO AL CAREGIVER DOMANDA Il suo ruolo di caregiver ha un impa o nega vo sulla sua vita? Ti sen poco supportato nel tuo ruolo da caregiver? SI SI SI SI (ad una delle domande) (ad una delle domande) (ad una delle domande) Analizzare i suppor per i caregiver come training, counseling, formazione, cure di sollievo, come centri diurni, comunità con assistenza, rete di supporto. (alcune idee sono date dal sito: iSupport: h ps://www.isuppor ordemen a.org) DOMANDA Nelle ul me due se mane ha provato sensazioni come: - Sen rsi giù, depresso o senza speranza? - Pochi interessi o piacere a fare cose VALUTAZIONE DELL’UMORE DEL CAREGIVER Ges one della depressione: Consulta la Guida di intervento mhGAP: h ps://apps.who.int/i ris/handle/1066 Indirizzare lo sforzo con supporto e la psicoeducazione Fornire un counselling di problemsolving Fornire un supporto cogni vo comportamentale Analizzare le opzioni di supporto finanziario locale Rafforzare il legame con il sistema di cure formale a lungo termine e il supporto comunitario come le associazioni di volontariato DOMANDA Sta affrontando una perdita di reddito e/o spese aggiun ve a causa dell’esigenza di assistenza? RIVALUTARE OGNI 6 MESI 74 11 Percorso di cure per il supporto al caregiver SUPPORTO AL CAREGIVER RISCHIO DI ABUSI E MALTRATTAMENTI La relazione bidirezionale tra la persona che riceve assistenza e il caregiver può essere complessa. I caregiver sani e felici sono capaci di un sostegno straordinario, ma a volte la relazione di cura può essere sgradita a uno o entrambi i partecipan . Ciò può dar luogo a confli , che possono rendere la persona anziana vulnerabile agli abusi. L'abuso può assumere la forma di negligenza, di trarre vantaggio materiale (ad esempio dal punto di vista finanziario) o di abuso fisico, emo vo o sessuale. L'abbandono può verificarsi anche a causa dell'ignoranza, della mancanza di competenze nell'assistenza o della mancanza di supporto o supervisione esterna. Né la persona anziana né l'assistente possono menzionare l'abuso all'operatore sanitario. Le informazioni basate sull'osservazione del comportamento della persona anziana, sul comportamento dei suoi caregiver o paren , o sui segni di abuso fisico dovrebbero essere u lizzate per iden ficare potenziali abusi (vedere Capitolo 10 sull'assistenza e il supporto sociale). I fa ori che aumentano la probabilità di una relazione violenta sono: • scarsa relazione a lungo termine; • una storia di violenza familiare; • la difficoltà del caregiver nel fornire costantemente il livello o il po di assistenza necessaria; • problemi di salute fisica o mentale del caregiver, in par colare depressione e, sopra u o negli uomini, abuso di alcol e sostanze. La probabilità di abuso non è legata esclusivamente alla natura delle cure fornite o anche a fa ori spesso associa allo stress del caregiver, come le sfide poste dal com- portamento di una persona affe a da demenza. Se si sospe a una relazione violenta è necessaria una valutazione specialis ca più de agliata, seguendo per- corsi di riferimento locali. VALUTAZIONE DELL’UMORE DEL CAREGIVER Se una persona riferisce almeno uno dei sintomi principali - sen rsi giù, depresso o senza speranza e avere poco interesse o piacere nel fare le cose - fai un’ulteriore valutazione dell’umore. È possibile u lizzare parole alterna ve se una persona non ha familiarità con quelle indicate nelle due domande screening. DOMANDA: “Durante le ul me 2 se mane, sei sen to a disagio per alcuni dei problemi successivi?” • Difficoltà ad addormentarsi o a rimanere addor- menta , o dormire troppo. • Sen rsi stanchi o avere poca energia. • Scarso appe to o eccesso di cibo. • Sen r male con te stesso o pensare di essere un fallimento o di aver deluso te stesso o la tua famiglia. • Difficoltà a concentrarsi su cose come leggere il giornale o guardare la televisione. • Muoversi o parlare così lentamente che altre persone potrebbero notarlo. • Essere così irrequieto o irrequieto da muoversi molto più del solito. • Pensieri che sarebbe stato meglio morire o che facessi del male in qualche modo. QUANDO È NECESSARIO L’INTERVENTO DI UNO SPECIALISTA • Per tra are a depressione • Per offrire una terapia di sostegno o una terapia cogni vo-comportamentale a un caregiver con sintomi depressivi. • Quando si sospe a un abuso. * Queste domande possono essere trovate nel Pa ent Health Ques onnaire (PHQ-9) (h p://www.cqaimh.org/pdf/tool_phq9.pdf), che è uno strumento per la valutazione dei sintomi depressivi. Oppure consulta la sezione sulla depressione della guida all'intervento mhGAP, su h ps://apps.who.int/iris/handle/10665/250239 75 11 Percorso di cure per il supporto al caregiver SUPPORTO AL CAREGIVER 11.1 DOMANDE AL CAREGIVERS Il percorso a pagina 74 guida il dialogo con il caregiver. In questo percorso, a ogni caregiver intervistato vengono poste domande su tre aree: 1. Il peso del caregiving (due domande), che poten- zialmente porta a strategie pra che a supporto dei caregiver. 2. I due sintomi principali della depressione, che poten- zialmente inducono a una valutazione completa della depressione (vedere il Capitolo 9 sui sintomi depressivi). 3. I cos finanziari dell'assistenza, che potenzialmente portano a fon di sostegno finanziario locale e di assistenza sociale organizzata, se disponibili. Quando parla con il caregiver, l'operatore cerca eventuali segni di stanchezza, rabbia, frustrazione o mancanza di rispe o. Inoltre, l'operatore sanitario può chiedere all'assistente se lo desidera come ulteriore valutazione o supporto da parte di un fornitore di assistenza sociale. Nel corso del tempo, gli oneri dell’assistenza possono accumularsi. È opportuna una rivalutazione ogni sei mesi. La valutazione del ruolo del caregiver e del suo impa o è meglio farlo lontano dalla persona anziana, per ridurre l’imbarazzo o l’esitazione del caregiver nel parlare apertamente e pienamente. La reazione tra i con della persona anziana e il caregiver può differire per vari mo vi, compresi i problemi di memoria della persona anziana. La valutazione dovrebbe quindi essere considerata alla luce delle conoscenze acquisite dalla valutazione completa della capacità intrinseca. 11.2 OFFRIRE SUPPORTO AL CAREGIVER Supportato e supervisionato a raverso il se ore sanitario e sociale i servizi di assistenza, i professionis adeguatamente forma e gli operatori sanitari retribui dovrebbero supportare gli operatori sanitari non retribui . Nella comunità, gli operatori sanitari e sociali - sia professionis che volontari - possono creare una rete per condividere le risorse disponibili per il sostegno dei caregiver non retribui . iSupport è un programma di formazione online dell’OMS che può aiutare gli operatori sanitari di persone affe e da demenza a fornire una buona assistenza e a prendersi cura di se stessi - vedere h ps://www. isuppor ordemen a.org. Il sostegno si concentra sul caregiver familiare primario. Per comprendere le esigenze del caregiver, l’operatore può chiedere quali compi vengono svol , come e con quale frequenza, cercando aspe dell’assistenza che potrebbero essere aiuta da consigli, supporto pra co o tecnologie assis ve innova ve (vedere riquadro a pagina 77). Il supporto dovrebbe rifle ere le scelte del caregiver 76 11 Percorso di cure per il supporto al caregiver SUPPORTO AL CAREGIVER Gli assisten sociali e gli operatori sanitari possono: • fornire al caregiver formazione e supporto per speci- fiche abilità di caregiving - ad esempio, ges re comportamen difficili; • prendere in considerazione la possibilità di fornire o organizzare un supporto pra co, come una tregua temporanea per il caregiver; • esplorare se la persona anziana con perdita di capacità funzionale ha diri o a eventuali benefici sociali o altro sostegno sociale o finanziario da parte del governo o di organizzazioni non governa ve. Consigliare. Riconoscere che l'assistenza può essere estremamente frustrante e stressante. Può anche essere complicato da sen men di dolore per la perdita della precedente relazione tra l'anziano e il caregiver, soprat- tu o se il caregiver è il coniuge dell'anziano. Incoraggiare gli operatori sanitari a rispe are la dignità degli anziani coinvolgendoli il più possibile nelle decisioni riguardan la loro vita e la loro assistenza. Fornire assistenza temporanea. Quando l'assistenza diventa troppo onerosa o fa cosa, può qualcun altro supervisionare e prendersi cura temporaneamente della persona anziana? Potrebbe tra arsi di un altro parente, di un'altra persona che vive nella casa o di un assistente sociale qualificato, professionista o volontario. Questa assistenza temporanea, come un centro diurno, può dare all'assistente principale del tempo libero per riposarsi o svolgere altre a vità. Un centro diurno è un po di servizio di supporto comunitario che offre cura personale (bagno, cibo, barbiere, igiene), programmi di riabili- tazione, a vità ricrea ve e sociali, pas e trasporto, diverse ore al giorno, per diversi giorni alla se mana. I centri diurni forniscono anche servizi di supporto agli operatori sanitari, come visite domiciliari, a vità fami- liari, gruppi di sostegno e formazione per gli operatori sanitari. L’assistenza di sollievo può aiutare a mantenere la relazione di accudimento sano e sostenibile e il tempo libero del caregiver non sono necessariamente dannosi per la persona assis ta. Offri supporto psicologico. Cercare di affrontare lo stress psicologico del caregiver con supporto e guida risolu- zione dei problemi, sopra u o quando l’assistenza è complessa ed estesa e la pressione sul caregiver è grande. TECNOLOGIE INNOVATIVE PER L’ASSISTENZA Le tecnologie sanitarie innova ve, come il monitorag- gio remoto e gli assisten robot, sono modi prom- e en per migliorare le capacità funzionali degli anziani; migliorare la loro qualità di vita e quella dei loro caregiver; aumentare la libertà di scelta, la sicurezza, l'indipendenza e il senso di controllo; e consen re l’invecchiamento nella comunità. L'uso di queste tecnologie dovrebbe essere basato sulle esigenze e preferenze degli anziani e di chi si prende cura di loro e richiede una formazione adeguata degli uten . Si dovrebbe prestare par colare a enzione allo sviluppo di un meccanismo di finanziamento per la ricerca e lo sviluppo per garan re un’implemen- tazione equa di tali tecnologie. Esempi di tecnologie assis ve innova ve: • Robot di assistenza sociale PARO. Questa foca robo ca funge da compagno. (22) h p://www.parorobots.com • Sistema di supporto lombare ibrido per gli ar assis vi (HAL). Questo disposi vo fornisce “muscoli robo ci” all’assistente, facilitando il sollevamento e il trasferimento del paziente dal le o alla sedia e alla vasca da bagno. h ps://www.cyberdyne.jp/english/products/Lumb ar_CareSupport.html 77 12 ELABORAZIONE DI UN PIANO DI CURE PERSONALIZZATO L’elaborazione dell’assistenza personalizzata è un approccio umanizzato che si allontana dai metodi tradizionali incentra sulla mala a e si concentra invece sui bisogni, i valori e le preferenze degli anziani. Una volta definito, il piano di assistenza personalizzato funge da guida per tu gli aspe dell’assistenza sanitaria e sociale e per supportare obie vi realis ci e incentra sulla persona. FASI NELLA PREPARAZIONE DI UN PIANO DI CURA PERSONALIZZATO 1. Analisi dei risulta e discussione delle opportunità per migliorare la capacità funzionale, la salute e il benessere. In presenza dell'anziano e dei suoi familiari e/o caregiver (se opportuno), l'équipe mul disciplinare effe ua le revisioni i risulta della valutazione centrata sulla persona e gli interven propos nella guida assistenziale. La valutazione centrata sulla persona genererà un elenco di interven propos che potranno essere inclusi nel piano di cura e discussi con il paziente. L'applicazione ICOPE può aiutare gli operatori sanitari in questo processo. I team mul disciplinari possono includere tu coloro che sono coinvol nella cura degli anziani, come il medico di base, i medici specialis , gli infermieri, gli operatori sanitari di comunità, gli assisten sociali, i terapis (fisioterapis , terapista occupazionale, logo- pedista, psicologo), operatori sanitari retribui e infor- mali, farmacis e volontari. 2. Definizione degli obie vi Un approccio centrato sulla persona per iden ficare, stabilire e dare priorità agli obie vi è un elemento chiave sviluppo di un piano di cura. È importante che il team mul disciplinare coinvolga gli anziani nel prendere decisioni sulla propria assistenza e comprenda e rispe i loro bisogni, valori, preferenze e priorità. Questo potrebbe rappresentare un cambiamento trasforma vo nel modo in cui oggi gli operatori sanitari interagiscono con i loro pazien . Gli obie vi dell’assistenza possono andare oltre la riduzione dell’impa o dire o dei problemi di salute e concentrarsi maggiormente sulle a vità che consentono agli anziani di fare ciò che apprezzano di più, come invecchiare in modo indipendente e sicuro nella comunità, mantenere il proprio sviluppo personale, sen rsi inclusi e contribuire alla propria comunità, mantenere la propria autonomia e salute. Oltre agli obie vi a medio e lungo termine (da 6 a 12 mesi), si consiglia di includere obie vi a breve termine (3 mesi), con l’obie vo di trarre vantaggio da miglioramen o benefici più immedia per mantenere gli anziani mo va e coinvol . PUNTI-CHIAVE 4 L'assistenza centrata sulla persona è olis ca e personalizzata, basata sulle relazioni di collabora- zione tra gli operatori sanitari, gli anziani e i fami- liari e gli amici che li sostengono. 4 Team mul disciplinari possono aiutare la persona anziana a definire gli obie vi. 4 Gli interven a sostegno dell'assistenza centrata sulla persona devono essere defini di comune ac- cordo, alla luce dei bisogni e degli obie vi priori- tari dell'anziano. 4 Per raggiungere ques obie vi è essenziale un monitoraggio periodico e costante. 78 12 3. Definire gli interven di comune accordo Saranno necessari interven propos per l'inserimento nel piano assistenziale a seguito della valutazione centra- ta sulla persona e percorsi assistenziali; a) Essere in armonia con gli obie vi, i bisogni, le preferenze e le priorità della persona anziana; b) tenere conto del loro ambiente fisico e sociale L’operatore sanitario o l’assistente sociale deve parlare con l’anziano e definire di comune accordo - uno per uno - ciascuno degli interven che dovranno rimanere nel piano assistenziale defini vo. 4. Finalizzazione e condivisione del piano di cure In questa fase, l'operatore sanitario deve ora docu- mentare i risulta delle discussioni nel piano di assistenza e condividere il documento con l'anziano, i suoi familiari, i caregiver e tu e le altre persone che potrebbero essere coinvolte nella sua cura, previo consenso. L'app ICOPE può aiutare in questo processo, inviando a tu i sogge coinvol un riepilogo del piano di assistenza che include gli obie vi prioritari e le condizioni iden ficate 5. Monitoraggio e accompagnamento Il monitoraggio con follow-up regolare dell’a uazione del piano di assistenza è essenziale per raggiungere gli obie vi concorda . Fornisce l'opportunità di monitorare i progressi e consente il rilevamento precoce delle difficoltà nella partecipazione agli interven , degli effe avversi degli interven e dei cambiamen di stato funzionale. Aiuta anche a mantenere una relazione di successo tra gli anziani e i loro caregiver. Il processo di tracciamento include, ma non è limitato a: • Garan re la corre a a uazione del piano di assisten- za, passo dopo passo; • Ripetere la valutazione centrata sulla persona e documentare eventuali modifiche; • Riassumere i risulta , gli ostacoli e le complicazioni affrontate nell'a uazione degli interven sanitari e sociali; • Iden ficare i cambiamen e le nuove esigenze; • Concordare di affrontare ulteriormente ques cam- biamen ed esigenze, anche ado ando nuovi interven ove necessario e rivedendo e migliorando il piano se necessario; • Ripetere il ciclo. DOMINI DELLE ABILITÀ FUNZIONALI • Soddisfare i bisogni primari come la sicurezza finanziaria, l’alloggio e la sicurezza personale • Imparare, crescere e prendere decisioni, il che include sforzi per con nuare ad apprendere e applicare la conoscenza, impegnarsi nella risolu- zione dei problemi, mantenere lo sviluppo perso- nale e la capacità di fare scelte. • Preservare la mobilità, necessaria per i lavori domes ci, l'accesso ai negozi, ai servizi e agli stabilimen della comunità e la partecipazione alle a vità sociali, economiche e culturali. • Costruire e mantenere un'ampia gamma di rela- zioni, comprese quelle con i bambini e altri membri della famiglia, relazioni sociali informali con amici, vicini, colleghi, nonché relazioni formali con gli operatori della comunità. • Contribuire, che è stre amente associato al coin- volgimento in a vità sociali e culturali, come aiutare amici e vicini, fare da mentore a colleghi e giovani e prendersi cura della famiglia e della comunità. 79 12 COME DEFINIRE GLI OBIETTIVI IDENTIFICARE GLI OBIETTIVI: Iden ficare gli obie vi con l’anziano e i suoi familiari congiuntamente (23): • DOMANDA 1 Spiega le cose che interessano di più in tu gli ambi della tua vita. • DOMANDA 2 Quali sono alcuni obie vi specifici che hai per la tua vita? • DOMANDA 3 Quali sono alcuni obie vi specifici che hai per la tua salute? • DOMANDA 4 Sulla base dell'elenco di obie vi di vita e salute di cui abbiamo appena discusso, puoi sceglierne tre su cui piacerebbe concentrar nei prossimi 3 mesi? E nei prossimi 6-12 mesi? STABILIRE GLI OBIETTIVI: Gli obie vi possono essere ada a ai bisogni degli anziani e alla loro definizione dei problemi. • DOMANDA 5 Su quali aspe dell'obie vo uno, due o tre piacerebbe lavorare specificatamente nei pros- simi tre mesi? E i prossimi 6-12 mesi? • DOMANDA 6 Cosa stai facendo a ualmente riguardo i tuoi obie vi • DOMANDA 7 Quale sarebbe un passo intermedio ideale ma possibile per raggiungere questo obie vo? OBIETTIVI PRIORITARI: La definizione di obie vi assistenziali prioritari, concorda di comune accordo tra gli anziani e gli operatori sanitari, porterà a risulta migliori. • DOMANDA 8 Di ques obie vi, su quale vorres lavorare di più nei prossimi 3 mesi, da solo o con il supporto di [Dr. XX e la sua squadra]? E i prossimi 6-12 mesi? Fonte: (h p://healthtapestry.ca, in inglese) 80 13 COME I SISTEMI SANITARI E DI ASSISTENZA A LUNGO TERMINE POSSONO SUPPORTARE L'ATTUAZIONE DELL'APPROCCIO ICOPE DELL'OMS PUNTI-CHIAVE 4 Un'implementazione efficace dell'approccio ICOPE richiede un approccio integrato che col- leghi i servizi sanitari e di assistenza sociale. 4 L'o mizzazione delle capacità intrinseche e fun- zionali dell'anziano inizia nella comunità e negli operatori che vi lavorano. I sistemi nei se ori sociale e sanitario devono sostenere l’assistenza basata sulla comunità. 4 I piani di assistenza personalizza sono al centro dell'approccio ICOPE. Per realizzare e ges re ques piani, i lavoratori possono aver bisogno di una formazione specifica nella ges one dei casi. ll rapporto mondiale dell'OMS sull'invecchiamento e la salute ha stabilito una nuova direzione per i sistemi sanitari e di assistenza a lungo termine (1). Ha invitato ques sistemi a concentrarsi sull'o mizzazione delle capacità intrinseche degli anziani con l'obie vo di preservare e migliorare le loro capacità funzionali. Le linee guida dell'OMS sugli interven a livello di comunità per ges re il declino delle capacità intrinseche, pub- blicate nel 2017, traducono questa nuova direzione in un approccio pra co alla valutazione e alla cura a livello di comunità (2). Insieme, promuovono l'assistenza sanitaria e sociale integrata e incentrata sulla persona e il supporto. Questo approccio inizia con una valutazione incentrata sulla persona, dei bisogni di assistenza sanitaria e sociale che un operatore a livello di comunità può condurre. Questo capitolo evidenzia alcune considerazioni chiave per l'implementazione dell'approccio ICOPE. La guida ICOPE dell'OMS per sistemi e servizi per implementare l'approccio ICOPE affronterà l'implementazione in det- taglio (h ps://apps.who.int/iris/handle/10665/325669) 81 13 13.3 INTEGRAZIONE DELLE CURE E SUP- PORTO NEI SERVIZI SANITARI E SOCIALI Tu gli interven di assistenza integrata dovrebbero seguire i principi della traduzione della conoscenza, che l'OMS ha definito nel 2005 come "la sintesi, lo scambio e l'applicazione della conoscenza da parte delle par interessate per accelerare i benefici dell'innovazione globale e locale nel rafforzamento dei sistemi sanitari e nel miglioramento della salute delle persone". Il quadro di traduzione delle conoscenze dell'OMS del 2012 per l'invecchiamento e la salute è stato sviluppato specifica- mente per applicare ques principi alla cura degli anziani con molteplici comorbilità e/o difficoltà di accesso ai servizi sanitari (24). Il quadro dell'OMS del 2016 sui servizi sanitari integra incentra sulla persona propone approcci chiave per garan re un'assistenza integrata di alta qualità (6). Un elemento importante dell'assistenza integrata è una solida ges one dei casi per supportare la proge azione, il coordinamento e il monitoraggio dei piani di assistenza, che possono estendersi a più ambi dell'assistenza sani- taria e sociale. Gli operatori sanitari e sociali possono aver bisogno di una formazione specifica nella ges one dei casi così come negli aspe clinici delle raccomandazioni ICOPE. Il quadro di a uazione di ICOPE dell'OMS so olinea le azioni chiave a livello di servizio e di sistema per l'a uazione di ICOPE (25). La guida copre le azioni che devono essere intraprese dai responsabili del servizio e del sistema per fornire assistenza integrata. Il quadro raccomanda azioni specifiche a seconda dell'estensione dei servizi sanitari e sociali esisten . 13.4 ALLINEARE I SERVIZI SANITARI E SOCIALI LOCALI PER SUPPORTARE L'ATTUAZIONE Gli interven ICOPE dovrebbero essere a ua al fine di sostenere l'invecchiamento in a o. Vale a dire, i servizi sanitari e di assistenza sociale dovrebbero essere forni in modo da consen re alle persone anziane di vivere nella propria casa e comunità in modo sicuro, indipendente e confortevole. Gli interven sono pensa per essere eroga a raverso modelli di cura che danno la priorità all'assistenza primaria e basata sulla comunità. Ciò include un focus sugli interven domiciliari, l'impegno della comunità e un sistema di riferimento completa- mente integrato. Questo obie vo può essere raggiunto solo riconoscendo e sostenendo il ruolo fondamentale che i lavoratori della comunità svolgono nell'aumentare l'accesso all'assisten- za sanitaria di base e alla copertura sanitaria universale. Le linee guida dell'OMS sulla poli ca sanitaria e il supporto del sistema per o mizzare i programmi di operatori sanitari basa sulla comunità forniscono suggerimen e raccomandazioni basa sull'evidenza, selezione, formazione, competenze fondamentali, supervisione e retribuzione degli operatori sanitari della comunità (26). h ps://apps.who.int/iris/handle/10665/325669 82 13 13.1 SOSTEGNO NAZIONALE PER L’ATTUAZIONE Come primo passo, sia le raccomandazioni dell'OMS che questo manuale, dovranno essere ada a al contesto locale, alla cultura e alla lingua in modo appropriato per gli operatori sanitari e di assistenza, gli operatori sanitari e con le stesse persone anziane. Un processo inclusivo di ada amento può contribuire a costruire un ampio sup- porto al nuovo approccio. L'a uazione dell'approccio ICOPE richiederà̀ una colla- borazione con nua a tu i livelli e a tu e le fasi tra le par interessate, compresi i responsabili poli ci, gli operatori sanitari, gli assisten sociali, i ricercatori, le comunità e le persone anziane. La conoscenza locale supporterà̀ la traduzione della guida globale in confi- gurazioni di servizio realizzabili e acce abili. Promuovere un invecchiamento sano richiede impegno sia del se ore sanitario che di quello socioassistenziale. Entrambi i se ori saranno maggiormente in grado di ado are e applicare l'approccio ICOPE quando le poli- che nazionali sosterranno un approccio integrato all'assistenza sanitaria e sociale. La poli ca dovrebbe quindi specificare come funzionerà il collegamento tra assistenza sanitaria e assistenza sociale a livello nazio- nale, regionale e comunitario. Incen vi e ricompense, meccanismi di finanziamento e monitoraggio delle prestazioni possono incoraggiare il cambiamento di priorità verso l'assistenza agli anziani che o mizza le capacità intrinseche e le abilità funzio- nali. I sistemi informa vi dovrebbero essere orienta a monitorare questa trasformazione a livello nazionale e locale. 13.2 FABBISOGNI DI BILANCIO E RISORSE UMANE Le implicazioni dell'a uazione dell'approccio ICOPE dovrebbero essere analizzate per iden ficare dove saranno necessari ulteriori inves men , ad esempio nella formazione degli operatori sanitari, nell'uso delle tecnologie e nell'adeguamento dei sistemi informa vi sanitari. In par colare, gli operatori sanitari e sociali della comunità e i team di assistenza primaria avranno bisogno di supporto per comprendere e applicare il nuovo approccio. Le società professionali nazionali e locali possono svolgere un ruolo importante in questo come parte di un processo partecipa vo che coinvolge tu e le par interessate. CONSIDERAZIONI CHIAVE PER L'ATTUAZIONE NAZIONALE La pianificazione per integrare l'approccio ICOPE nei sistemi sanitari e di assistenza a lungo termine dovrebbe garan re: • fa bilità – finanziaria e organizza va • sostenibilità – efficienza e capacità della forza lavoro • coerenza – in linea con le poli che a sostegno di un invecchiamento sano • integrazione – collegamen tra i servizi sanitari e di assistenza sociale. 83 13 Quando è necessaria un'assistenza specializzata, una rete di operatori sanitari a livello secondario e terziario deve sostenere il lavoro degli operatori sanitari di comunità. Criteri e percorsi di riferimento chiari devono essere stabili a raverso un accordo tra tu e le par a livello opera vo e quindi monitora per la garanzia della qualità. Disposizioni per il follow-up devono essere chiari per garan re che i piani di assistenza rimangano adegua e che la fornitura di assistenza sanitaria e supporto sia efficace. Il follow-up e il sostegno possono essere par colarmente importan a seguito di importan cambiamen nello stato di salute o se la persona anziana vive un evento importante della vita come il cambio di residenza o la morte di un coniuge o di chi se ne prende cura. AZIONI PER I SERVIZI Coinvolgere e responsabilizzare le persone e le comunità. Coinvolgere le persone anziane, le loro famiglie e la società civile nella fornitura di servizi; sostenere e formare gli operatori sanitari. Supportare il coordinamento dei servizi forni da gruppi mul disciplinari. Iden ficare le persone anziane nella comunità che hanno bisogno di cure, intraprendendo valutazioni complete e sviluppando piani di assistenza comple , creando re di operatori sanitari e sociali. Orientare i servizi verso l'assistenza basata sulla comunità. Fornire assistenza efficace e acce abile, focalizzata sulla capacità funzionale a raverso lavoratori di comunità e servizi supporta da infrastru ure adeguate. AZIONI PER I SERVIZI Rafforzare i sistemi di governance e responsabilità. Coinvolgere le par interessate nella poli ca e lo sviluppo dei servizi; sviluppare la poli ca e la regolamentazione per sostenere l'assistenza integrata e le risposte all'abuso sugli anziani; intraprendere una garanzia di qualità con nua e un miglioramento della qualità stessa; rivedere regolarmente la capacità di fornire assistenza in modo equo. Abilitare il rafforzamento dei sistemi. Sviluppare la capacità della forza lavoro, il finanziamento e la ges one delle risorse umane; u lizzare la tecnologia scambiare informazioni tra i fornitori di servizi; raccogliere e riportare da sulla capacità intrinseca e sull'abilità funzionale; u lizzare le tecnologie digitali per supportare l'autoges one. SINTESI DELLE AZIONI DEL QUADRO DI ATTUAZIONE DELL'ICOPE 84 13.5 COINVOLGIMENTO DELLE COMUNITÀ E SOSTEGNO AL CAREGIVER Gli operatori sanitari hanno bisogno dell'aiuto di risorse aggiun ve per la comunità. Coinvolgimento più a vo e dire o delle comunità e dei quar eri, nella cura e nel sostegno per gli anziani, perciò, può essere necessaria sia l'organizzazione locale che la volontà poli ca, in par - colare per incoraggiare il volontariato e facilitare il contributo dei membri più anziani della comunità. I club e le associazioni di anziani sono allea naturali in questo sforzo. Allo stesso tempo, il sistema sanitario ha una responsa- bilità nei confron dei suoi partner nel sostenere un invecchiamento sano: comunità, organizzazioni comu- nitarie, familiari e altri caregiver non retribui . Questa responsabilità include l'a enzione alla salute e al benes- sere degli operatori sanitari, come discusso nel capitolo 11, e il sostegno reciproco, la collaborazione e il coordina- mento con le comunità e le organizzazioni comunitarie per creare un ambiente sano per un invecchiamento in salute. 9685 1. Rapporto mondiale su invecchiamento e salute. 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JAMA Ophthalmol. 2013;131(5):573- 81. doi: 10.1001/jamaophthalmol.2013.2597. 19. Spo ng the signs of harm, abuse and neglect Scotland. Streatham: Ac on on Elder Abuse; sem data (h ps://www. elderabuse.org.uk/spo ng- thesigns-of-harm-abuse-and- neglect, acessado em 2 de abril de 2019). 20. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community se ngs: a systema c review and meta-analysis. Lancet Glob Health. 2017;5(2):e147-e156. doi: 10.1016/S2214- 109X(17)30006-2. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Monte- negro H. Impact of a disease management program upon caregivers of chronically cri cally ill pa ents. Chest. 2005;128(6):3925-36. doi: 10.1378/chest. 128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM, et al. A pilot randomized trial of a companion robot for people with demen a living in the community. J Am Med Dir Assoc. 2017;18(10): 871-8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M, et al. Feasibility study of goal se ng discussions between older adults and volunteers facilitated by an eHealth applica on: development of the Health TAPESTRY approach. Pilot Feasibility Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. BIBLIOGRAFIA 86 24. "Traduzione della conoscenza. Ginevra: OMS; senza data (h ps://www.who.int/ageing/projects /knowledge_transla on/es/, consultato il 2 aprile 2019)." 25. Assistenza integrata agli anziani: orientamento per Sistemi e Servizi. Ginevra: OMS; 2019(Hps://apps. who.int/iris/handle/10665/325669, consultato nel giugno 2019). 26. Community-based health workers (CHWs). Genebra: O M S ; sem data (h ps://www.who. int/hrh /community, consultado em 2 de abril de 2019). 87 Questa traduzione non è stata creata dall'Organizzazione Mondiale della Sanità (OMS). L'OMS non è responsabile del contenuto o dell'accuratezza di questa traduzione. L'edizione originale inglese sarà̀ l'edizione vincolante e auten ca. Traduzione Dr. L. Solimando, Prof M. Barbagallo, Prof. N. Veronese Revisione Prof.ssa A. Lopez, Prof. A. Bosco Anno di pubblicazione 2024 www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organiza on Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int Le spese di questa Pubblicazione sono coperte da Fondi FFR 2021 Prof. N. Veronese, Università di Palermo. 88
Εγχειρίδιο Οδηγός προσωποκεντρικής αξιολόγησης και μονοπατιών στην πρωτοβάθμια φροντίδα
Εγχειρίδιο Οδηγός προσωποκεντρικής αξιολόγησης και μονοπατιών στην πρωτοβάθμια φροντίδα Κέντρο Γηριατρικής Αξιολόγησης, Ερρίκος Ντυνάν Hospital Center, Αθήνα, 2024. Αυτή η μετάφραση δεν εκπονήθηκε από τον Παγκόσμιο Οργανισμό Υγείας (ΠΟΥ). Ο ΠΟΥ δεν είναι υπεύθυνος για το περιεχόμενο ή την ακρίβεια αυτής της μετάφρασης. Η πρωτότυπη Αγγλική έκδοση Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. Geneva: World Health Organization; 2018. License: CC BY-NC-SA 3.0 IGO αποτελεί τη δεσμευτική και πρωτότυπη έκδοη. Αυτή η μετάφραση είναι διαθέσιμη σύμφωνα με το CC BY-NC-SA 3.0 Center for geriatric assessment Henry Dunant Hospital, Athens Greece, 2024. This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. Geneva: World Health Organization; 2018. License: CC BY-NC-SA 3.0 IGO shall be the binding and authentic edition. This translated work is available under the CC BY-NC-SA 3.0 Ευχαριστίες iv Συντομογραφίες v 1. Ολοκληρωμένη φροντίδα για ηλικιωμένους (ICOPE) 1 2. Βελτιστοποίηση Ικανοτήτων και δυνατοτήτων: προς την κατεύθυνση της υγιούς γήρανσης για όλους 5 3. Αξιολόγηση των αναγκών των ηλικιωμένων και ανάπτυξη ενός εξατομικευμένου πλάνου φροντίδας 9 4. Μονοπάτια φροντίδας για τη διαχείριση της ΕΚΠΤΩΣΗΣ ΓΝΩΣΤΙΚΩΝ ΛΕΙΤΟΥΡΓΙΩΝ 19 5. Μονοπάτια φροντίδας για τη βελτίωση της ΚΙΝΗΤΙΚΟΤΗΤΑΣ 25 6. Μονοπάτια φροντίδας για τη διαχείριση της ΔΥΣΘΡΕΨΙΑΣ 33 7. Μονοπάτια φροντίδας για τη διαχειρηση των ΠΡΟΒΛΗΜΑΤΩΝ ΟΡΑΣΗΣ 41 8. Μονοπάτια φροντίδας για τη διαχείριση της ΑΠΩΛΕΙΑΣ ΑΚΟΗΣ 51 9. Μονοπάτια φροντίδας για τη διαχείριση των ΚΑΤΑΘΛΙΠΤΙΚΩΝ ΣΥΜΠΤΩΜΑΤΩΝ 59 10. Μονοπάτια φροντίδας για την ΚΟΙΝΩΝΙΚΗ ΜΕΡΙΜΝΑ ΚΑΙ ΥΠΟΣΤΗΡΙΞΗ 67 11. Μονοπάτια φροντίδας για την ΥΠΟΣΤΗΡΙΞΗ ΤΟΥ ΦΡΟΝΤΙΣΤΗ 73 12. Αναπτύξτε ένα εξατομικευμένο πλάνο φροντίδας 78 13. Πώς μπορούν τα συστήματα υγείας και μακροχρόνιας φροντίδας να υποστηρίξουν την υλοποίηση της προσέγγισης ICOPE του ΠΟΥ 81 Βιβλιογραφία 86 ΠΕΡΙΕΧΟΜΕΝΑ Το παρόν εγχειρίδιο βασίζεται στο έργο πολλών ανθρώπων σε όλο τον κόσμο που ασχολούνται με τη φροντίδα και την υποστήριξη των ηλικιωμένων. Οι Ιslene Araujo de Carvalho και Yuka Sumi στο Τμήμα του Παγκόσμιου Οργανισμού Υγείας (ΠΟΥ) Γήρανσης και Πορείας Ζωής ηγήθηκαν της προετοιμασίας αυτού του εγχειριδίου. Μια βασική ομάδα που ήταν υπεύθυνη για τη συγγραφή του εγχειρίδιο και την ανάπτυξη των μονοπατιών περιλάμβανε την Islene Araujo de Carvalho, John Beard, Yuka Sumi, Andrew Briggs (Πανεπιστήμιο Curtin, Αυστραλία) και Finbarr Martin (King's College London, Ηνωμένο Βασίλειο). Sarah Johnson και ο Ward Rinehart από την Jura Editorial Services ήταν υπεύθυνοι για τη συγγραφή του τελικού κειμένου. Πολλοί άλλοι υπάλληλοι του ΠΟΥ από τα περιφερειακά γραφεία και διάφορα τμήματα συνέβαλαν τόσο σε συγκεκριμένες ενότητες που αφορούν τους τομείς εργασίας τους όσο και στην ανάπτυξη των μονοπατιών περίθαλψης: Shelly Chadha (ΠΟΥ Τμήμα Διαχείρισης Μη Μεταδοτικών Diseases, Disability, Violence and Injury Prevention), Neerja Chowdhary (Τμήμα ψυχικής υγείας του ΠΟΥ). και κατάχρησης ουσιών), Tarun Dua (Τμήμα ΠΟΥ Department of Mental Health and Substance Abuse), Maria De Las Nieves Garcia Casal (Τμήμα Διατροφής του ΠΟΥ για την υγεία και την υγεία). Υγείας και Ανάπτυξης), Zee A Han (Τμήμα ΠΟΥ Department of Management of Noncommunicable Diseases, Disability, βίας και πρόληψης τραυματισμών), Dena Javadi (ΠΟΥ Τμήμα Συμμαχίας για την πολιτική και τα συστήματα υγείας Research), Silvio Paolo Mariotti (WHO Department of Management of Noncommunicable Diseases, Disability, Βίας και Πρόληψης Τραυματισμών), Alarcos Cieza (ΠΟΥ Τμήμα Διαχείρισης Μη Μεταδοτικών Diseases, Disability, Violence and Injury Prevention), Alana Margaret Officer (Τμήμα Γήρανσης και Ζωής), Juan Pablo Peña-Rosas (Τμήμα του ΠΟΥ Διατροφή για την Υγεία και την Ανάπτυξη), Taiwo Adedamola Oyelade (Μονάδα Οικογενειακής και Αναπαραγωγικής Υγείας, ΠΟΥ Περιφερειακό Γραφείο για την Αφρική), Ramez Mahaini (Αναπαραγωγική και μητρικής υγείας, Περιφερειακό Γραφείο ΠΟΥ για την Ανατολική Μεσογείου), Karen Reyes Castro (Τμήμα του ΠΟΥ Διαχείρισης των μη μεταδοτικών ασθενειών, αναπηρία, Πρόληψη της βίας και των τραυματισμών), Enrique Vega Garcia (Υγιεινή πορεία ζωής, Παναμερικανικός Οργανισμός Υγείας/ WHO). Το εγχειρίδιο ωφελήθηκε από την πλούσια συμβολή πολλών εμπειρογνωμόνων και ακαδημαϊκών που συνέβαλαν επίσης στο τη συγγραφή συγκεκριμένων κεφαλαίων: Matteo Cesari (Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Ιταλία), Jill Keeffe (Συνεργαζόμενο Κέντρο Πρόληψης του ΠΟΥ) of Blindness, Ινδία), Elsa Dent (The University of Queensland, Αυστραλία), Naoki Kondo (University of Tokyo, Ιαπωνία), Arunee Laiteerapong (Chulalongkorn Πανεπιστήμιο, Ταϊλάνδη), Mikel Izquierdo (Universidad Pública de Navarra, Ισπανία), Peter Lloyd- Sherlock (University of East Anglia, Ηνωμένο Βασίλειο), Luis Miguel Gutierrez Robledo (Institutos Nacionales de Salud de México, Mexico), Catherine McMahon (Πανεπιστήμιο Macquarie, Αυστραλία), Serah Ndegwa (Πανεπιστήμιο του Ναϊρόμπι, Κένυα), Hiroshi Ogawa (Πανεπιστήμιο Niigata, Ιαπωνία), Hélène Payette (Université de Sherbrooke, Καναδάς), Ian Philp (University of Stirling, Ηνωμένο Βασίλειο), Leocadio Rodriguez- Mañas (Πανεπιστημιακό Νοσοκομείο Getafe, Ισπανία), John Starr (Πανεπιστήμιο του Εδιμβούργου, Ηνωμένο Βασίλειο), Kelly Tremblay (Πανεπιστήμιο της Ουάσινγκτον, Ηνωμένες Πολιτείες της Αμερικής), Michael Valenzuela (Πανεπιστήμιο του Σίδνεϊ, Αυστραλία), Bruno Vellas (συνεργαζόμενο κέντρο του ΠΟΥ για την αδυναμία, την κλινική Research and Geriatric Training, Gérontopôle, Τουλούζη Πανεπιστημιακό Νοσοκομείο, Γαλλία), Marjolein Visser (Vrije Universiteit Amsterdam, Κάτω Χώρες), Kristina Zdanys (Πανεπιστήμιο του Κονέκτικατ, Ηνωμένες Πολιτείες της Αμερικής), Έρευνα και γηριατρική εκπαίδευση (Gérontopôle, Τουλούζη) Πανεπιστημιακό Νοσοκομείο, Γαλλία) και για τις πτυχές της δημόσιας υγείας της μυοσκελετικής υγείας και της γήρανσης (Πανεπιστήμιο της Λιέγης, Βέλγιο). Η Αυστραλιανή Εθνική Υπηρεσία Υγείας και Ιατρικής Έρευνας Συμβούλιο, Παγκόσμια Συμμαχία για τη μυοσκελετική υγεία και το Πανεπιστήμιο Chulalongkorn, Ταϊλάνδη, υποστήριξαν το την ανάπτυξη αυτής της καθοδήγησης παρέχοντας προσωπικό για την ανάπτυξη του περιεχομένου του και διοργανώνοντας τις συνεδριάσεις των εμπειρογνωμόνων. Ωφεληθήκαμε επίσης από τις εισηγήσεις των συμμετεχόντων στις ετήσιας συνάντησης της κλινικής κοινοπραξίας του ΠΟΥ για την υγιή Γήρανσης, τον Δεκέμβριο του 2018. Το Τμήμα γήρανσης και πορείας ζωής του ΠΟΥ αναγνωρίζει την οικονομική υποστήριξη της κυβέρνησης της Ιαπωνίας, της κυβέρνησης της Γερμανίας και του Kanagawa Νομαρχιακής Κυβέρνησης στην Ιαπωνία. Επιμέλεια: Green Ink. ΕΥΧΑΡΙΣΤΙΕΣ ADLs activities of daily living (δραστηριότητες της καθημερινής ζωής) BMI body mass index (δείκτης μάζας σώματος) CBT cognitive behavioural therapy (γνωσιακή συμπεριφορική θεραπεία) ICOPE intergrated care for older people (ολοκληρωμένη φροντίδα για ηλικιωμένους) MNA mini nutritional assessment (συνοπτική διατροφική αξιολόγηση) OSN oral supplemental nutrition (από του στόματος συμπληρωματική θρέψη) PTA pure tone audiometry (ακουομετρία καθαρών τόνων) SPPB short physical performance battery WHO world health organization (παγκόμιος οργανισμός υγείας - ΠΟΥ) σημειώστε ότι εξειδικευμένη γνώση και ικανότητες χρειάζονται για την παροχή της φροντίδας ΣΥΝΤΟΜΟΓΡΑΦΙΕΣ
Η παγκόσμια αναφορά για την γήρανση και την υγεία του 2015, όρισε ως στόχο της υγιούς γήρανσης την υποβοήθηση των αν- θρώπων να αναπτύξουν και να διατηρήσουν τη λειτουργική ικα- νότητα που επιτρέπει την ευεξία. Η λειτουργική ικανότητα ορίζε- ται ως τα “χαρακτηριστικά που σχετίζονται με την υγεία που επιτρέ- πουν στους ανθρώπους να είναι και να κάνουν ό,τι έχει για αυτούς αξία’’. Η λειτουργική ικανότητα απαρτίζεται από την ενδογενή ικα- νότητα του ατόμου, το περιβάλλον του ατόμου, και τις αλληλεπι- δράσεις μεταξύ των δύο. Η ενδογενής ικανότητα είναι “η σύνθε- ση όλων των σωματικών και νοητικών ικανοτήτων που μπορεί ένα άτομο να αντλήσει’’ (1). Αυτή η έννοια της υγιούς γήρανσης εμπνέει μια νέα προσέγγιση της φροντίδας για τους ηλικιωμένους – μια προσέγγιση που επι- κεντρώνεται στη βελτίωση της ενδογενούς ικανότητας και της λει- τουργικότητας των ανθρώπων καθώς γερνούν. Τον Οκτώβριο 2017, ο Παγκόσμιος Οργανισμός Υγείας (ΠΟΥ) δη- μοσίευσε την Ολοκληρωμένη φροντίδα για τους ηλικιωμένους: Κατευθυντήριες οδηγίες για παρεμβάσεις στην κοινότητα για την αντιμετώπιση της έκπτωσης της ενδογενούς ικανότητας (2). Οι κατευθυντήριες οδηγίες περιλαμβάνουν 13 συστάσεις τεκμηρι- ωμένες βάσει μελετών για επαγγελματίες υγείας και φροντίδας, που βοηθούν στην ανάπτυξη και εφαρμογή προσωποκεντρικής, ολοκληρωμένης φροντίδας για ηλικιωμένους (Integrated Care for Older People [ICOPE]) σε επίπεδο κοινότητας. Η προσέγγιση ICOPE ενσαρκώνει την εστίαση στη βελτιστοποίηση της ενδογενούς και της λειτουργικής ικανότητας ως το κλειδί για την υγιή γήρανση. Οι συστάσεις αυτές μπορούν να αποτελέσουν τη βάση για εθνικές κατευθυντήριες οδηγίες. Μπορούν να χρη- σιμοποιηθούν για να υποστηρίξουν προγράμματα πρωτοβάθμι- ας φροντίδας και βασικά πακέτα φροντίδας για καθολική κάλυψη υγείας, ή για υπηρεσίες πρόληψης της εξάρτησης από φροντίδα. Για τα συστήματα υγείας, το κλειδί για την υποστήριξη της υγιούς γήρανσης για όλους είναι η βελτιστοποίηση της εν- δογενούς και της λειτουργικής ικανότητας, παρά τη σταδι- ακή μείωση της ικανότητας λόγω της γήρανσης. Η εξάρτηση από φροντίδα μπορεί να αποφευχθεί, αν οι συνθήκες που σχετίζονται με έκπτωση στην ενδογενή ικα- νότητα διαγιγνώσκονται έγκαιρα και αντιμετωπίζονται. Επαγγελματίες υγείας και κοινωνικοί λειτουργοί της κοι- νότητας στην πρωτοβάθμια φροντίδα μπορούν να εντοπί- σουν ηλικιωμένους με απώλειες σε ικανότητες και να πα- ράσχουν κατάλληλη φροντίδα που μπορεί να ανατρέψει ή καθυστερήσει τις απώλειες ακολουθώντας αυτές τις οδη- γίες. Αυτή η προσέγγιση είναι απλή και χαμηλού κόστους. Οι συνθήκες που συνδέονται με έκπτωση στην ενδογε- νή ικανότητα είναι αλληλοσυνδεόμενες και ως εκ τούτου απαιτούν μια ολοκληρωμένη και προσωποκεντρική προ- σέγγιση στην εκτίμηση και την αντιμετώπιση. ΟΛΟΚΛΗΡΩΜΕΝΗ ΦΡΟΝΤΙΔΑ ΓΙΑ ΗΛΙΚΙΩΜΕΝΟΥΣ ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ Οι κατευθυντήριες οδηγίες αυτού του οδηγού θα βοηθήσουν τους επαγγελματίες υγείας και φροντίδας της κοινότητας να εφαρμόσουν την ολοκληρωμένη φροντίδα για τους ηλικιω- μένους. Ο οδηγός παρουσιάζει μονοπάτια φροντίδας (care patways) για την αντιμετώπιση υψηλής προτεραιότητας ζη- τημάτων υγείας, που σχετίζονται με έκπτωση της ενδογενούς ικανότητας – απώλεια κινητικότητας, δυσθρεψία, προβλήμα- τα όρασης, απώλεια ακοής, έκπτωση γνωστικών λειτουργιών, συμπτώματα κατάθλιψης. Αυτά τα μονοπάτια ξεκινούν με εξε- τάσεις διαλογής που ταυτοποιούν τους ηλικιωμένους που εί- ναι πιο πιθανό να βιώνουν ήδη κάποια απώλεια της ενδογε- νούς ικανότητας. Οι επαγγελματίας υγείας και οι κοινωνικοί λειτουργοί μπορούν εύκολα να πραγματοποιήσουν αυτή την διαλογή στην κοινό- τητα. Αυτή είναι η πύλη εισόδου σε μια πιο εις βάθος εκτίμη- ση των αναγκών των ηλικιωμένων ανθρώπων σε ζητήματα που αφορούν την υγεία και την κοινωνική μέριμνα. Η εκτίμη- ση οδηγεί με τη σειρά της σε ένα εξατομικευμένο πλάνο φρο- ντίδας που ενσωματώνει στρατηγικές για αναστροφή, επιβρά- δυνση ή πρόληψη περαιτέρω έκπτωσης της ικανότητας, αντι- μετωπίζει ασθένειες και ανταποκρίνεται στις ανάγκες για κοι- νωνική μέριμνα. Η προσωποκεντρική εκτίμηση και η ανάπτυξη πλάνου φροντί- δας συνήθως απαιτεί εκπαιδευμένους επαγγελματίες υγείας στην πρωτοβάθμια υγειονομική περίθαλψη, όπως είναι οι γε- νικοί ιατροί και οι νοσηλευτές. Ωστόσο, εκπτώσεις της ενδογε- νούς ικανότητας μπορούν να αντιμετωπιστούν στην κοινότητα όπου διαμένουν οι ηλικιωμένοι και οι φροντιστές τους, με την υποστήριξη διεπιστημονικής ομάδας. ΓΙΑΤΙ ΧΡΕΙΑΖΟΜΑΣΤΕ ΟΛΟΚΛΗΡΩΜΕΝΗ ΦΡΟΝΤΙΔΑ ΓΙΑ ΤΟΥΣ ΗΛΙΚΙΩΜΕΝΟΥΣ ΑΝΘΡΩΠΟΥΣ; Οι ηλικιωμένοι άνθρωποι αποτελούν το μεγαλύτερο ποσοστό του παγκόσμιου πληθυσμού, κάτι που δεν έχει ξανασυμβεί πο- τέ στο παρελθόν. Το 2017 ο αριθμός των ανθρώπων άνω των 65 ετών υπολογίστηκε σε 962 εκατομμύρια άτομα που αποτελεί το 13% του παγκόσμιου πληθυσμού. (3) Το ποσοστό αυτό θα αυξη- θεί ταχέως τις επόμενες δεκαετίες, ειδικότερα σε χώρες χαμη- λού ή μέσου εισοδήματος. Έως το 2050, ένα στα 5 άτομα θα εί- ναι 60 ετών ή άνω. Αυτή η τάση ξεκίνησε εδώ και περίπου 50 έτη. Αντανακλά τον συνδυασμό της ταχείας πτώσης των ποσοστών γο- νιμότητας και της ταχείας αύξησης του προσδόκιμου επιβίωσης σε πολλά μέρη του κόσμου, που συχνά συνοδεύουν την κοινωνι- κοοικονομική ανάπτυξη. Η διατήρηση της υγείας των ηλικιωμένων ανθρώπων αποτελεί επένδυση στο ανθρώπινο και κοινωνικό κεφάλαιο και υποστηρί- ζει τους στόχους Βιώσιμης Ανάπτυξης των Ηνωμένων Εθνών (4). Ταυτόχρονα η φροντίδα του αυξανόμενου πληθυσμού των ηλικι- ωμένων δημιουργεί μια πρόκληση για τα συστήματα υγείας. Οι πόροι υγειονομικής περίθαλψης θα πρέπει να εξισορροπηθούν μεταξύ των διάφορων ηλικιακών ομάδων. Απαιτείται μια θεμελι- ώδης αλλαγή της προσέγγισης της δημόσιας υγείας σχετικά με τη γήρανση. Η συμβατική προσέγγιση για την φροντίδα υγείας των ηλικιωμέ- νων ανθρώπων επικεντρώνεται σε ιατρικά προβλήματα, τοποθε- τώντας τη διάγνωση και την αντιμετώπιση τους στο επίκεντρο. Η αντιμετώπιση αυτών των προβλημάτων παραμένει σημαντική, αλλά η υπερβολική επικέντρωση σε αυτά τείνει να παραβλέπει δυσκολίες στην ακοή, την όραση, την μνήμη, και την κίνηση, κα- θώς και τις άλλες συνήθεις απώλειες της ενδογενούς ικανότη- τας που έρχονται με την ηλικία. Η αναγνώριση και αντιμετώπιση αυτών των προβλημάτων θα συμβάλει στην ευεξία του κάθε αν- θρώπου σε κάποια στιγμή της ζωής του. Η επικέντρωση του συ- στήματος υγείας στην ενδογενή ικανότητα των ηλικιωμένων αν- θρώπων θα συμβάλει στην ευημερία μιας μεγάλης και διαρκώς αυξανόμενης μερίδας του πληθυσμού. Οι περισσότεροι επαγγελματίες υγείας δεν έχουν την καθοδήγη- ση και την εκπαίδευση για να αναγνωρίσουν και να αντιμετωπί- σουν αποτελεσματικά την έκπτωση της ενδογενούς ικανότητας. Όσο ο πληθυσμός γερνά υπάρχει μια πιεστική ανάγκη να αναπτυ- χθούν εμπεριστατωμένες προσεγγίσεις με βάση την κοινότητα, που θα περιλαμβάνουν παρεμβάσεις που προλαμβάνουν την έκ- πτωση της ενδογενούς ικανότητας, στηρίζουν την υγιή γήρανση και υποστηρίζουν τους φροντιστές των ηλικιωμένων ανθρώπων. Η προσέγγιση ICOPE του ΠΟΥ αντιμετωπίζει αυτή την ανάγκη. ΠΟΙΟΥΣ ΑΦΟΡΟΥΝ ΑΥΤΕΣ ΟΙ ΟΔΗΓΙΕΣ; Το πρωταρχικό κοινό αυτού του εγχειριδίου είναι επαγγελματί- ες υγείας και εργαζόμενοι στην κοινωνική μέριμνα της κοινότη- τας και της πρωτοβάθμιας φροντίδας υγείας. Οι οδηγίες πρέπει επίσης να καθοδηγούν τους επαγγελματίες υγείας των οποίων η εξειδικευμένη γνώση θα κληθεί κατά περίπτωση να αντιμετωπί- σει και να σχεδιάσει την φροντίδα για ανθρώπους με απώλεια της ενδογενούς και της λειτουργικής ικανότητας. ΤΙ ΠΡΟΣΦΕΡΟΥΝ ΟΙ ΟΔΗΓΙΕΣ; Οι οδηγίες στοχεύουν να υποστηρίξουν τους επαγγελματί- ες υγείας και κοινωνικής φροντίδας στο πλαίσιο της κοινότη- τας, να ανιχνεύσουν και να αντιμετωπίσουν την έκπτωση της ενδογενούς ικανότητας, βασιζόμενοι στις κατευθυντήριες οδηγίες του ΠΟΥ για παρεμβάσεις στο επίπεδο της κοινότη- τας και αντιμετώπιση της μείωσης της ενδογενούς ικανότη- τας (2), και να αντιμετωπίσουν τις ανάγκες υγείας και κοινω- νικής φροντίδας των ηλικιωμένων ολοκληρωμένα. Οι οδηγίες περιγράφουν πώς: • Να τίθενται προσωποκεντρικοί στόχοι (Κεφάλαιο 2) • Να υποστηρίζεται η αυτοδιαχείριση (Κεφάλαιο 2) • Να αναπτύσσεται ένα πλάνο φροντίδας που περιλαμβά- νει πολλαπλές παρεμβάσεις για την αντιμετώπιση συνθη- κών που σχετίζονται με την απώλεια της ενδογενούς ικα- νότητας. (Κεφάλαιο 3) • Να γίνεται έλεγχος για απώλεια της ενδογενούς ικανότη- τας και εκτίμηση των αναγκών υγείας και κοινωνικής φρο- ντίδας (Κεφάλαιο 4-10) • Να υποστηρίζονται οι φροντιστές (Κεφάλαιο 11) και • Να αναπτύσσεται ένα εξατομικευμένο πλάνο φροντίδας (Κεφάλαιο 12). ΤΟ ΠΛΑΙΣΙΟ ΤΗΣ ΠΡΟΣΕΓΓΙΣΗΣ ΤΟΥ ICOPE Η καθολική κάλυψη της υγείας είναι το θεμέλιο για την επίτευξη του υγειονομικού στόχου της βιώσιμης ανάπτυ- ξης (4). Για να επιτευχθεί η βιώσιμη ανάπτυξη, η υγεία των ηλικιωμένων και οι κοινωνικές ανάγκες πρέπει να αντι- μετωπισθούν με έναν ολοκληρωμένο τρόπο και με συνέ- χιση της φροντίδας μακροπρόθεσμα. Η στρατηγική και το σχέδιο δράσης του ΠΟΥ για την γήρανση και την υγεία (5) περιγράφουν τον ρόλο των συστημάτων υγείας στην προ- αγωγή της υγιούς γήρανσης μέσω βελτιστοποίησης της ενδογενούς ικανότητας. Οι συστάσεις του ICOPE (2) και ο οδηγός συμβάλλουν στο να επιτευχθούν οι στόχοι αυτής της στρατηγικής. Οι οδηγίες αποτελούν επίσης ένα εργαλείο για να εφαρ- μογή του λειτουργικού πλαισίου του ΠΟΥ για ολοκληρω- μένες ανθρωποκεντρικές υπηρεσίες υγείας (6). Το λει- τουργικό πλαίσιο απαιτεί μια μετατόπιση του τρόπου με τον οποίον γίνεται η διαχείριση και η εφαρμογή των υπη- ρεσιών υγείας, προς μια ολοκληρωμένη ανθρωποκε- ντρική προσέγγιση. Στο πλαίσιο αυτής της προσέγγισης οι προτάσεις για φροντίδα των ηλικιωμένων του ICOPE βα- σίζονται: • Σε εκτίμηση των ατομικών αναγκών, προτιμήσεων και- στόχων, • Στην ανάπτυξη ενός εξατομικευμένου πλάνου φροντί- δας, • Σε συντονισμένες υπηρεσίες, που οδηγούνται προς τον μοναδικό στόχο της διατήρησης της ενδογενούς και λει- τουργικής ικανότητας που προσφέρεται όσο το δυνατόν περισσότερο μέσω πρωτοβάθμιας περίθαλψης και με βάση την κοινότητα. ΚΑΤΕΥΘΥΝΤΗΡΙΕΣ ΑΡΧΕΣ Οι οδηγίες βασίζονται στις ακόλουθες αρχές: 3 Οι ηλικιωμένοι έχουν το δικαίωμα για την καλύτερη δυνατή υγεία 3 Οι ηλικιωμένοι πρέπει να έχουν ίσες ευκαιρίες πρό- σβασης στους παράγοντες που καθορίζουν την υγιή γήρανση, ανεξαρτήτως κοινωνικής ή οικονομικής θέ- σης, τόπου γέννησης ή κατοικίας ή άλλων κοινωνικών παραγόντων. 3 Η φροντίδα πρέπει να παρέχεται εξίσου σε όλους, χω- ρίς διακρίσεις, ιδιαιτέρως χωρίς διακρίσεις που βασί- ζονται στο φύλο και την ηλικία. Επιπροσθέτως, οι επαγγελματίες που είναι υπεύθυνοι να ανα- πτύξουν την εκπαίδευση στην ιατρική, στη νοσηλευτική και σε τομείς υγείας και δημόσιας υγείας, μπορούν να βασιστούν τό- σο στις έννοιες όσο και στις πρακτικές προσέγγισης που περι- γράφονται εδώ. Άλλα ακροατήρια περιλαμβάνουν διαχειρι- στές υγειονομικής περίθαλψης και φορείς χάραξης πολιτικής, όπως εθνικοί, περιφερειακοί και δημοτικοί διαχειριστές προ- γραμμάτων υπεύθυνων για τον προγραμματισμό και την οργά- νωση υπηρεσιών υγείας, καθώς και υπηρεσίες που χρηματο- δοτούν ή/και διενεργούν προγράμματα δημόσιας υγείας, και μη κυβερνητικοί οργανισμοί και φιλανθρωπικές οργανώσεις που παρέχουν υπηρεσίες σε ηλικιωμένους ανθρώπους στην κοινότητα.
ΕΙΚΟΝΑ 1 ΒΑΣΙΚΟΙ ΤΟΜΕΙΣ ΤΗΣ ΕΝΔΟΓΕΝΟΥΣ ΙΚΑΝΟΤΗΤΑΣ ΒΕΛΤΙΣΤΟΠΟΙΗΣΗ ΙΚΑΝΟΤΗΤΩΝ ΚΑΙ ΔΥΝΑΤΟΤΗΤΩΝ: ΠΡΟΣ ΤΗΝ ΚΑΤΕΥΘΥΝΣΗ ΤΗΣ ΥΓΟΥΣ ΓΗΡΑΝΣΗΣ ΓΙΑ ΟΛΟΥΣ ΠΩΣ ΜΕΤΑΒΑΛΛΕΤΑΙ Η ΕΝΔΟΓΕΝΗΣ ΙΚΑΝΟΤΗΤΑ ΚΑΤΑ ΤΗΝ ΠΟΡΕΙΑ ΤΗΣ ΖΩΗΣ; Η Εικόνα 2, δείχνει ένα τυπικό μοτίβο της ενδογενούς ικανότητας και λειτουργικής δυνατότητας κατά την διάρκεια της ενήλικης ζωής. Η ενδογενής ικανότητα και η λειτουργική δυνατότητα εκπίπτουν με την ηλικία ως αποτέλεσμα της διαδικασίας της γήρανσης και των υποκείμε- νων νοσημάτων. Αυτό το μοτίβο μπορεί να χωριστεί σε τρεις περιόδους: Μια περίοδο με σχετικά υψηλή και σταθερή ικανότητα, μια περίοδο με φθίνουσα ικανότητα, και μια περίοδο με σημαντική απώλεια της ικανό- τητας, που χαρακτηρίζεται από εξάρτηση από άλλους για φροντίδα. Η Παγκόσμια αναφορά του ΠΟΥ για τη γήρανση και την υγεία ορίζει την υγιή γήρανση ως την ανάπτυξη και δια- τήρηση της λειτουργικής ικανότητας που επιτρέπει την ευεξία (1). Αυτές οι οδηγίες στηρίζουν την υγιή γήρανση, εστιάζο- ντας στις ακόλουθες καταστάσεις υψηλής προτεραιότη- τας που συνδέονται με έκπτωση σε όλους τους τομείς της ενδογενούς ικανότητας (Εικόνα 1), με τις ανάγκες κοι- νωνικής φροντίδας των ηλικιωμένων, και με την υπο- στήριξη των φροντιστών. • Έκπτωση γνωστικής ικανότητας (Κεφάλαιο 4) • Περιορισμός κινητικότητας (Κεφάλαιο 5) • Δυσθρεψία (Κεφάλαιο 6) • Προβλήματα όρασης (Κεφάλαιο 7) • Απώλεια ακοής (Κεφάλαιο 8) • Συμπτώματα κατάθλιψης (Κεφάλαιο 9) • Κοινωνική φροντίδα και στήριξη (Κεφάλαιο 10) • Στήριξη φροντιστών (Κεφάλαιο 11) Ζωτικότητα Οπτική ικανότητα Ακουστική ικανότητα Γνωστική ικανότητα Ψυχολογική ικανότητα Κινητική ικανότητα Υπάρχει ένα ευρύ φάσμα της ενδογενούς ικανότητας γύ- ρω από το μέσο όρο. Οι διαφορές αυτές είναι εμφανείς τόσο εντός μιας χώρας όσο και μεταξύ των διαφορετικών χωρών. Αντικατοπτρίζονται στις επίμονες διαφορές στο προσδόκιμο επι- βίωσης, που κυμαίνεται από τα 82 ή και περισσότερα έτη σε χώ- ρες όπως η Αυστραλία, η Ιαπωνία και η Ελβετία, σε κάτω των 55 ετών σε χώρες όπως η Κεντροαφρικανική Δημοκρατία, το Τσαντ και η Σομαλία. Η διακύμανση της ενδογενούς ικανότητας μεταξύ των ηλικιω- μένων είναι πολύ μεγαλύτερη από ό,τι είναι μεταξύ των ατόμων που ανήκουν σε νεότερες ομάδες. Αυτή η ποικιλομορφία είναι ένα από τα βασικά χαρακτηριστικά της γήρανσης. Ένα άτομο εί- ναι πιθανό να έχει μια ηλικιακή διαφορά 10 ετών ή περισσότερο από ένα άλλο άτομο αλλά την ίδια ενδογενή ικανότητα ή/και λει- τουργική δυνατότητα. Για αυτόν τον λόγο η χρονολογική ηλικία είναι ανεπαρκής δείκτης της κατάστασης της υγείας. ΠΑΡΕΜΒΑΣΗ ΓΙΑ ΤΗ ΒΕΛΤΙΣΤΟΠΟΙΗΣΗ ΤΗΣ ΕΝΔΟΓΕΝΟΥΣ ΙΚΑΝΟΤΗΤΑΣ Η αναγνώριση συνθηκών που συνδέονται με απώλεια της εν- δογενούς ικανότητας δίνει κάποια ευκαιρία για παρέμβαση με στόχο την επιβράδυνση, ανακοπή ή αναστροφή της απώλειας (Εικόνα 2). Οι επαγγελματίες υγείας σε χώρους παροχής υπη- ρεσιών υγείας και στην κοινότητα μπορούν να ανιχνεύσουν κα- ταστάσεις που σχετίζονται με έκπτωση στην ενδογενή ικανότη- τα. Επαναλαμβανόμενες εκτιμήσεις σε βάθος χρόνου καθιστούν εφικτή την καταγραφή αλλαγών που είναι μεγαλύτερες από τις αναμενόμενες, έτσι ώστε να προταθούν ειδικές παρεμβάσεις προτού χαθεί η λειτουργική ικανότητα. Με αυτό τον τρόπο, παρεμβάσεις που παρέχονται σε δομές της κοινότητας μπορούν να λειτουργήσουν προληπτικά και να απο- τρέψουν ένα άτομο από το να καταστεί ευπαθές ή εξαρτημένο από φροντίδα. Οι πολυδιάστατες παρεμβάσεις εμφανίζονται να είναι πιο αποτελεσματικές. ΕΝΔΟΓΕΝΗΣ ΚΑΙ ΛΕΙΤΟΥΡΓΙΚΗ ΙΚΑΝΟΤΗΤΑ Ο ΠΟΥ ορίζει την ενδογενή ικανότητα ως ένα συνδυασμό της σωματικής και νοητικής, συμπερι- λαμβανομένης και της ψυχολογικής, ικανότητας. Η λειτουργική ικανότητα είναι ο συνδυασμός και η αλληλεπίδραση της ενδογενούς ικανότητας με το περιβάλλον που το άτομο κατοικεί. ΕΙΚΟΝΑ 2. ΠΛΑΙΣΙΟ ΔΗΜΟΣΙΑΣ ΥΓΕΑΣ ΓΙΑ ΥΓΙΗ ΓΗΡΑΝΣΗ: ΕΥΚΑΙΡΙΕΣ ΓΙΑ ΔΡΑΣΕΙΣ ΓΙΑ ΤΗΝ ΔΗΜΟΣΙΑ ΥΓΕΙΑ ΚΑΤΑ ΤΗΝ ΔΙΑΡΚΕΙΑ ΤΗΣ ΖΩΗΣ Πολλά από τα χαρακτηριστικά που καθορίζουν την ενδογενή ικανότητα μπορούν να μεταβληθούν. Αυτά περιλαμβάνουν συμπεριφορές που σχετίζο- νται με την υγεία και την παρουσία νοσημάτων. Ως εκ τούτου το σκεπτικό για την εισαγωγή αποτελε- σματικών παρεμβάσεων για βελτιστοποίηση της ενδογενούς ικανότητας είναι ισχυρό. Αυτό το σκε- πτικό αποτελεί το θεμέλιο της προσέγγισης ICOPE και αυτών των οδηγιών. Οι διαφορετικές καταστάσεις υγείας που σχετίζο- νται με απώλεια της ενδογενούς ικανότητας αλλη- λοεπιδρούν σε διάφορα επίπεδα. Η απώλεια ακο- ής, για παράδειγμα, σχετίζεται με έκπτωση γνωστι- κών ικανοτήτων. Η θρέψη ενισχύει το αποτέλεσμα της άσκησης και έχει άμεσο αντίκτυπο στη μυϊκή μάζα και την ισχύ. Αυτές οι αλληλεπιδράσεις καθι- στούν αναγκαία την ολοκληρωμένη προσέγγιση στη διαλογή, αξιολόγηση και αντιμετώπιση της έκ- πτωσης της ενδογενούς ικανότητας. ΠΡΟΣΕΓΓΙΣΗ ICOPE Υψηλή και σταθερή ικανότητα Φθίνουσα ικανότητα Σημαντική απώλεια ικανότητας ΥΠΗΡΕΣΙΕΣ ΥΓΕΙΑΣ: ΜΑΚΡΟΧΡΟΝΙΑ ΦΡΟΝΤΙΔΑ: ΠΕΡΙΒΑΛΛΟΝ: Πηγή: Παγκόσμιος Οργανισμός Υγείας, 2015 (1). Λειτουργική ικανότητα Προλάβετε χρόνιες καταστάσεις ή διασφαλίστε έγκαιρη διάγνωση και έλεγχο Αναστρέψτε ή καθυστερήστε την έκπτωση ικανότητας Ενδογενής ικανότητα Διαχειριστείτε τις προχωρημένες χρόνιες καταστάσεις Υποστηρίξτε τις συμπεριφορές που βελτιώνουν την ικανότητα Προωθήστε συμπεριφορές που βελτιώνουν την ικανότητα Διασφαλίστε ένα αξιοπρεπές τελικό στάδιο ζωής Απομακρύνετε τα εμπόδια των συμμετεχόντων, αντισταθμίστε την απώλεια ικανότητας
ΑΞΙΟΛΟΓΗΣΗ ΤΩΝ ΑΝΑΓΚΩΝ ΤΩΝ ΗΛΙΚΙΩΜΕΝΩΝ ΚΑΙ Η ΑΝΑΠΤΥΞΗ ΕΝΟΣ ΕΞΑΤΟΜΙΚΕΥΜΕΝΟΥ ΠΛΑΝΟΥ ΦΡΟΝΤΙΔΑΣ Σημεία κλειδιά 3Ο εντοπισμός ηλικιωμένων στην κοινότητα, για τους οποίους συ- ντρέχουν συνθήκες υψηλής προτεραιότητας που συνδέονται με έκπτωση της ενδογενούς ικανότητας, μπορεί να επιτευχθεί με τη βοήθεια του εργαλείου διαλογής για την ολοκληρωμένη φρο- ντίδα ηλικιωμένων (ICOPE) 3Όσοι εντοπίζονται να συντρέχουν αυτές οι συνθήκες, παραπέ- μπονται σε μια δομή πρωτοβάθμιας φροντίδας υγείας για περαι- τέρω αξιολόγηση, πάνω στην οποία θα στηριχθεί η ανάπτυξη ενός εξατομικευμένου πλάνου φροντίδας. 3Το πλάνο φροντίδας μπορεί να περιλαμβάνει πολλαπλές πα- ρεμβάσεις για την αντιμετώπιση της έκπτωσης της ενδογενούς ικανότητας και τη βελτιστοποίηση της λειτουργικής ικανότητας, όπως είναι η σωματική άσκηση, η από στόματος συμπληρωματι- κή θρέψη, η παροχή γνωστικών ερεθισμάτων και οι μετατροπές στο σπίτι για την πρόληψη πτώσεων. Η προσωποκεντρική εξατομικευμένη φροντίδα στηρίζεται στην προ- σέγγιση ότι οι ηλικιωμένοι άνθρωποι δεν είναι απλώς φορείς των δια- ταραχών ή των προβλημάτων υγείας τους. Όλοι οι άνθρωποι ανεξαρ- τήτως ηλικίας, είναι άτομα με μοναδικές εμπειρίες, ανάγκες και επι- θυμίες. Η πρoσωποκεντρική φροντίδα αναφέρεται περισσότερο στις ατομικές ανάγκες υγείας και κοινωνικής φροντίδας παρά καθοδηγεί- ται από μεμονωμένα προβλήματα υγείας ή συμπτώματα. Μια προσω- ποκεντρική, ολοκληρωμένη προσέγγιση, εμπεριέχει επίσης την έν- νοια της καθημερινής διαβίωσης των ατόμων, περιλαμβάνοντας συγ- χρόνως τον αντίκτυπο της υγείας και των αναγκών τους σε αυτούς που είναι κοντά τους και στην κοινότητά τους. Υπάρχουν πέντε βήματα για την ικανοποίηση των αναγκών των ηλικι- ωμένων σε θέματα υγείας και κοινωνικής φροντίδας, με μια ολοκλη- ρωμένη προσέγγιση φροντίδας, όπως φαίνεται στην ακόλουθη γενι- κή πορεία. Μονοπάτια Γενικής Φροντίδας Προσωποκεντρική αξιολόγηση και μονοπάτια στη πρωτοβάθμια φροντίδα ΒΗΜΑ 1 ΒΗΜΑ 2 ΑΞΙΟΛΟΓΗΣΤΕ ΣΕ ΜΕΓΑΛΥΤΕΡΟ ΒΑΘΟΣ ΓΙΑ ΚΑΤΑΣΤΑΣΕΙΣ ΠΟΥ ΣΧΕΤΙΖΟΝΤΑΙ ΜΕ ΑΠΩΛΕΙΑ ΕΝΔΟΓΕΝΟΥΣ ΙΚΑΝΟΤΗΤΑΣ ΠΡΟΣΩΠΟΚΕΝΤΙΚΗ ΑΞΙΟΛΟΓΗΣΗ ΣΤΗΝ ΠΡΩΤΟΒΑΘΜΙΑ ΦΡΟΝΤΙΔΑ ΕΛΕΓΞΤΕ ΓΙΑ ΑΠΩΛΕΙΕΣ ΕΝΔΟΓΕΝΟΥΣ ΙΚΑΝΟΤΗΤΑΣ ΣΤΗΝ ΚΟΙΝΟΤΗΤΑ Ν Α Ι Ν Α Ι Ν Α Ι Ο Χ Ι Ο Χ Ι Ο Χ Ι Ενισχύστε γενικές συμβουλές υγείας και τρόπου ζωής ή τη συνήθη φροντίδα Κατανοήστε τη ζωή του ηλικιωμένου, αξίες, τις προτεραιότητες και το κοινωνικό πλαίσιο Παρεμβάσεις στο επίπεδο της κοινότητας για διαχείριση εκπτώσεων ενδογενούς ικανότητας Ολοκληρωμένη διαχείριση νοσημάτων Αποκατάσταση Παρηγορητική φροντίδα ή φροντίδα τέλους ζωής ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΑΝΑΓΚΗ ΓΙΑ ΥΠΗΡΕΣΙΕΣ ΚΟΙΝΩΝΙΚΗΣ ΜΕΡΙΜΝΑΣ (σπίτι, ίδρυμα)g 10 Πλάνο κοινωνικής φροντίδας & υποστήριξης Απομακρύνετε τα εμπόδια για την κοινωνική συμμετοχή Προσαρμογή του περιβάλλοντος Καμία απώλεια ενδογενούς ικανότητας ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΑ ΥΠΟΚΕΙΜΕΝΑ ΝΟΣΗΜΑΤΑ ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ ΕΛΕΓΞΤΕ ΒΗΜΑ 3 ΒΗΜΑ 5 ΒΗΜΑ 4 Α Ν Α Π Τ Υ Ξ Τ Ε Ε Ξ ΑΤ Ο Μ Ι Κ Ε Υ Μ Ε Ν Ο Π Λ Α Ν Ο Φ Ρ Ο Ν Τ Ι Δ Α Σ Προσωποκεντρική στοχοθεσία Διεπιστημονική ομάδα Σχεδιάστε ένα πλάνο φροντίδας που περιλαμβάνει πολυδιάστατες παρεμβάσεις, διαχείριση υποκείμενων νοσημάτων, αυτοφροντίδα και αυτοδιαχείριση, και κοινωνική φροντίδα και υποστήριξη Ε Μ Π Λ Ε Ξ Τ Ε Τ Ι Σ Κ Ο Ι Ν Ο Τ Η Τ Ε Σ Κ Α Ι Τ Ο Υ Σ Φ Ρ Ο Ν Τ Ι Σ Τ Ε Σ Ε Ξ Α Σ Φ Α Λ Ι Σ Τ Ε Τ Ο Μ Ο Ν Ο Π ΑΤ Ι Π Α ΡΑ Π Ο Μ Π Η Σ Κ Α Ι Τ Η Ν Π Α ΡΑ Κ Ο Λ Ο Υ Θ Η Σ Η Τ Ο Υ Π Λ Α Ν Ο Υ Φ Ρ Ο Ν Τ Ι Δ Α Σ ΜΕΣΩ ΔΙΑΣΥΝΔΕΣΗΣ ΜΕ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΓΗΡΙΑΤΡΙΚΗ ΦΡΟΝΤΙΔΑ ΠΙΝΑΚΑΣ 1. ΕΡΓΑΛΕΙΟ ΔΙΑΛΟΓΗΣ ICOPE ΤΟΥ ΠΟΥ Συνθήκες υψηλής προτεραιότητας που συνδέονται Δοκιμασίες με έκπτωση της ενδογενούς ικανότητας ΕΚΠΤΩΣΗ ΓΝΩΣΤΙΚΗΣ ΙΚΑΝΟΤΗΤΑΣ (Κεφάλαιο 4) ΠΕΡΙΟΡΙΣΜΕΝΗ ΚΙΝΗΤΙΚΟΤΗΤΑ (Κεφάλαιο 5) ΔΥΣΘΡΕΨΙΑ (Κεφάλαιο 6) ΟΠΤΙΚΗ ΔΥΣΧΕΡΕΙΑ (Κεφάλαιο 7) ΑΠΩΛΕΙΑ ΑΚΟΗΣ (Κεφάλαιο 8) ΚΑΤΑΘΛΙΠΤΙΚΗ ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ (Κεφάλαιο 9) 1. Απομνημονεύστε τρεις λέξεις: π.χ. λουλούδι, πόρτα, ρύζι 2. Προσανατολισμός στον χρόνο και τον χώρο: Ποια είναι η πλήρης ημερομηνία σήμερα; Πού βρίσκεστε αυτή τη στιγμή (σπίτι, κλινική κλπ.); 3. Μπορεί να ανακαλέσει τις τρεις λέξεις; 1. Απώλεια βάρους: Έχετε χάσει περισσότερα από 3 κιλά μέσα στους τελευταίους τρείς μήνες; 2. Απώλεια όρεξης: Έχετε βιώσει απώλεια όρεξης; Λάθος σε όποια από τις ερωτήσεις ή δεν γνωρίζει Δεν μπορεί να ανακαλέσει τις τρεις λέξεις Όχι Ναι Ναι Ναι Ναι Ναι Αποτυγχάνει Αξιολογήστε πλήρως κάθε τομέα του οποίου ο κύκλος έχει σημειωθεί με ✔ Δοκιμασία έγερσης από την καρέκλα: Σηκωθείτε πέντε φορές χωρίς να χρησιμοποιήσετε τα χέρια σας. Ολοκλήρωσε το άτομο πέντε εγέρσεις από την καρέκλα εντός 14 δευτερολέπτων; Έχετε κάποιο πρόβλημα με τα μάτια σας: δυσκολία να δείτε μακριά, να διαβάσετε, κάποιο οφθαλμικό νόσημα, ή βρίσκεστε στην παρούσα φάση υπό κάποια φαρμακευτική αγωγή (π.χ. για σακχαρώδη διαβήτη, αρτηριακή υπέρταση); Μπορεί να ακούσει ψιθύρους (δοκιμασία ψιθυριστής φωνής) ή Αποτέλεσμα ακοομετρίας διαλογής ίσο ή μικρότερο με 35dB ή Περνά αυτοματοποιημένη δοκιμασία αναγνώρισης ψηφίων σε θόρυβο σε εφαρμογή κινητού Στη διάρκεια των τελευταίων δύο εβδομάδων, σας έχει ενοχλήσει • η αίσθηση ότι είστε πεσμένος, καταθλιμμένος ή απελπισμένος; • ελάχιστο ενδιαφέρον ή ευχαρίστηση, να κάνετε πράγματα; ΒΗΜΑ 1 ΕΛΕΓΞΤΕ ΓΙΑ ΕΚΠΤΩΣΗ ΤΗΣ ΕΝΔΟΓΕΝΟΥΣ ΙΚΑΝΟΤΗΤΑΣ Με τη διαδικασία και τα εργαλεία αυτού του οδηγού, οι εκπαιδευ- μένοι επαγγελματίες υγείας μπορούν να ξεκινήσουν τον εντοπι- σμό των ατόμων με απώλειες της ενδογενούς ικανότητας στην κοινότητα ή στο σπίτι. Για να το κάνουν αυτό, μπορούν να χρησιμο- ποιήσουν το εργαλείο διαλογής ICOPE (Πίνακας 1). Το εργαλείο διαλογής ICOPE είναι το πρώτο βήμα σε κάθε μονοπάτι φροντίδας που παρουσιάζεται στα Κεφάλαια 4 έως 9 και καλύπτει έξι σχε- τικές καταστάσεις σε όλο το φάσμα της ενδογενούς ικανότητας (Εικόνα 1 στη σελίδα 5 ). Στρατηγικές προσέγγισης της κοινότη- τας, όπως οι κατ’ οίκον επισκέψεις από κοινοτικούς επαγγελμα- τίες υγείας και αυτοαξιολογήσεις με τη χρήση τεχνολογιών κινη- τών τηλεφώνων, μπορούν να χρησιμοποιηθούν για την ανεύρεση περιστατικών. Όσοι παρουσιάζουν ενδείξεις ή αναφέρουν απώλειες στην ικανό- τητα σε αυτό το πρώτο βήμα, θα πρέπει να προχωρήσουν σε πλή- ρη αξιολόγηση. Η πλήρης αξιολόγηση πιθανώς απαιτεί επαγγελ- ματίες υγείας με την απαραίτητη κατάρτιση, που συχνά αλλά όχι απαραίτητα είναι ιατροί. Οι επαγγελματίες υγείας και φροντίδας πρέπει να διασφαλίζουν ότι όταν διαπιστώνεται οποιοσδήποτε περιορισμός στην ικανότη- τα μέσω του εργαλείου διαλογής ICOPE, θα πρέπει πάντα να ακο- λουθεί μια περαιτέρω εις βάθος αξιολόγηση. Η ανάπτυξη του εξατομικευμένου πλάνου φροντίδας πρέπει να στηρίζεται στα ευ- ρήματα αυτής. ΒΗΜΑ 2 ΠΡΑΓΜΑΤΟΠΟΙΗΣΤΕ ΜΙΑ ΠΡΟΣΩΠΟΚΕΝΤΡΙΚΗ ΑΞΙΟΛΟΓΗΣΗ ΣΤΗΝ ΠΡΩΤΟΒΑΘΜΙΑ ΠΕΡΙΘΑΛΨΗ Μια προσωποποκεντρική αξιολόγηση της υγείας ενός ηλικιωμένου ατό- μου και των αναγκών κοινωνικής φροντίδας του στην πρωτοβάθμια πε- ρίθαλψη είναι ζωτικής σημασίας για τη βελτιστοποίηση της ενδογενούς ικανότητας. 2A. Κατανοήστε τη ζωή του ηλικιωμένου Μια προσωποκεντρική αξιολόγηση ξεκινά όχι μόνο με μια συμβατική λή- ψη ιστορικού, αλλά και με τη διεξοδική κατανόηση της ζωής, των αξιών, των προτεραιοτήτων και των προτιμήσεων του ατόμου για την πορεία της υγείας του και τη διαχείρισή της. 2B. Αξιολογήστε σε μεγαλύτερο βάθος τις συνθήκες που σχετίζονται με απώλεια της ενδογενούς ικανότητας Η αξιολόγηση εκτιμά επίσης σε μεγαλύτερο βάθος τις συνθήκες που συνδέονται με την έκπτωση της ενδογενούς ικανότητας. Τα μονοπάτια φροντίδας για κομβικές καταστάσεις σε όλους τους τομείς της ενδογε- νούς ικανότητας, που παρουσιάζονται στα Κεφάλαια 4 έως 9, κατανέμο- νται γενικώς σε τρεις συνιστώσες, με τον έλεγχο στην κοινότητα να βρί- σκεται στην κορυφή, την αξιολόγηση στην πρωτοβάθμια περίθαλψη στη μέση, και τον σχεδιασμό εξατομικευμένης φροντίδας στο τέλος. 2Γ. Αξιολογήστε και διαχειριστείτε τα υποκείμενα νοσήματα Οι πιθανές υποκείμενες χρόνιες νόσοι θα πρέπει να διερευνηθούν, όπως και πιθανή πολυφαρμακία (η χρήση πολλαπλών φαρμάκων). Η πολυφαρμακία και οι τυχόν επακόλουθες ανεπιθύμητες ενέργειες μπορεί να προκαλέσουν απώλειες σε πολλαπλούς τομείς της ενδογε- νούς ικανότητας και για αυτό χρήζουν πάντα διερεύνησης (βλ. πλαίσιο, Πολυφαρμακία, σελίδα 18). Η διάγνωση υποκείμενων νόσων, όπως η νόσος Αλτσχάιμερ, η κατάθλι- ψη, η οστεοαρθρίτιδα, η οστεοπόρωση, ο καταρράκτης, ο διαβήτης και η υπέρταση, είναι ζωτικής σημασίας για μια προσωποκεντρική αξιολόγη- ση. Τέτοιες διαγνώσεις μπορεί να απαιτούν πολύπλοκες διαγνωστικές εξετάσεις που δεν είναι πάντα διαθέσιμες σε δομές πρωτοβάθμιας φρο- ντίδας υγείας. Ανάλογα με το πλαίσιο, μπορεί να χρειαστεί παραπομπή σε δευτεροβάθμιο ή τριτοβάθμιο επίπεδο εξειδικευμένης γηριατρικής πε- ρίθαλψης. 2Δ. Αξιολογήστε το κοινωνικό και φυσικό περιβάλλον και την ανάγκη για κοινωνική φροντίδα και υποστήριξη Για τα άτομα με απώλειες στην ενδογενή ικανότητα, απαιτείται τόσο η αξι- ολόγηση του κοινωνικού και φυσικού περιβάλλοντος, όσο και ο προσ- διορισμός τυχόν αναγκών για κοινωνικές και υποστηρικτικές υπηρεσί- ες. Αυτό αποτελεί ουσιαστικό μέρος της προσωποκεντρικής αξιολόγη- σης των ηλικιωμένων στην πρωτοβάθμια περίθαλψη. Οι ανάγκες κοι- νωνικής φροντίδας μπορούν να προσδιοριστούν ρωτώντας έναν ηλικι- ωμένο αν μπορεί να εκτελέσει διάφορες καθημερινές εργασίες χωρίς τη βοήθεια τρίτων. Το μονοπάτι στο Κεφάλαιο 10 παρουσιάζει ένα σύνο- λο ερωτήσεων για την αξιολόγηση και τον προσδιορισμό των αναγκών κοινωνικής φροντίδας γενικά. Επιπλέον, κάθε μονοπάτι φροντίδας στα Κεφάλαια 4 έως 9 σημειώνει πιθανές ανάγκες κοινωνικής φροντίδας εξειδικευμένες για την κάθε κατάσταση υψηλής προτεραιότητας. ΒΗΜΑ 3 ΚΑΘΟΡΙΣΤΕ ΤΟ ΣΤΟΧΟ ΤΗΣ ΦΡΟΝΤΙΔΑΣ ΚΑΙ ΑΝΑΠΤΥΞΤΕ ΕΝΑ ΕΞΑΤΟΜΙΚΕΥΜΕΝΟ ΠΛΑΝΟ ΦΡΟΝΤΙΔΑΣ 3Α. Καθορίστε μαζί με τον ηλικιωμένο τον στόχο της φροντίδας. Ο κοινός στόχος της βελτιστοποίησης της ενδογενούς και της λει- τουργικής ικανότητας διασφαλίζει την ολοκλήρωση της φροντίδας, και παρέχει επίσης την ευκαιρία παρακολούθησης της προόδου του ηλικιωμένου και της αποτελεσματικότητας των παρεμβάσεων. Είναι σημαντικό ο ηλικιωμένος και ο φροντιστής να συμμετέχουν στη λήψη των αποφάσεων και στον καθορισμό των στόχων εξαρχής, και οι στόχοι να τίθενται και να ιεραρχούνται σύμφωνα με τις προτε- ραιότητες, τις ανάγκες και τις προτιμήσεις του ατόμου. 3Β. Σχεδιάστε ένα πλάνο φροντίδας Μέσω της προσωποκεντρικής αξιολόγησης διαμορφώνεται η ανά- πτυξη ενός εξατομικευμένου πλάνου φροντίδας. Αυτό το εξατομι- κευμένο πλάνο φροντίδας εφαρμόζει μια ολοκληρωμένη προσέγ- γιση για την υλοποίηση παρεμβάσεων που αντιμετωπίζουν τις απώ- λειες σε διάφορους τομείς της ενδογενούς ικανότητας. Όλες οι πα- ρεμβάσεις θα πρέπει να εξετάζονται και να εφαρμόζονται μαζί. Η υποστήριξη της αυτοδιαχείρισης περιλαμβάνει την παροχή πληροφοριών, δεξιοτήτων και εργαλείων στους ηλικιωμένους για τη διαχείριση των προβλη- μάτων της υγείας τους, την πρόληψη των επιπλοκών, τη μεγιστοποίηση της ενδογενούς ικανότητας τους και τη διατήρηση της ποιότητας ζωής τους. Αυτό δεν σημαίνει ότι οι ηλικιωμένοι θα πρέπει να ‘πο- ρευθούν μόνοι τους’ ή ότι θα τους τεθούν παράλογες και υπερβολικές απαιτήσεις. Αντιθέτως, αναγνωρίζει την αυτονομία και τις ικανότητές τους να κατευθύνουν τη δική τους φροντίδα, σε διαβούλευση και συνεργα- σία με τους εργαζομένους στον τομέα της υγείας, τις οικογένειές τους και άλλους φροντιστές. Η εφαρμογή για κινητά του ΠΟΥ για την υγεία στη γήραν- ση (The WHO mobile health for ageing) (mAgeing) μπο- ρεί να λειτουργήσει συμπληρωματικά στη συνήθη φροντίδα των επαγγελματιών υγείας, υποστηρίζοντας την αυτοφροντί- δα και την αυτοδιαχείριση. Παρέχοντας πληροφορίες για την υγεία, συμβουλές και υπενθυμίσεις μέσω κινητών τηλεφώ- νων, ενθαρρύνει συμπεριφορές υγιούς τρόπου διαβίωσης και βοηθά τους ηλικιωμένους να βελτιώσουν και να διατηρή- σουν την ενδογενή ικανότητά τους. Για πληροφορίες σχετικά με την προσαρμογή και εγκατά- σταση (set-up) του προγράμματος mAgeing και των προτει- νόμενων μηνυμάτων κειμένου, ανατρέξτε στη διεύθυνση: https://www.who.int/ageing/health-systems/mAgeing Μονοπάτια Γενικής Φροντίδας Προσωποκεντρική αξιολόγηση και μονοπάτια στη πρωτοβάθμια φροντίδα Αυτή η ολοκληρωμένη προσέγγιση είναι σημαντική επειδή οι πε- ρισσότερες προδιαθεσικές συνθήκες που σχετίζονται με απώλειες της ενδογενούς ικανότητας μοιράζονται τους ίδιους υποκείμενους φυσιολογικούς και συμπεριφορικούς καθοριστικούς παράγοντες. Κατά συνέπεια οι παρεμβάσεις έχουν οφέλη σε όλους τους τομείς. Για παράδειγμα, η εντατική προπόνηση με ασκήσεις ενδυνάμωσης είναι η βασική παρέμβαση για την πρόληψη της απώλειας κινητι- κότητας. Ταυτόχρονα, οι ασκήσεις ενδυνάμωσης προστατεύουν έμ- μεσα τον εγκέφαλο από την κατάθλιψη και την έκπτωση γνωστικών ικανοτήτων και βοηθούν στην πρόληψη των πτώσεων. Η διατρο- φή ενισχύει τα αποτελέσματα της άσκησης και ταυτόχρονα αυξάνει τη μυϊκή μάζα και τη δύναμη. Μέσω μιας ολοκληρωμένης, ενοποι- ημένης προσέγγισης, μπορεί να είναι δυνατή η αλλαγή του συνό- λου των παραγόντων που αυξάνουν τον κίνδυνο της εξάρτησης από φροντίδα. Το εξατομικευμένο πλάνο φροντίδας αποτελείται από αρκετά δια- φορετικά στοιχεία τα οποία μπορεί να περιλαμβάνουν: • ένα σύνολο πολυδιάστατων παρεμβάσεων για τη διαχείριση της απώλειας της ενδογενούς ικανότητας. Τα περισσότερα πλάνα φροντίδας περιλαμβάνουν παρεμβάσεις για τη βελτίωση της δια- τροφής και την ενθάρρυνση της σωματικής άσκησης. • τη διαχείριση και θεραπεία των υποκείμενων νοσημάτων, της πο- λυνοσηρότητας και των γηριατρικών συνδρόμων. Ο ΠΟΥ έχει ανα- πτύξει κατευθυντήριες οδηγίες για την αντιμετώπιση των περισ- σότερων σχετικών χρόνιων παθήσεων που μπορεί να συμβάλ- λουν στη μείωση της ενδογενούς ικανότητας (2). Κάθε πάροχος υγειονομικής περίθαλψης θα πρέπει να έχει πρόσβαση σε αυτές τις οδηγίες. • την υποστήριξη της αυτοφροντίδας και της αυτοδιαχείρισης. • τη διαχείριση τυχόν προχωρημένων χρονίων παθήσεων (παρηγο- ρητική φροντίδα, αποκατάσταση) ή τη διασφάλιση ότι οι ηλικιωμέ- νοι θα μπορούν να συνεχίσουν να ζουν τις ζωές τους με νόημα και αξιοπρέπεια. • την κοινωνική φροντίδα και την υποστήριξη, συμπεριλαμβανομέ- νων περιβαλλοντολογικών προσαρμογών για την αντιστάθμιση τυχόν λειτουργικών απωλειών. • ένα σχέδιο για την κάλυψη των αναγκών της κοινωνικής φροντί- δας, με τη βοήθεια των μελών της οικογένειας, των φίλων και των κοινοτικών υπηρεσιών. Οι επαγγελματίες υγείας και κοινωνικής φροντίδας μπορούν να υποστηρίξουν την εφαρμογή ενός πλάνου φροντίδας στην κοινότη- τα ή στις δομές πρωτοβάθμιας περίθαλψης. Η αυτοδιαχείριση, υπο- στηριζόμενη από συμβουλές, εκπαίδευση και ενθάρρυνση από πα- ρόχους υπηρεσιών υγείας στην κοινότητα, μπορεί να τροποποιήσει κάποιους από τους παράγοντες που ευθύνονται για τη μείωση της ενδογενούς ικανότητας. Μια συνεργασία που εμπλέκει τους ηλικι- ωμένους, τους εργαζόμενους στη πρωτοβάθμια φροντίδα υγείας, την οικογένεια και την κοινότητα θα συμβάλει στη διατήρηση της ευημερίας των ανθρώπων καθώς γερνούν. ΒΗΜΑ 4 ΔΙΑΣΦΑΛΙΣΤΕ ΕΝΑ ΜΟΝΟΠΑΤΙ ΠΑΡΑΠΟΜΠΗΣ ΚΑΙ ΠΑΡΑΚΟΛΟΥΘΗΣΗΣ ΤΟΥ ΠΛΑΝΟΥ ΦΡΟΝΤΙΔΑΣ ΜΕΣΩ ΤΗΣ ΔΙΑΣΥΝΔΕΣΗΣ ΜΕ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΓΗΡΙΑΤΡΙΚΗ ΦΡΟΝΤΙΔΑ Η τακτική και παρατεταμένη παρακολούθηση με ενσωμάτωση διαφο- ρετικών επιπέδων και τύπων υπηρεσιών φροντίδας, είναι ζωτικής ση- μασίας για την εφαρμογή των παρεμβάσεων που συστήνονται σε αυ- τόν τον οδηγό. Μια τέτοια προσέγγιση προωθεί τον πρώιμο εντοπισμό επιπλοκών ή αλλαγών στη λειτουργική κατάσταση, και έτσι οδηγεί στη αποφυγή περιττών εκτάκτων καταστάσεων και στην εξοικονόμη- ση πόρων, μέσω έγκαιρων ενεργειών. Η τακτική παρακολούθηση παρέχει επίσης την ευκαιρία να παρακο- λουθείται η πρόοδος του πλάνου φροντίδας, και επίσης αποτελεί ένα μέσο για τον σχεδιασμό επιπρόσθετης υποστήριξης όταν χρειάζεται. Η παρακολούθηση και η υποστήριξη μπορεί να είναι ιδιαιτέρως ση- μαντικές μετά από μείζονες αλλαγές της κατάστασης της υγείας, του θεραπευτικού πλάνου ή του κοινωνικού ρόλου ή συνθηκών της ζω- ής του ατόμου (όπως για παράδειγμα η αλλαγή κατοικίας ή ο θάνατος συντρόφου). Τα σαφή πρωτόκολλα παραπομπής είναι σημαντικά στην διασφάλι- ση της ταχείας πρόσβασης στην επείγουσα φροντίδα σε περίπτωση απρόβλεπτων γεγονότων, όπως είναι οι πτώσεις, και στην παρηγορη- τική φροντίδα και τη φροντίδα τέλους ζωής ή μετά από το εξιτήριο από το νοσοκομείο. Ο ΡΟΛΟΣ ΤΗΣ ΕΞΕΙΔΙΚΕΥΜΕΝΗΣ ΓΗΡΙΑΤΡΙΚΗΣ ΦΡΟΝΤΙΔΑΣ. Οι γηρίατροι εστιάζουν την εξειδίκευση τους σε ηλικιωμέ- νους με μακροχρόνιες πολύπλοκες παθήσεις όπως είναι τα γηριατρικά σύνδρομα (η ακράτεια, οι πτώσεις, το ντελί- ριο κ.λπ.), η πολυφαρμακία και οι ασθένειες όπως η άνοια, και προσφέρουν φροντίδα σε εκείνους που αντιμετωπίζουν περιορισμούς στις δραστηριότητες της καθημερινής τους ζωής. Η πολυνοσηρότητα αυξάνεται με την ηλικία και οδη- γεί σε πολύπλοκες κλινικές εικόνες. Όταν βρίσκονται αντι- μέτωποι με αυτές, οι γιατροί της πρωτοβάθμιας φροντίδας πρέπει να παραπέμπουν στους γηριάτρους. Στην προσέγγιση ICOPE, οι γηρίατροι είναι μέρος της διε- πιστημονικής ομάδας που είναι υπεύθυνη για τη φροντί- δα των ηλικιωμένων, βοηθούν στην εποπτεία των ομάδων πρωτοβάθμιας φροντίδας και παρεμβαίνουν όταν απαιτεί- ται εξειδικευμένη φροντίδα. Η διασύνδεση με την εξειδικευμένη γηριατρική φροντίδα είναι επί- σης κρίσιμη. Τα συστήματα υγείας χρειάζεται να εξασφαλίσουν ότι οι άνθρωποι έχουν έγκαιρη πρόσβαση στην εξειδίκευση και στην επείγουσα φροντίδα όταν αυτό χρειάζεται. Υπάρχουν ισχυρές απο- δείξεις ότι οι εξειδικευμένες μονάδες για την γηριατρική φροντίδα οξέων περιστατικών παρέχουν φροντίδα υψηλότερης ποιότητας, με μικρότερη διάρκεια νοσηλείας και χαμηλότερα κόστη από ό,τι η φροντίδα του γενικού νοσοκομείου. Μονοπάτια Γενικής Φροντίδας Προσωποκεντρική αξιολόγηση και μονοπάτια στη πρωτοβάθμια φροντίδα ΒΗΜΑ 5 Εμπλέξτε τις κοινότητες και υποστηρίξτε τους φροντιστές Η παροχή φροντίδας μπορεί να είναι απαιτητική, και οι φροντιστές ανθρώπων με έκπτωση ικανοτήτων συχνά νιώθουν απομονωμέ- νοι και διατρέχουν υψηλό κίνδυνο ψυχολογικής δυσφορίας και κα- τάθλιψης. Ένα εξατομικευμένο πλάνο φροντίδας πρέπει να περι- λαμβάνει τεκμηριωμένες παρεμβάσεις για την υποστήριξη των φροντιστών. Οι φροντιστές χρειάζονται επίσης βασική πληροφόρη- ση σχετικά με τα προβλήματα υγείας του ηλικιωμένου και εκπαί- δευση, προκειμένου να αναπτύξουν ένα εύρος πρακτικών δεξιοτή- των, όπως για παράδειγμα σχετικά με το πώς θα μεταφέρουν το άτο- μο από την καρέκλα στο κρεβάτι με ασφάλεια και πώς να το βοη- θούν να κάνει μπάνιο. Ο ηλικιωμένος και ο φροντιστής πρέπει να λαμβάνουν πληροφό- ρηση σχετικά με τους διαθέσιμους σε αυτούς κοινοτικούς πόρους. Οι ευκαιρίες για τη συμμετοχή της κοινότητας και της γειτονιάς πιο άμεσα στην υποστηρικτική φροντίδα πρέπει να διερευνώνται, ιδί- ως με την ενθάρρυνση του εθελοντισμού και της συνεισφοράς από ηλικιωμένα μέλη της κοινότητας.. Τέτοιες δραστηριότητες μπορούν συχνά να πραγματοποιηθούν στους συλλόγους και στις ομάδες στις οποίες συμμετέχουν οι ηλικιωμένοι. Το Κεφάλαιο 11 περιλαμβάνει ένα μονοπάτι φροντίδας για την αξι- ολόγηση της επιβάρυνσης των φροντιστών και την αντιμετώπιση των αναγκών φροντίδας και υποστήριξης των ίδιων των μη αμειβό- μενων φροντιστών. Η προσέγγιση ICOPE βασίζεται στην κοινότητα ή στην πρωτοβάθμια φροντίδα, που μπορεί να είναι προσβάσιμη στον μεγαλύτερο δυ- νατό αριθμό ατόμων. Ταυτόχρονα, η προσέγγιση απαιτεί ισχυρή δι- ασύνδεση με εξειδικευμένες δομές και δομές τριτοβάθμιας φρο- ντίδας για όσους τη χρειάζονται, όπως π.χ. με διατροφολόγους και φαρμακοποιούς. Η εφαρμογή κινητής (app) του εγχειρίδιου ICOPE Εφαρμογές για κινητές συσκευές θα είναι διαθέσιμες για να καθοδηγούν τους εργαζομένους στον τομέα της υγείας και της κοινωνικής φροντίδας σε όλα τα βήματα που πρέπει να διεκπεραιώσουν, από τον έλεγχο έως την αξιολόγηση, και μέχρι το σχεδιασμό ενός εξατομικευμένου πλάνου φροντί- δας. Η εφαρμογή θα παράγει επίσης μια εκτυπώσιμη περί- ληψη των αποτελεσμάτων της αξιολόγησης και των παρεμ- βάσεων που θα συμπεριληφθούν στο σχέδιο φροντίδας σε μορφή PDF. Μονοπάτια Γενικής Φροντίδας Προσωποκεντρική αξιολόγηση και μονοπάτια στη πρωτοβάθμια φροντίδα Πολυφαρμακία Η πολυφαρμακία συχνά περιγράφεται ως η χρήση πέντε ή περισσό- τερων φαρμάκων ταυτόχρονα, και συχνά σχετίζεται με ανεπιθύμητες ενέργειες φαρμάκων. Αυτή η χρήση πολλαπλών φαρμάκων αυξάνει τον κίνδυνο αρνητικών συνεπειών για την υγεία, μπορεί να οδηγήσει σε περιττές απώλειες της ενδογενούς ικανότητας, και αποτελεί μια αι- τία επείγουσας εισαγωγής στο νοσοκομείο. Οι ηλικιωμένοι που επισκέ- πτονται πολλούς επαγγελματίες υγείας ή που έχουν νοσηλευθεί προ- σφάτως, διατρέχουν μεγαλύτερο κίνδυνο πολυφαρμακίας. Ένα ηλικιω- μένο άτομο με πολυνοσηρότητες είναι πιθανό να επηρεαστεί περισσό- τερο από τις σχετιζόμενες με την ηλικία φυσιολογικές μεταβολές που πιθανώς να μεταβάλουν τη φαρμακοκινητική και φαρμακοδυναμική των φαρμάκων που λαμβάνουν. Επειδή η πολυφαρμακία μπορεί να συμβάλει σε απώλειες σε πολλα- πλούς τομείς της ενδογενούς ικανότητας, οι προσωποκεντρικές αξιο- λογήσεις θα πρέπει να περιλαμβάνουν ανασκόπηση των φαρμάκων που λαμβάνει το ηλικιωμένο άτομο. Η πολυφαρμακία μπορεί να μειωθεί με την εξάλειψη των περιττών, αναποτελεσματικών φαρμάκων καθώς και των φαρμάκων με κοινό αποτέλεσμα. Πως να συνταγογραφήσετε κατάλληλα και να μειώσετε τα λάθη της φαρμακευτικής αγωγής • πάρτε ένα πλήρες ιστορικό φαρμακευτικής αγωγής, εξετάστε εάν τα φάρμακα μπορεί να επηρεάσουν την ικανότητα, • αποφύγετε τη συνταγογράφηση πριν γίνει η διάγνωση, εκτός από περιπτώσεις έντονου οξέος πόνου, • επανεξετάζετε τα φάρμακα τακτικά και πριν από τη συνταγογράφηση νέας φαρμακευτικής αγωγής, • βεβαιωθείτε ότι γνωρίζετε τη δράση, τις ανεπιθύμητες ενέργειες, τις αλληλεπιδράσεις φαρμάκων, τις απαιτήσεις παρακολούθησης και την τοξικότητα των συνταγογραφούμενων φαρμάκων, • προσπαθήστε να χρησιμοποιήσετε ένα φάρμακο για τη θεραπεία δυο ή περισσοτέρων παθήσεων, • δημιουργήστε μια καρτέλα χαπιών για τον ασθενή και εκπαιδεύστε τον ασθενή και το φροντιστή σχετικά με το κάθε φάρμακο. Εάν έχετε αμφιβολίες σχετικά με το εάν ένα φάρμακο μπορεί να διακοπεί με ασφάλεια, απευθυνθείτε σε ένα κατάλληλο ειδικό. Μονοπάτια Γενικής Φροντίδας Προσωποκεντρική αξιολόγηση και μονοπάτια στη πρωτοβάθμια φροντίδα Η έκπτωση γνωστικών λειτουργιών εκδηλώνεται ως αυξανόμενη απώλεια μνήμης, απώλεια της προσοχής και μειωμένη ικανότητα επί- λυσης προβλημάτων. Η ακριβής αιτία μπορεί να μην είναι γνωστή, ωστόσο η έκπτωση γνωστικών λειτουργιών μπορεί να συνδέεται με τη γήρανση του εγκεφάλου, με νοσήματα (π.χ. καρδιαγγειακά νοσήμα- τα όπως είναι η υπέρταση και το εγκεφαλικό, η με τη νόσο Αλτσχάιμερ), ή ακόμα και με περιβαλλοντολογικούς παράγοντες όπως είναι η έλ- λειψη σωματικής άσκησης, ο κοινωνικός αποκλεισμός και το χαμηλό μορφωτικό επίπεδο. Η έκπτωση γνωστικών λειτουργιών προκαλεί μεγαλύτερη ανησυχία όταν αρχίζει να επηρεάζει την ικανότητα του ατόμου να λειτουργεί απο- τελεσματικά στο περιβάλλον του, δηλαδή όταν το άτομο αναπτύσσει άνοια. Αυτό το μονοπάτι στοχεύει να εφαρμοστεί στους ηλικιωμένους με κά- ποιο βαθμό έκπτωσης γνωστικών ικανοτήτων, που όμως δεν έχουν άνοια. Οι επαγγελματίες υγείας πρέπει να είναι ικανοί να εκτιμήσουν την ανάγκη για κοινωνική φροντίδα και υποστήριξη (βλ. Κεφάλαιο 10). ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Η έκπτωση στη γνωστική ικανότητα μπορεί να ελαχιστοποιηθεί και κάποιες φορές να αναστραφεί μέσα από μια γενικευμένη προσέγγιση ενός πιο υγιεινού τρόπου ζωής, γνωστικής διέγερσης και κοινωνικής συμμετοχής • Η θεραπεία νοσημάτων, όπως ο σακχαρώδης διαβήτης και η υπέρτα- ση, μπορεί να αποτρέψει την έκπτωση στη γνωστική λειτουργία • Η έκπτωση σε άλλα πεδία της ενδογενούς ικανότητας, όπως η ακοή και η κινητική ικανότητα, μπορεί να επηρεάσει την γνωστική λειτουρ- γία και θα πρέπει επίσης να αξιολογείται και να αντιμετωπίζεται. • Προκειμένου να σχεδιαστούν και να υλοποιηθούν σύνθετες παρεμ- βάσεις για ένα άτομο με άνοια, χρειάζεται εξειδικευμένη φροντίδα. ΜΟΝΟΠΑΤΙΑ ΦΡΟΝΤΙΔΑΣ ΓΙΑ ΤΗ ΔΙΑΧΕΙΡΙΣΗ ΤΗΣ ΕΚΠΤΩΣΗΣ ΓΝΩΣΤΙΚΩΝ ΛΕΙΤΟΥΡΓΙΩΝ Γνωστική Ικανότητα Γνωστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείρηση της έκπτωσης γνωστικών λειτουργιών Απλό τεστ μνήμης και προσανατολισμού 1. Απομνημόνευση τριών λέξεων: Ζητήστε από το άτομο να απομνημονεύσει τρεις λέξεις που θα του πείτε. Χρησιμοποιείστε απλές, χειροπιαστές λέξεις όπως «λουλούδι», «πόρτα», «ρύζι». 2. Προσανατολισμός στον χρόνο και τον χώρο: Έπειτα, ρωτήστε «ποια είναι η πλήρης ημερομηνία σήμε- ρα;» και «Πού βρίσκεστε αυτήν τη στιγμή;» (σπίτι, κλινική κ.λπ.) 3. Ανάκληση τριών λέξεων: Τώρα ζητήστε από το άτομο να επαναλάβει τις τρεις λέξεις που αναφέρατε. Περνά ή αποτυγχάνει; Εάν ένα άτομο δεν μπορεί να απαντήσει μία από τις δύο ερω- τήσεις του προσανατολισμού Ή δεν μπορεί να θυμηθεί και τις τρεις λέξεις, είναι πιθανή η έκπτωση των γνωστικών λει- τουργιών και απαιτείται περαιτέρω αξιολόγηση. * Ανεπάρκεια βιταμινών, διαταραχή των ηλεκτρολυτών, σοβαρή αφυδάτωση ** Καρδιαγγειακοί παράγοντες κινδύνου: υπέρταση, υψηλή χο- ληστερόλη, σακχαρώδης διαβήτης, κάπνισμα, παχυσαρκία, καρ- διακά νοσήματα, προηγούμενα εγκεφαλικά ή παροδικά ισχαιμι- κά επεισόδια. Μείωση κινδύνου έκπτωσης γνωστικών λειτουρ- γιών και άνοιας: Κατευθυντήριες οδηγίες ΠΟΥ – https://apps. who.int/iris/handle/10665/312180 Ν Α Ι ΑΠΟΤΥΓΧΑΝΕΙ ΑΠΟΤΥΓΧΑΝΕΙ Π Ε Ρ Ν Α Π Ε Ρ Ν Α ΡΩΤΗΣΤΕ ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΓΝΩΣΤΙΚΗ ΙΚΑΝΟΤΗΤΑ ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ g 4.1 ΕΛΕΓΞΤΕ ΓΙΑ ΕΚΠΤΩΣΗ ΓΝΩΣΤΙΚΩΝ ΛΕΙΤΟΥΡΓΙΩΝ ΟΧΙ Έχετε προβλήματα μνήμης ή προσανατολισμού (όπως π.χ. να μη γνωρίζετε πού βρίσκετε κάποιος ή τι μέρα είναι;) απίθανο να υπάρχει έκπτωση γνωστικών λειτουργιών μη πιθανή έκπτωση γνωστικής λειτουργίαςπιθανή έκπτωση γνωστικής λειτουργίας Ενισχύστε γενικές συμβου- λές υγείας και τρόπου ζωής ή τη συνήθη φροντίδα Πολυδιάστατη άσκηση g 5.1 Παράσχετε γνωστική διέγερση g 4.2 Παράσχετε ολοκληρωμένη διαχείριση των νοσημάτων Μειώστε τους καρδιαγγειακούς παράγοντες κινδύνου: - προτείνετε τη διακοπή καπνίσματος - αντιμετωπίστε την υπέρταση και τον διαβήτη - παράσχετε διατροφικές συμβουλές για έλεγχο του βάρους - ΔΥΣΘΡΕΨΙΑ * - ΠΑΡΑΛΗΡΗΜΑ -ΠΟΛΥΦΑΡΜΑΚΙΑ - ΑΓΓΕΙΑΚΑ ΕΓΚΕΦΑΛΙΚΑ ΝΟΣΗΜΑΤΑ - ΚΑΤΑΘΛΙΠΤΙΚΑ ΣΥΜΠΤΩΜΑΤΑ Βλ. μονοπάτι δυσθρεψίας g αναγνωρίστε την αιτία (ιατρική, δηλητηρίαση από ουσί- ες ή χρήση φαρμάκων) και αντιμετωπίστε Αναθεωρήστε τη φαρμακευτική αγωγή και αποσύρετε αναλόγως Αξιολογήστε το ιστορικό των αγγειακών εγκεφαλικών (αγγειακό/παροδικό ισχαιμικό εγκεφαλικό) και προλάβετε περαιτέρω συμβάντα Βλ. μονοπάτι καταθλιπτικών συμπτωμάτων g Αξιολογήστε την ανάγκη για κοινωνική φροντίδα και υποστήριξη g Αν η γνωστική έκπτωση επηρεάζει την αυτονομία και την ανεξαρτησία, βλ. το κεφάλαιο περί άνοιας στον οδηγό παρέμβασης mhGAP https://iris.who.int/handle/10665/250239 Παράσχετε ατομική φροντίδα και υποστήριξη με τις δραστηριότητες της καθημερινής ζωής Προσφέρετε συμβουλές για τη διατήρηση της αυτονομίας στην τουαλέτα Αξιολογήστε τον φόρτο ή την επιβάρυνση του φροντιστή (βλ. μονοπάτι φροντιστών) g Αναπτύξτε πλάνο κοινωνικής φροντίδας και υποστήρι- ξης που περιλαμβάνει υποστήριξη των φροντιστών 6 10 11 9 ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ ΑΠΟΤΡΕΨΤΕ ΠΕΡΑΙΤΕΡΩ ΕΚΠΤΩΣΗ ΤΗΣ ΓΝΩΣΤΙΚΗΣ ΙΚΑΝΟΤΗΤΑΣ ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΚΑΡΔΙΑΓΓΕΙΑΚΑ ΝΟΣΗΜΑΤΑ ΚΑΙ ΠΑΡΑΓΟΝΤΕΣ ΚΙΝΔΥΝΟΥ** Ν Α Ι Γνωστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείρηση της έκπτωσης γνωστικών λειτουργιών ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ • Διάγνωση και θεραπεία της άνοιας • Διαχείριση των πολλαπλών σχετιζόμενων νοσημάτων, όπως είναι το παραλήρημα, οι αγγειακές εγκεφαλικές και οι καρδιαγγειακές νόσοι. ΠΑΡΑΔΕΙΓΜΑΤΑ ΕΡΓΑΛΕΙΩΝ ΑΞΙΟΛΟΓΗΣΗΣ ΤΗΣ ΓΝΩΣΤΙΚΗΣ ΛΕΙΤΟΥΡΓΙΑΣ ΓΙΑ ΧΡΗΣΗ ΣΤΗΝ ΠΡΩΤΟΒΑΘΜΙΑ ΦΡΟΝΤΙΔΑ ΥΓΕΙΑΣ Τι είναι η άνοια; Η άνοια είναι ένα χρόνιο και προοδευτικό σύνδρομο, που οφείλεται σε αλλαγές στον εγκέφαλο. Η άνοια έχει ως αποτέλεσμα την έκπτωση της γνωστικής λειτουργίας και παρεμποδίζει τις δραστηριότητες της καθημερινής ζωής, όπως το πλύσιμο, το ντύσιμο, η λήψη τροφής, η ατομική υγιεινή και οι δραστηριότητες που σχετίζονται με την τουαλέτα. Περισσότερες πληροφορίες: Οδηγός παρέμβασης mhGAP του ΠΟΥ: https://apps.who.int/iris/handle/10665/250239 ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΓΝΩΣΤΙΚΗ ΛΕΙΤΟΥΡΓΙΑ Η περισσότερο εις βάθος αξιολόγηση της γνωστικής λειτουργίας χρησι- μοποιεί, εφόσον είναι δυνατό, σταθμισμένα σε τοπικό επίπεδο εργαλεία. Κάτω δεξιά, παρατίθεται μια λίστα επιλογών για την αξιολόγηση της γνω- στικής λειτουργίας σε ηλικιωμένους στο πλαίσιο της πρωτοβάθμιας φρο- ντίδας υγείας Δεν έχει πάει σχολείο. Σχεδόν όλες οι προτυποποιημένες αξιολογήσεις της γνωστικής λειτουργίας για τη διαλογή και τη διάγνωση της γνωστικής διαταραχής, προϋποθέτουν ένα ελάχιστο χρονικό διάστημα σχολικής εκ- παίδευσης. Αν κάποιο άτομο έχει λιγότερο από πέντε ή έξι χρόνια σχολι- κής εκπαίδευσης, ή καθόλου σχολική εκπαίδευση, η γνωστική αξιολό- γηση μπορεί να έχει περιορισμούς. Σε αυτή την περίπτωση η αξιολόγηση θα πρέπει να βασίζεται στη συνέντευξη και στην κλινική εκτίμηση. Για αυ- τά τα άτομα, συστήνεται η ένταξη σε ένα πρόγραμμα εκπαίδευσης ενηλί- κων (εάν είναι διαθέσιμο) καθώς προάγει τη γνωστική υγεία. Εάν δεν υπάρχουν προτυποποιημένα εργαλεία αξιολόγησης, ή δεν είναι κατάλληλα, ο επαγγελματίας υγείας μπορεί να ρωτήσει το άτομο καθώς και κάποιον που το γνωρίζει καλά, σχετικά με προβλήματα με την μνή- μη , τον προσανατολισμό, το λόγο και τη γλώσσα, και σχετικά με δυσκολί- ες στην εκτέλεση βασικών του ρόλων και δραστηριοτήτων της καθημε- ρινής ζωής. Η αποτυχία στη γνωστική αξιολόγηση ή η αναφορά προβλημάτων μνή- μης ή προσανατολισμού υποδεικνύουν γνωστική διαταραχή. Ένα τέτοιο άτομο πρέπει να αξιολογηθεί σχετικά με δυσκολίες στις δραστηριότητες της καθημερινής ζωής (ADL), ή στις σύνθετες δραστηριότητες της καθη- μερινής ζωής (IADL). Αυτές είναι σημαντικές πληροφορίες για τον σχεδι- ασμό των παρεμβάσεων κοινωνικής φροντίδας και υποστήριξης, ως μέ- ρος του εξατομικευμένου πλάνου φροντίδας. Αν η έκπτωση της γνωστικής λειτουργάς επηρεάζει την ικανότητα του ηλικιωμένου να λειτουργήσει αποτελεσματικά μέσα στο περιβάλλον του, τότε μπορεί να απαιτείται μια εξειδικευμένη αξιολόγηση για τη δι- άγνωση της άνοιας ή της νόσου Αλτσχάιμερ (η πιο συχνή αιτία άνοιας). Πρωτόκολλα για την αξιολόγηση και τη διαχείριση της άνοιας βρίσκονται στον Οδηγό Παρεμβάσεων του WHO mhGAP Intervention Guide, στη δι- εύθυνση https://apps.who.int/iris/handle/10665/250239 ΕΡΓΑΛΕΙΟ/ΔΟΚΙΜΑΣΙΑ ΠΛΕΟΝΕΚΤΗΜΑΤΑ ΜΕΙΟΝΕΚΤΗΜΑΤΑ ΧΡΟΝΙΚΗ ΔΙΑΡΚΕΙΑ Mini-Cog 🔗 http://mini-cog.com/wp-content/uploads/2015/ 12/Universal-Mini-Cog-Form-011916.pdf pdf Σύντομο, ελάχιστη επιρροή από τη γλώσσα, την εκπαίδευση και τη φυλή Η χρήση διαφορετικής λίστας λέξεων μπορεί να επηρεάσει την βαθμολογία Γνωστική Αξιολόγηση του Μόντρεαλ (Montreal Cognitive Assessment – MoCA) 🔗 https://www.mocatest.org/ Μπορεί να διακρίνει την ήπια γνωστική διαταραχή, είναι διαθέσιμο σε πολλές γλώσσες Υπάρχει επιρροή από το εκπαι- δευτικό και πολιτισμικό επίπεδο, περιορισμένα δημοσιευμένα δε- δομένα Σύντομη εξέταση της νοητικής κατάστασης (Mini- Mental State Examination – MMSE) 🔗 https://www.parinc.com/products/pkey/237 Χρησιμοποιείται και έχει μελετηθεί εκτενώς Υπόκειται σε επιρροή από την ηλικία και το πολιτισμικό επίπεδο του ατόμου, φαινόμενο οροφής Αξιολόγηση της Γνωστικής Λειτουργίας από τον Γενικό Ιατρό (GPCOG) 🔗 http://gpcog.com.au/index/downloads Υπάρχει ελάχιστη επιρροή από το εκπαιδευτικό και πολιτισμικό επίπεδο, διαθέσιμο σε πολλές γλώσσες Μπορεί να είναι ιδιαίτερα απαιτητικό να πάρει κάποιος στοιχεία από κάποιον πληροφοριοδότη λεπτά λεπτά λεπτά λεπτά Ένα σημαντικό βήμα, πριν από οποιαδήποτε διαγνωστική προσέγγιση για την έκπτωση της γνωστικής λειτουργίας, είναι η αξιολόγηση της παρουσίας οποιασδήποτε σχετιζόμενης νόσου και η θεραπεία αυτής κατά προτεραιότητα. 4.1 ΝΟΣΗΜΑΤΑ ΚΑΙ ΚΑΤΑΣΤΑΣΕΙΣ ΠΟΥ ΠΡΟΚΑΛΟΥΝ ΣΥΜΠΤΩΜΑΤΑ ΣΧΕΤΙΖΟΜΕΝΑ ΜΕ ΤΗΝ ΓΝΩΣΤΙΚΗ ΛΕΙΤΟΥΡΓΙΑ ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΑ ΣΧΕΤΙΖΟΜΕΝΑ ΝΟΣΗΜΑΤΑ Η αποκάλυψη μιας αναστρέψιμης ιατρικής αιτίας της έκ- πτωσης των γνωστικών λειτουργιών περιλαμβάνει μια πλήρη διαγνωστική διαδικασία. Ενδεχομένως να απαιτεί- ται η διερεύνηση αρκετών διαφορετικών δυνητικών εξη- γήσεων των συμπτωμάτων προκειμένου να καταλήξετε σε μια ακριβή προσέγγιση για το πλάνο φροντίδας. Συνηθισμένες, αναστρέψιμες καταστάσεις που προκαλούν έκπτω- ση της γνωστικής λειτουργίας περιλαμβάνουν την αφυδάτωση, τη δυσθρεψία, τις λοιμώξεις καθώς και προβλήματα με τη φαρμακευτι- κή αγωγή. Με την κατάλληλη αντιμετώπιση αυτών των καταστάσε- ων, τα συμπτώματα που αφορούν την γνωστική λειτουργία θα υπο- χωρήσουν. Σοβαρή αφυδάτωση. Η σοβαρή αφυδάτωση και άλλα διατροφικά προβλήματα μπορεί να προκαλέσουν οξύ συγχυτικό επεισόδιο (ντε- λίριο) (που μοιάζει με άνοια), και, σε σοβαρές περιπτώσεις, θάνατο. Οξύ συγχυτικό επεισόδιο (ντελίριο/ παραλήρημα). Το παραλήρη- μα είναι μια απότομη και δραστική απώλεια της ικανότητας συγκέ- ντρωσης. Τα άτομα επίσης μπερδεύονται σε ακραίο βαθμό σχετικά με το πού βρίσκονται και τι ώρα είναι. Το παραλήρημα εμφανίζεται σε σύντομο χρονικό διάστημα και έχει την τάση να έρχεται και να φεύγει κατά τη διάρκεια της ημέρας. Μπορεί να προκύψει ως αποτέλεσμα κάποιας οξείας οργανικής αιτίας, όπως μια λοίμωξη, κάποιου φαρ- μάκου, μεταβολικών διαταραχών (όπως υπογλυκαιμία ή υπονατρι- αιμία), δηλητηρίασης από ουσίες ή διακοπής ουσιών. Πολυφαρμακία. Δυο ή περισσότερα φάρμακα μπορεί να αλληλεπι- δρούν και να προκαλούν ανεπιθύμητες ενέργειες (βλ. κουτί 3 στο Κεφάλαιο 3, σελ. 18). Τα ηρεμιστικά και τα υπνωτικά είναι τα φάρμα- κα που ευθύνονται πιο συχνά για νοητικές διαταραχές στους ηλικιω- μένους. Μείζονα χειρουργεία και γενική αναισθησία. Οι μείζονες χειρουργι- κές επεμβάσεις και η γενική αναισθησία είναι αναγνωρισμένοι κίν- δυνοι για έκπτωση των γνωστικών λειτουργιών. Οι επαγγελματίες υγείας θα πρέπει να ρωτούν εάν η έκπτωση της γνωστικής λειτουρ- γίας ακολούθησε κάποιο μείζον χειρουργείο. Αν έχει συμβεί αυτό, το άτομο αυτό θα διατρέχει μεγαλύτερο κίνδυνο για περαιτέρω έκπτω- ση της γνωστικής λειτουργίας μετά από κάποιο επόμενο μείζον χει- ρουργείο. Αυτός ο αυξημένος κίνδυνος θα πρέπει να αναγνωρίζεται και να συζητείται με τη χειρουργική ομάδα και τον αναισθησιολόγο πριν από κάποιο επόμενο χειρουργείο ή αναισθησία. Αγγειακή εγκεφαλική νόσος. Η αγγειακή νόσος στον εγκέφαλο σχε- τίζεται στενά με την έκπτωση της γνωστικής λειτουργίας. Εάν ο ασθε- νής έχει ιστορικό αγγειακού εγκεφαλικού/μικρής έκτασης εγκεφα- λικού, παροδικού ισχαιμικού εγκεφαλικού επεισοδίου, τότε η πρό- ληψη περαιτέρω συμβάντων είναι η πρωταρχική προσέγγιση για να σταματήσει η περαιτέρω έκπτωση της γνωστικής λειτουργίας. Γνωστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείρηση της έκπτωσης γνωστικών λειτουργιών ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗΝ ΕΚΠΤΩΣΗ ΤΩΝ ΓΝΩΣΤΙΚΩΝ ΛΕΙΤΟΥΡΓΙΩΝ • Άτομα με έκπτωση γνωστικών λειτουργιών μπορούν να επωφεληθούν από γνωστική διέγερση. • Άλλες παρεμβάσεις ICOPE, όπως η πολυδιάστατη άσκηση (βλ. κεφάλαιο 5, περιορισμένη κινητικότητα), συνεισφέρουν επίσης στην υγεία του εγκε- φάλου . g 5 • Απώλειες σε άλλα πεδία της ενδογενούς ικανότητας, ειδικότερα στην ακοή, στην όραση και στη διάθεση, μπορούν να επηρεάσουν τη γνωστική λειτουργία. Για να επιτύχουμε το βέλτιστο αποτέλεσμα, ενδεχομένως αυ- τά να χρειαστεί να αντιμετωπιστούν. Τα άτομα με έκπτωση της γνωστικής λειτουργίας, διαφέρουν ως προς το μοτίβο με το οποίο εμφανίζουν έκπτω- ση της λειτουργικότητας στα διαφορετικά πεδία. 4.2 ΓΝΩΣΤΙΚΗ ΔΙΕΓΕΡΣΗ Η γνωστική διέγερση μπορεί να επιβραδύνει την έκπτωση των γνωστικών ικανοτήτων (7). Η γνωστική διέγερση στοχεύει στη διέγερση των συμμετε- χόντων μέσω γνωστικών δραστηριοτήτων και ανάκλησης, της διέγερσης πολλαπλών αισθήσεων και της επαφής με άλλους ανθρώπους. Η γνωστική διέγερση μπορεί να προσφερθεί ατομικά ή σε ομάδα. Οι ομάδες μπορεί να είναι καλύτερες για κάποιους: η κοινωνική επαφή μέ- σα στην ομάδα μπορεί να βοηθήσει. Οι ομάδες μπορεί να είναι κατάλλη- λες και αποτελεσματικές αν όσοι είναι στην ομάδα μοιράζονται έναν κοινό σκοπό, όπως για παράδειγμα η βελτίωση της ικανότητας να βρίσκουν, να κατανοούν και να αξιοποιούν πληροφορίες και υπηρεσίες υγείας. Η συνηθισμένη προσέγγιση ομάδας περιλαμβάνει μέχρι 14 θεματικές συ- νεδρίες των 45 λεπτών περίπου, δυο φορές την εβδομάδα. Ένα άτομο που διευκολύνει τη διαδικασία, καθοδηγεί αυτές τις συνεδρίες. Συνήθως μια συνεδρία μπορεί να ξεκινήσει με μια μη γνωστική δραστηριότητα προθέρ- μανσης, και στη συνέχεια να προχωρήσει σε μια πληθώρα γνωστικών ερ- γασιών, που περιλαμβάνουν τον προσανατολισμό στην πραγματικότητα (για παράδειγμα ένας πίνακας που δείχνει πληροφορίες όπως το μέρος, η ημερομηνία και η ώρα). Οι συνεδρίες εστιάζουν σε διαφορετικά θέμα- τα, που επί παραδείγματι περιλαμβάνουν, την παιδική ηλικία, τη χρήση του χρήματος, πρόσωπα ή σκηνές. Αυτές οι δραστηριότητες αποφεύγουν σε γενικές γραμμές την ανάκληση γεγονότων, αλλά αντί για αυτό εστιά- ζουν σε ερωτήσεις, όπως «Τι κοινό έχουν αυτές οι λέξεις ή αυτά τα αντικεί- μενα;» Ποιοι μπορούν να διεξαγάγουν την γνωστική διέγερση; Σε χώρες υψη- λού εισοδήματος, είναι συνήθως κάποιος ψυχολόγος που πραγματοποιεί τη θεραπεία γνωστικής διέγερσης. Με προσαρμογή, μπορεί να διενεργη- θεί από κατάλληλα εκπαιδευμένους και υποστηριζόμενους μη ειδικούς. Ωστόσο, ο σχεδιασμός και η χορήγηση μιας εξατομικευμένης παρέμβα- σης για κάποιο άτομο με σημαντική έκπτωση, μπορεί να απαιτεί πιο λεπτο- μερή αξιολόγηση και σχεδιασμό – εργασίες που απαιτούν εξειδικευμένες δεξιότητες. Ως εκ τούτου, τα τοπικά πρωτόκολλα, θα πρέπει να περιλαμβά- νουν κριτήρια παραπομπής σε ειδικούς ψυχικής υγείας για θεραπεία γνω- στικής διέγερσης. Τα μέλη της οικογένειας και οι φροντιστές μπορούν να παίξουν σημαντι- κό ρόλο στη γνωστική διέγερση. Είναι σημαντικό να ενθαρρύνουμε τα μέ- λη της οικογένειας και τους φροντιστές να προσφέρουν σε τακτική βάση στους ηλικιωμένους πληροφορίες όπως η ημέρα, η ημερομηνία, ο και- ρός, η ώρα, τα ονόματα ανθρώπων κ.λπ. Αυτές οι πληροφορίες τους βοη- θάνε να παραμείνουν προσανατολισμένοι στο χρόνο και στο χώρο. Η πα- ροχή υλικού, όπως οι εφημερίδες, το ραδιόφωνο και προγράμματα στην τηλεόραση, άλμπουμ οικογενειακών φωτογραφιών και αντικείμενα του νοικοκυριού, μπορούν να προάγουν την επικοινωνία, να προσανατολί- σουν τον ηλικιωμένο σε τρέχοντα γεγονότα, να διεγείρουν αναμνήσεις και να διευκολύνουν το άτομο να μοιραστεί τις εμπειρίες του και να τους δώ- σει αξία. Γνωστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείρηση της έκπτωσης γνωστικών λειτουργιών Γνωστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείρηση της έκπτωσης γνωστικών λειτουργιών Αν η έκπτωση των γνωστικών λειτουργιών περιορίζει την αυτονομία και ανεξαρτησία κάποιου ατόμου, αυτό το άτομο είναι πιθανό να έχει σοβα- ρή ανάγκη κοινωνικής φροντίδας. Ένας επαγγελματίας υγείας μπορεί να βοηθήσει τους φροντιστές να διαμορφώσουν ένα πλάνο δραστηριο- τήτων της καθημερινής ζωής που μεγιστοποιεί την ανεξάρτητη δραστη- ριότητα, ενισχύει τη λειτουργικότητα, βοηθά στην προσαρμογή και ανά- πτυξη δεξιοτήτων και μειώνει την ανάγκη υποστήριξης. Τα μέλη της οικογένειας και οι φροντιστές μπορούν: • να προσφέρουν πληροφορίες προσανατολισμού, όπως η ημερομη- νία, τα τρέχοντα γεγονότα που αφορούν την κοινότητα, την ταυτότητα των επισκεπτών, τον καιρό, τα νέα των μελών της οικογένειας, • να ενθαρρύνουν και να κανονίζουν επαφές με φίλους και μέλη της οικογένειας στο σπίτι και στην κοινότητα, • να καταστήσουν και να διατηρήσουν το σπίτι ασφαλές, για να μειωθεί ο κίνδυνος πτώσεων και τραυματισμών, • να αναρτούν ταμπέλες στο σπίτι -για παράδειγμα για την τουαλέτα, το υπνοδωμάτιο- την εξώπορτα, ώστε να βοηθήσουν το άτομο να βρίσκει το δρόμο του και • να κανονίζουν εργοθεραπευτικές δραστηριότητες (κατάλληλες κατά περίπτωση με βάση τις ικανότητες του ατόμου) και να συμμετέχουν σε αυτές. ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Οι φροντιστές των ατόμων με σοβαρή έκπτωση των γνωστικών λειτουργιών έρχονται αντιμέτωποι με υψηλές απαιτήσεις. Αυτό το στρες μπορεί να θέσει σε κίνδυνο την υγεία τους. Βλ. Κεφάλαιο 11 σχετικά με την αντιμετώπιση των αναγκών των φροντιστών. g 11 Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας Κινητική Ικανότητα Η κινητικότητα είναι ένας κρίσιμος καθοριστικός παράγοντας για την υγιή γήρανση. Είναι σημαντική για τη διατήρηση της αυτονομίας και την πρόληψη εξάρτησης από φροντίδα. Η σωματική ικανότητα ενός ατόμου να μετακινείται από το ένα μέρος στο άλλο ονομάζεται κινητι- κή ικανότητα. Πολλοί ηλικιωμένοι και οι οικογένειές τους αποδέχονται τις απώλει- ες της κινητικής ικανότητας και τον σχετικό πόνο που προκαλεί ως αναπόφευκτες. Όμως δεν είναι. Πράγματι, υπάρχουν αποτελεσματι- κές στρατηγικές για τη βελτίωση και τη διατήρηση της κινητικότητας στους ηλικιωμένους. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Η περιορισμένη κινητικότητα είναι κάτι κοινό μεταξύ των ηλικιωμένων, αλλά δεν είναι αναπόφευκτη. • Οι εργαζόμενοι στον τομέα της υγειονομικής περίθαλψης σε κοινοτικό επίπεδο μπορούν να διεξάγουν έλεγχο για περιορισμένη κινητικότητα με απλές δοκιμασίες. • Ένα πρόγραμμα τακτικής άσκησης, προσαρμοσμένο στις ατομικές ικανότητες και ανάγκες, είναι η πιο σημαντική προσέγγιση για τη βελτίωση ή τη διατήρηση της κινητικής ικανότητας. • Η προσαρμογή του περιβάλλοντος και η χρήση βοηθητικών συσκευών είναι καλοί τρόποι διατήρησης της κινητικότητας, παρά τη μειωμένη κινητική ικανότητα. ΠΟΛΥΔΙΑΣΤΑΤΗ ΑΣΚΗΣΗ g 5.1 Ένα πολυδιάστατο πρόγραμμα άσκησης για άτομα με περιορισμένη κινητικότητα συνδυάζει την άσκηση και τη κυκλική προπόνηση (cross-training) με έμφαση σε βασικές μυϊκές ομάδες της πλάτης, των μηρών, της κοι- λιάς και του κάτω μέρους του σώματος. Ένα πολυδιάστατο πρόγραμμα άσκησης θα πρέπει να είναι προσαρμοσμένο ώστε να ταιριάζει στις ατομικές ικανότητες και ανάγκες. Το Vivifrail Project προσφέρει έναν πρακτικό οδηγό για την ανάπτυξη ενός προγράμ- ματος άσκησης, προσαρμοσμένο στις ικανότητες. http://www.vivifrail.com/resources Για τις γενικές συστάσεις του ΠΟΥ σχετικά με τη σωματι- κή δραστηριότητα δείτε το πλαίσιο στη σελίδα 30. Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας Είναι ικανός να ολοκληρώσει 5 εγέρσεις από την καρέκλα χωρίς χρήση χεριών εντός 14 δευτερολέπτων; Ν Α Ι Ν Α Ι Ο Χ Ι ΟΧΙ σε όλα Ενισχύστε γενικές συμβουλές υγείας και τρόπου ζωής ή τη συνήθη φροντίδα ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΚΙΝΗΤΙΚΟΤΗΤΑ ΕΛΕΓΞΤΕ ΓΙΑ ΑΠΩΛΕΙΕΣ ΚΙΝΗΤΙΚΟΤΗΤΑΣ ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ - ΠΟΛΥΦΑΡΜΑΚΙΑ - ΟΣΤΕΟΑΡΘΡΙΤΙΔΑ, ΟΣΤΕΟΠΟΡΩΣΗ ΚΑΙ ΑΛΛΕΣ ΠΑΘΗΣΕΙΣ ΟΣΤΩΝ ΚΑΙ ΑΡΘΡΩΣΕΩΝ - ΕΥΠΑΘΕΙΑ & ΣΑΡΚΟΠΕΝΙΑ - ΠΟΝΟΣ Δοκιμασία έγερσης από καρέκλα i 2 (SPPB ή άλλη δοκιμασία σωματικής επίδοσης) Περιορισμένη κινητικότητα (βαθμολογία SPPB 0–9 βαθμοί) Κανονική κινητικότητα (βαθμολογία SPPB 10–12 βαθμοί) Παράσχετε πολυδιάστατα πργράμματα άσκησης με στενή εποπτεία Εξετάστε την παραπομπή για αποκατάσταση Εξετάστε την αύξηση πρόσληψης πρωτεϊνών Εξετάστε και παράσχετε βοηθητικές συσκευές για την υποβοήθηση της κινητικότητας Συστήστε ένα πρόγραμμα πολυδιάστατης άσκησης στο σπίτι Υποστηρίξτε την αυτοδιαχείριση προκειμένου να αυξήσετε τη συμμόρφωση g 5.2 Αναθεωρήστε τη φαρμακευτική αγωγή με σκοπό τη μείωση g 5.3 Ολοκληρωμένη διαχείριση των νοσημάτων Εξετάστε τη διαχείριση πόνου g 5.4 Αξιολογήστε το φυσικό περιβάλλον για να μειώσετε τον κίνδυνο πτώσεων g 5.5 Συμπεριλάβετε παρεμβάσεις πρόληψης πτώσεων όπως π.χ. προσαρμογές του σπιτιού Εξετάστε και παράσχετε βοηθητικές συσκευές για υποβοήθηση της κινητικότητας g 5.6 Παράσχετε ασφαλείς χώρους για βάδιση Απαιτείται εξειδικευμένη φροντίδα Α. Θέση με τα πέλματα το ένα πλάι στο άλλο Για 10 δευτερόλεπτα 1 βαθμός Για λιγότερο από 10 δευτερόλεπτα 0 βαθμοί Δεν έγινε απόπειρα 0 βαθμοί Εάν δεν γίνει απόπειρα τερματίστε τις δοκιμασίες ισορροπίας. Β. Θέση με τα πέλματα μερικώς το ένα πίσω από το άλλο Για 10 δευτερόλεπτα 1 βαθμός Για λιγότερο από 10 δευτερόλεπτα 0 βαθμοί Δεν έγινε απόπειρα 0 βαθμοί Εάν δεν γίνει απόπειρα τερματίστε τις δοκιμασίες ισορροπίας. Γ. Θέση με τα πέλματα το ένα πίσω από το άλλο για 10 δευτερολεπτά 2 βαθμοί για 3-9,99 δευτερολεπυα 1 βαθμός για <3 δευτερόλεπτα 0 βαθμοί δεν έγινε απόπειρα 0 βαθμοί ΤΕΣΤ ΕΓΕΡΣΗΣ ΑΠΟ ΤΗΝ ΚΑΡΕΚΛΑ Ένα απλό τεστ μπορεί να καθορίσει εάν ένα ηλικιωμένο άτομο χρειάζεται περαιτέρω αξιολόγηση για περιορισμένη κινητικότητα. Οδηγίες: Ρωτήστε το άτομο, «Πιστεύετε ότι θα ήταν ασφαλές για εσάς να προσπαθήσετε να σηκωθείτε από την καρέκλα 5 φορές χωρίς να χρησιμο- ποιήσετε τα χέρια σας;». (Επιδείξτε στο άτομο). Εάν ΝΑΙ, ζητήστε τους: - να καθίσουν στο μέσο της καρέκλας - να σταυρώσουν και να κρατήσουν τα χέρια τους σταυρωμέ- να επάνω στο στήθος τους - να σηκωθούν στην πλήρη όρθια θέση και μετά να καθίσουν ξανά - να το επαναλάβουν πέντε φορές, όσο το δυνατόν γρηγορότερα χωρίς δι- ακοπή. Χρονομετρήστε πόσο διαρκεί το τεστ. Απαιτείται περαιτέρω αξιολόγηση εάν δεν μπορούν να σηκωθούν όρθιοι πέντε φορές εντός 14 δευτερολέπτων. SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) Ενώ είναι διαθέσιμο ένα ευρύ φάσμα δοκιμασιών σωματικής απόδοσης, συ- στήνεται το SPPB, καθώς έχει ανώτερες ιδιότητες μέτρησης και είναι χρήσι- μο για ένα ευρύ φάσμα ικανοτήτων. Το SPPB μετρά το χρόνο απόδοσης σε τρεις δοκιμασίες, καθεμία με βαθμολογία έως το τέσσερα, για να εξαχθεί μια βαθμολογία από το μηδέν (χειρότερη απόδοση) έως το 12 (καλύτερη απόδοση). Αρχικά, περιγράψτε κάθε δοκιμασία και ρωτήστε το άτομο εάν αισθάνεται ικανό να την διεκπεραιώσει. Εάν όχι, βαθμολογείστε αναλόγως και προχω- ρήστε στο επόμενο βήμα. 1. Δοκιμασίες ισορροπίας: Σταθείτε για 10 δευτερόλεπτα με τα πέλματα σε κάθε μία από τις τρεις ακόλουθες θέσεις. Χρησιμοποιείστε το άθροισμα των βαθμολογιών από τις τρεις θέσεις. 2. Δοκιμασία ταχύτητας βάδισης: χρονομετρήστε τη βάδιση στα 4 μέτρα. Χρόνος βάδισης 4 μέτρων: < 4,82 δευτερόλεπτα 4 βαθμοί 4,82 – 6,20 δευτερόλεπτα 3 βαθμοί 6,21 – 8,70 δευτερόλεπτα 2 βαθμοί > 8,70 δευτερόλεπτα 1 βαθμός Αδυναμία ολοκλήρωσης 0 βαθμοί 3. Δοκιμασία έγερσης από την καρέκλα: χρονομετρήστε την έγερση από την καρέκλα πέντε φορές < 11,19 δευτερόλεπτα 4 βαθμοί 11,2 – 13,69 δευτερόλεπτα 3 βαθμοί 13,7 – 16,69 δευτερόλεπτα 2 βαθμοί 16,7 – 59,9 δευτερόλεπτα 1 βαθμός > από 60 δευτερόλεπτα ή αδυναμία ολοκλήρωσης 0 βαθμοί Τελική βαθμολογία SPPB = το άθροισμα των βαθμολογιών των τριών παραπάνω δοκιμασίων. ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ Η κινητική ικανότητα θα πρέπει να αξιολογείται μαζί με άλλες πτυχές της ενδογενούς ικανότητας, όπως οι γνωστικές και οι αισθητηριακές, η ζωτικότητα και οι ψυχολογικές ικανότητες. Εάν οι σημαντικές εκπτώ- σεις της σωματικής ή της νοητικής ικανότητας ή οι συννοσηρότητες κα- θιστούν τη σύσταση της άσκησης πιο περίπλοκη, μπορεί να απαιτούνται εξειδικευμένες γνώσεις για τον σχεδιασμό ενός κατάλληλου προγράμ- ματος άσκησης. Η παραπομπή σε αποκατάσταση μπορεί ενδεχομένως να εξεταστεί. Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας Περισσότερες λεπτομέρειες για τη δοκιμασία SPPB: http://hdcs.fullerton.edu/csa/research/documents/sp- pbinstruction_scoresheet.pdf V ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ (ΠΕΡΑΙΤΕΡΩ ΠΛΗΡΟΦΟΡΙΕΣ) Εξειδικευμένη φροντίδα μπορεί επίσης να απαιτείται για ένα άτομο που έχει: • επίμονο πόνο που επηρεάζει τη διάθεση ή άλλους τομείς της λειτουργικότητας • σημαντικές βλάβες στις λειτουργίες των αρθρώσεων • κάταγμα οστού μετά από ελάχιστο τραύμα • κινδύνους για την ασφάλεια (βλ. πλαίσιο στην απέναντι σελίδα) • ανάγκη βοήθειας για την επιλογή μιας κατάλληλης βοηθητικής συσκευής για την κινητικότητα. ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΚΙΝΗΤΙΚΟΤΗΤΑ Η κινητικότητα μπορεί να αξιολογηθεί πιο ολοκληρωμένα βαθμολογώντας την απόδοση ενός ατόμου σε τρία απλά τεστ. Μαζί αυτές οι δοκιμασίες είναι γνωστές ως Short Physical Performance Battery -SPPB. Η δοκιμασία έγερσης από την καρέκλα είναι ένα τέτοιο τεστ. Πρέπει να επαναλαμβάνεται μετά από τις άλλες δύο δοκιμασίες: * η δοκιμασία ισορροπίας - διατήρηση ορθοστασίας για 10 δευτερόλε- πτα σε κάθε μια από τις τρεις θέσεις των πελμάτων. • η δοκιμασία ταχύτητας βάδισης - πόσο χρόνο χρειάζεται για να βαδί- σει τέσσερα μέτρα. Οι βαθμολογίες της κάθε δοκιμασίας αθροίζονται. Χαμηλότερες συνο- λικά βαθμολογίες σημαίνουν περιορισμένη κινητικότητα. Το μονοπάτι φροντίδας υποδεικνύει δυο διαφορετικούς τρόπους διαχείρισης, ανα- λόγως της συνολικής βαθμολογίας. Περισσότερες πληροφορίες για τις δοκιμασίες και τον τρόπο βαθμολό- γησής τους μπορείτε να βρείτε στην προηγουμένη σελίδα. Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας 5.1 ΠΟΛΥΔΙΑΣΤΑΤΑ ΠΡΟΓΡΑΜΜΑΤΑ ΑΣΚΗΣΗΣ Για όσους έχουν περιορισμένη κινητικότητα, ένα πολυδιάστατο πρό- γραμμα άσκησης θα πρέπει να είναι προσαρμοσμένο ώστε να ταιριάζει στις ατομικές ικανότητες και ανάγκες. Ένα πολυδιάστατο πρόγραμμα άσκησης για άτομα με περιορισμένη κινητικότητα μπορεί να περιλαμβάνει: • προπόνηση δύναμης/αντίστασης, που απαιτεί από τους μυς να δου- λέψουν υπό φορτίο, χρησιμοποιώντας βάρη, λάστιχα αντίστασης ή ασκήσεις σωματικού βάρους, όπως βαθιά καθίσματα, προβολές και ασκήσεις από καθιστή σε όρθια θέση. • αερόβια/καρδιαγγειακή προπόνηση, όπως γρήγορο περπάτημα ή ποδήλατο που αυξάνει τον καρδιακό ρυθμό έως ότου το άτομο λαχα- νιάσει ελαφρά αλλά να μπορεί να διατηρήσει μια συνομιλία. • προπόνηση ισορροπίας, η οποία προκαλεί το σύστημα της ισορροπί- ας, και περιλαμβάνει στατικές και δυναμικές ασκήσεις. Προοδευτικά μπορεί να εκτελείται σε διαφορετικές επιφάνειες και με μάτια ανοι- χτά και κλειστά. Παραδείγματα αυτής είναι η μονοποδική στήριξη και το περπάτημα φτέρνα - δάχτυλα σε ευθεία γραμμή. • προπόνηση ελαστικότητας, η οποία βελτιώνει την εκτασιμότητα των μαλακών ιστών, όπως οι μυς, και το εύρος κίνησης των αρθρώσεων. Παραδείγματα αυτής είναι οι διατάσεις και άλλες ασκήσεις yoga και pilates. Διατροφή. Η αυξημένη πρόσληψη πρωτεΐνης και άλλες διατροφικές παρεμβάσεις μπορούν να ενισχύσουν τα πλεονεκτήματα ενός προ- γράμματος άσκησης. Βλ. Κεφάλαιο 6 για τη δυσθρεψία. g Το Vivifrail project παρέχει έναν πρακτικό οδηγό για την ανάπτυξη ενός προσαρμοσμένου προγράμματος άσκησης. http://www.vivifrail.com/resources ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗΝ ΠΕΡΙΟΡΙΣΜΕΝΗ ΚΙΝΗΤΙΚΟΤΗΤΑ Ασφάλεια της άσκησης. Πριν δώσετε συμβουλές σχετικά με την άσκηση ή σχεδιάσετε ένα πρόγραμμα άσκησης ρωτήστε για προ- βλήματα υγείας που θα μπορούσαν να επηρεάσουν το χρόνο ή την ένταση της δραστηριότητας. Εάν το άτομο απαντήσει ναι σε οποιοδήποτε από τα ακόλουθα ερωτήματα, ένας εξειδικευμένος επαγγελματίας υγείας πρέπει να αναπτύξει ένα προσαρμοσμένο πρόγραμμα άσκησης. • Είχατε πόνο στο στήθος σε κατάσταση ηρεμίας; • Έχετε υποστεί έμφραγμα μέσα στους τελευταίους έξι μήνες; • Έχετε λιποθυμήσει ή χάσει τις αισθήσεις σας; • Έχετε πέσει τους τελευταίους 12 μήνες; • Έχετε σπάσει κάποιο οστό τον τελευταίο μήνα; • Σας κόβεται η ανάσα όταν κάνετε συνηθισμένες καθημερινές δραστηριότητες στο σπίτι, όπως για παράδειγμα όταν ντύνε- στε; • Έχετε κάποια ασθένεια των αρθρώσεων ή των μυών που περι- ορίζει την άσκηση; • Σας έχει συστήσει κάποιος επαγγελματίας της υγείας να περι- ορίσετε την άσκηση; Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας 6 Διαχείριση περιορισμών. Όταν ο πόνος περιορίζει την κινητικότητα, η ρύθμιση της σωματικής δραστηριότητας σε χρονικά διαστήματα που μπορεί να τον διαχειριστεί, και η αργή αύξηση των σωματικών απαιτήσεων βοηθάει στη δόμηση της σωματικής ανθεκτικότητας και στη διαχείριση του πόνου. Για άτομα με σοβαρά μειωμένη κινη- τικότητα, ένα ασκησιολόγιο στο κρεβάτι ή σε καθιστή θέση σε καρέ- κλα μπορεί να αποτελεί ένα σημείο εκκίνησης. Για άτομα με περι- ορισμούς στην γνωστική λειτουργία, όπως είναι η άνοια, ένα απλό και λιγότερο δομημένο πρόγραμμα ασκήσεων μπορεί να είναι κα- ταλληλότερο. ΠΑΓΚΟΣΜΙΕΣ ΚΑΤΕΥΘΥΝΤΗΡΙΕΣ ΟΔΗΓΙΕΣ ΤΟΥ ΠΟΥ ΓΙΑ ΤΗ ΣΩΜΑΤΙΚΗ ΔΡΑΣΤΗΡΙΟΤΗΤΑ Όλοι οι ηλικιωμένοι μπορούν να επωφεληθούν από συμβουλές σχετικά με τη σωματική δραστηριότητα που συστήνεται για την ηλικία τους, λαμβάνο- ντας υπ’ όψιν τα προβλήματα της υγείας τους. Αυτό το πλαίσιο συνοψίζει τις παγκόσμιες συστάσεις του ΠΟΥ για τη σωματική δραστηριότητα για άτομα ηλικίας 65 ετών και άνω. 3 Εβδομαδιαία, εκτελέστε τουλάχιστον 150 λεπτά αερόβιας σωματικής δραστηριότητας μέτριας έντασης ή τουλάχιστον 75 λεπτά εντατικής αε- ρόβιας δραστηριότητας ή έναν ισοδύναμο συνδυασμό. 3 Ασκηθείτε τουλάχιστον για 10 λεπτά τη φορά. 3 Για πρόσθετο όφελος, εκτελέστε 300 λεπτά μέτριας έντασης αερόβιας άσκησης ανά εβδομάδα ή 150 λεπτά εντατικής αερόβιας δραστηριότη- τας ανά εβδομάδα ή έναν ισοδύναμο συνδυασμό. 3 Εκτελέστε δραστηριότητες μυϊκής ενδυνάμωσης δυο ή περισσότερες ημέρες ανά εβδομάδα. 3 Εάν η κινητικότητα είναι κακή, εκτελέστε σωματική δραστηριότητα που ενισχύει την ισορροπία τρεις ή περισσότερες φορές την εβδομάδα. 3 Εάν δεν μπορείτε να ασκηθείτε όσο συστήνεται, γίνετε όσο πιο σωματι- κά δραστήριοι μπορείτε. 5.2 ΥΠΟΣΤΗΡΙΞΗ ΑΥΤΟΔΙΑΧΕΙΡΙΣΗΣ Η υποστήριξη της αυτοδιαχείρισης αυξάνει τη συμμόρφωση με ένα πολυδιάστατο πρόγραμμα άσκησης, καθώς και τα οφέλη αυτού. Τα άτομα των οποίων οι βαθμολογίες SPPB είναι μεταξύ 10 - 12, μπο- ρούν να ασκηθούν στο σπίτι και στην κοινότητα. Τα άτομα με πιο σο- βαρούς περιορισμούς κινητικότητας πιθανώς να χρειάζονται επί- βλεψη και καθοδήγηση κατά τη διάρκεια της άσκησης. Το εγχειρίδιο του ΠΟΥ στα κινητά τηλέφωνα για τη γήρανση (mAgeing) εξηγεί πώς μια εφαρμογή για κινητά τηλέφωνα μπορεί να λειτουργήσει συμπληρωματικά προς τη συνήθη φροντίδα των επαγγελματιών υγείας, υποστηρίζοντας την αυτοεξυπηρέτηση και την αυτοδιαχείριση. Για περισσότερες πληροφορίες: http://www.who.int/ageing/health-systems/mAgeing Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας Περισσότερες πληροφορίες: http://www.who.int/dietphysicalactivity/pa/en/index.html ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ V 5.3 ΠΟΛΥΦΑΡΜΑΚΙΑ Ορισμένα φάρμακα μπορεί να βλάψουν την κινητικότητα ή να επηρεά- σουν την ισορροπία, ωστόσο μερικές φορές είναι περιττά ή αναποτελε- σματικά για ένα συγκεκριμένο άτομο (8). Αυτά περιλαμβάνουν, αλλά δεν περιορίζονται, στα ακόλουθα: • αντισπασμωδικά • βενζοδιαζεπίνες • μη βενζοδιαζεπινικά υπνωτικά • τρικυκλικά αντικαταθλιπτικά • εκλεκτικός αναστολέας επαναπρόσληψης σεροτονίνης (SSRI) • αντικαταθλιπτικά • αντιψυχωσικά • οπιοειδή. Η εξάλειψη των περιττών, αναποτελεσματικών φαρμάκων καθώς και των φαρμάκων με όμοιο αποτέλεσμα μειώνει την πολυφαρμακία. Εάν έχετε αμφιβολίες σχετικά με το εάν ένα φάρμακο μπορεί να διακοπεί με ασφά- λεια, απευθυνθείτε στον κατάλληλο ειδικό. V 5.4 ΠΟΝΟΣ Αξιολογήστε τον πόνο. Ο έντονος πόνος που σχετίζεται με την κίνηση μπορεί να περιορίσει ή ακόμα και να αποτρέψει την άσκηση. Είναι χρήσι- μο να βαθμολογήσετε τη σοβαρότητα του πόνου που σχετίζεται με την κι- νητικότητα, τόσο για να βοηθήσετε στο σχεδιασμό ενός προγράμματος άσκησης όσο και για τη διαχείριση του πόνου. Μπορείτε να χρησιμοποι- ήσετε το ερωτηματολόγιο μέτρησης πόνου: https://www.aci.health. nsw.gov.au/__data/ assets/pdf_file/0015/212910/Brief_Pain_ Inventory_Final.pdf Μερικές από αυτές τις παρεμβάσεις μπορούν να είναι διαθέσιμες στην κοινότητα. Άλλες πιθανόν να απαιτούν παραπομπή σε μια κεντρικότερη δομή. Διαχειριστείτε τον πόνο (9). Οι μυοσκελετικές παθήσεις που επη- ρεάζουν την κινητικότητα συχνά περιλαμβάνουν επίμονο πόνο. Ωστόσο, σπάνια μπορεί να βρεθεί μια συγκεκριμένη βιολογική αι- τία επίμονου πόνου. Επομένως, μια προσέγγιση βέλτιστης πρακτι- κής για τη διαχείριση του πόνου αντιμετωπίζει πολλαπλούς παράγο- ντες που μπορεί να σχετίζονται με τον πόνο - σωματικούς παράγοντες (όπως η μυϊκή δύναμη, το εύρος κίνησης και η αντοχή), ψυχολογική ευεξία, διατροφή και ύπνο. Όπου ο πόνος αποτελεί σημαντικό εμπό- διο στην κίνηση και τη δραστηριότητα, ένας επαγγελματίας υγείας με εξειδικευμένες γνώσεις στη διαχείριση του θα πρέπει να αναπτύξει το σχέδιο διαχείρισης του πόνου. Οι παρεμβάσεις για τον πόνο περιλαμβάνουν: • αυτοδιαχείριση g 5.2 • ασκήσεις και άλλες σωματικές δραστηριότητες • φάρμακα που κυμαίνονται από την παρακεταμόλη και τα μη στε- ρο ειδή αντιφλεγμονώδη φάρμακα έως την γκαμπαπεπτίνη και τα οπιοειδή • θεραπεία με χειρισμούς όπως το μασάζ, ο χειρισμός των αρθρώσε- ων και η κινητοποίηση των αρθρώσεων • ψυχολογική θεραπεία και γνωσιακή συμπεριφορική θεραπεία (βλ. κεφάλαιο 9 για τα συμπτώματα κατάθλιψης) g • βελονισμό • ενέσεις στη σπονδυλική στήλη/ επισκληρίδια έκχυση • απονεύρωση με ραδιοσυχνότητες. Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας 9 ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ Ο ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Κάποιος με περιορισμένη κινητικότητα πιθανώς να χρειάζεται βοήθεια για να ανταποκριθεί στις καθημερινές δραστηριότητες. Το πρώτο βήμα είναι να εκτιμήσετε τις ανάγκες κοινωνικής φροντίδας (βλ. Κεφάλαιο 10). Οι συγκεκριμένες ανάγκες κοινωνικής φροντίδας για ηλικιωμένους με απώ- λεια κινητικότητας μπορεί να περιλαμβάνουν αυτές που αποκαλύπτονται από την αξιολόγηση του φυσικού τους περιβάλλοντος ή της ανάγκης τους για τη χρήση βοηθητικών συσκευών. Ένα πρόγραμμα άσκησης μπορεί να βοηθήσει στην πρόληψή των πτώσεων. Με συγκεκριμένη εκπαίδευ- ση ένας φροντιστής στην κοινότητα ή στην πρωτοβάθμια φροντίδα υγείας μπορεί να εκτιμήσει την οικία του ατόμου. Εάν η κατ’ οίκον επίσκεψη δεν είναι εφικτή, ένας εργαζόμενος στην πρωτοβάθμια φροντίδα υγείας μπο- ρεί να δώσει γενικές οδηγίες στο άτομο ή το φροντιστή του για το πώς να δημιουργήσει ένα πιο ασφαλές περιβάλλον στο σπίτι. Η πλήρης εκτίμηση και διαχείριση του κινδύνου πτώσεων ενός ατόμου απαιτεί εξειδικευμένη γνώση. 5.5 ΑΞΙΟΛΟΓΗΣΤΕ ΤΟ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ ΓΙΑ ΝΑ ΜΕΙΩΣΕΤΕ ΤΟΝ ΚΙΝΔΥΝΟ ΠΤΩΣΕΩΝ. Η αξιολόγηση του φυσικού περιβάλλοντος περιλαμβάνει τη διε- ρεύνηση του σπιτιού για την εύρεση πιθανών κινδύνων και τη δη- μιουργία προτάσεων. Παραδείγματα μπορεί να περιλαμβάνουν τη μείωση της ακαταστασίας, την αφαίρεση χαλαρών χαλιών, την εξο- μάλυνση εξογκωμάτων σε δάπεδα και σε σκαλοπάτια , τη μετακί- νηση επίπλων για τη δημιουργία μιας ευρείας ανεμπόδιστης δια- δρομής, τη βελτίωση του φωτισμού και τη βελτίωση της πρόσβα- σης στην τουαλέτα (ειδικά τη νύχτα προσθέτοντας, για παράδειγμα, λαβές στον τοίχο). Μια ράμπα προς την κύρια είσοδο θα διευκολύ- νει τους ανθρώπους που χρησιμοποιούν αναπηρικά αμαξίδια κα- θώς και άλλους που δυσκολεύονται να ανέβουν σκαλιά. Οι ειδικοί περιορισμοί της κινητικότητας ενός ατόμου θα αποτελέσουν οδη- γό για το ποιες περιβαλλοντολογικές προσαρμογές είναι οι πιο ση- μαντικές. 5.6 ΕΞΕΤΑΣΤΕ ΚΑΙ ΠΑΡΕΧΕΤΕ ΒΟΗΘΗΤΙΚΕΣ ΣΥΣΚΕΥΕΣ Τα άτομα με περιορισμούς στην κινητικότητα μπορεί να χρειάζονται βοη- θητικές συσκευές για να μετακινούνται. Βοηθητικές συσκευές είναι εκεί- νες των οποίων πρωταρχικός σκοπός είναι να διατηρήσουν ή να βελτιώ- σουν τη λειτουργική ικανότητα και την ανεξαρτησία ενός ατόμου, να δι- ευκολύνουν τη συμμετοχή του και να βελτιώνουν τη συνολική ευημερία του (10). Αυτές περιλαμβάνουν μπαστούνια, πατερίτσες, περιπατητήρες, αναπηρικά αμαξίδια και προσθετικές ή ορθωτικές συσκευές. Οι επιλογές μπορεί να περιορίζονται από τη διαθεσιμότητα και το κόστος, αλλά εάν εί- ναι διαθέσιμος ένας επαγγελματίας υγείας με γνώσεις φυσικοθεραπείας, αυτός μπορεί να δώσει τις καλύτερες συμβουλές για την επιλογή της κα- τάλληλης συσκευής και οδηγίες για την ασφαλή χρήση της. Η έκπτωση σε οποιονδήποτε τομέα της ενδογενούς ικανότη- τας μπορεί να αυξήσει τον κίνδυνο πτώσεων. Το φυσικό περιβάλλον και ο τρόπος με τον οποίο εκτελού- νται οι εργασίες και οι δραστηριότητες μπορεί να επίσης να παίζουν ρόλο. Εκτός από την αξιολόγηση του φυσικού περιβάλλοντος, η πλήρης εκτίμηση του κινδύνου πτώσης περιλαμβάνει: • λήψη ιστορικού πτώσεων, συμπεριλαμβανομένων και των λεπτομερειών των δραστηριοτήτων που εκτελούνταν • αξιολόγηση της βάδισης, της ισορροπίας, της κινητικότη- τας και της λειτουργικότητας και ελαστικότητας των μυών και των αρθρώσεων • εκτίμηση του φόβου πτώσης, της όρασης, της γνωστικής λειτουργίας, της καρδιαγγειακής και νευρολογικής κατά- στασης, και της επιτακτικής ούρησης και της νυκτουρίας (ξύπνημα για ούρηση τη νύχτα) και • επανεξέταση της φαρμακευτικής αγωγής για ανίχνευση πολυφαρμακίας (βλ. κεφάλαιο 3 σχετικά με την αξιολόγηση και την ανάπτυξη ενός πλάνου). Μερικοί άνθρωποι θα χρειαστούν περαιτέρω αξιολόγη- ση και διαχείριση για προβλήματα όπως το συγκοπτικό (blackout/κατάρρευση), η επιληψία και νευρογενείς διαταραχές, όπως είναι η νόσος Πάρκινσον. Κινητική Ικανότητα Μονοπάτια φροντίδας για τη βελτίωση της κινητικότητας Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας Ζωτικότητα Ο ΠΟΥ χρησιμοποιεί τον όρο ζωτικότητα για να περιγράψει τους φυσιολογικούς παράγοντες που συμβάλλουν στην ενδογενή ικα- νότητα ενός ατόμου. Αυτοί μπορεί να περιλαμβάνουν το ενεργεια- κό ισοζύγιο και τον μεταβολισμό. Αυτό το εγχειρίδιο επικεντρώνε- ται σε μία βασική αιτία για τη μειωμένη ζωτικότητα στη μεγαλύτε- ρη ηλικία - τη δυσθρεψία. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Οι επαγγελματίες πρωτοβάθμιας φροντίδας υγείας μπορούν εύ- κολα να κάνουν μια αρχική αξιολόγηση της διατροφικής κατάστα- σης. Αυτό πρέπει να αποτελεί μέρος κάθε αξιολόγησης της υγείας ενός ηλικιωμένου ατόμου. Μια πλήρης αξιολόγηση της διατροφι- κής κατάστασης απαιτεί εξειδικευμένες γνώσεις και, μερικές φο- ρές, αιματολογικές εξετάσεις. • Τόσο η ανεπαρκής διατροφή όσο και η μειωμένη σωματική δρα- στηριότητα οδηγούν στην απώλεια μυϊκής μάζας και δύναμης. • Μια ισορροπημένη δίαιτα με κατάλληλες ποσότητες, συνήθως παρέχει τις απαραίτητες βιταμίνες και μέταλλα για τους ηλικιωμέ- νους, αλλά οι ελλείψεις των βιταμινών D και B12 είναι συχνές. • Η δυσθρεψία οδηγεί συχνά - αλλά όχι πάντα - σε απώλεια βά- ρους. Η λιπώδης μάζα μπορεί να αντικαταστήσει τη μυϊκή μάζα, αφήνοντας το βάρος αμετάβλητο. • Μία άλλη πτυχή της δυσθρεψίας είναι η παχυσαρκία, η οποία δεν έχει αναφερθεί σε αυτόν τον οδηγό. Η από του στόματος συμπληρωματική διατροφή παρέχει επιπλέον υψηλής ποιότητας πρωτεΐνη, θερμίδες και κατάλ- ληλες ποσότητες βιταμινών και μετάλλων προσαρμοσμέ- νες στις ανάγκες, τις προτιμήσεις και τους σωματικούς περι- ορισμούς του ατόμου. V Η από του στόματος συμπληρωματική διατροφή Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας Ν Α Ι Ο Χ Ι Ο Χ Ι ΕΛΕΓΞΤΕ ΓΙΑ ΔΥΣΘΡΕΨΙΑ ΣΤΗΝ ΚΟΙΝΟΤΗΤΑ ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΔΙΑΤΡΟΦΙΚΗ ΚΑΤΑΣΤΑΣΗ Παράδειγμα: Mini nutritional assessment (MNA) (8) ΡΩΤΗΣΤΕ "Έχετε χάσει ακούσια 3 κιλά τους τελευταίους τρεις μήνες;" "Έχετε βιώσει απώλεια όρεξης; Ενισχύστε την γενική υγεία και τις συμβουλές τρόπου ζωής ή την συνήθη φροντίδα." (Σε όποια από τις ερωτήσεις) i 2 Φυσιολογική διατροφική κατάσταση (Βαθμολογία MNA: 24-30 βαθμοί) Σε κίνδυνο δυσθρεψίας (Βαθμολογία MNA: 17–23.5 βαθμοί) Δυσθρεψία (Βαθμολογία MNA: < 17 βαθμοί) Ενισχύστε την γενική υγεία και τις συμβουλές τρόπου ζωής ή την συνήθη φροντίδα. ΕΠΑΝΑΞΙΟΛΟΓΗΣΤΕ - μετά από οξύ συμβάν ή ασθένεια - μια φορά το χρόνο για τους ηλικιωμένους που ζουν στην κοινότητα - κάθε τρεις μήνες για τους ηλικιωμένους με ανάγκες κοινωνικής φροντίδας ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ g 6.3 - ΕΥΠΑΘΕΙΑ - ΣΑΡΚΟΠΕΝΙΑ Ολοκληρωμένη διαχείριση των νοσημάτων Εξετάστε την αποκατάσταση για να βελτιωθεί η μυϊκή λειτουργία ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Ξεπεράστε τα εμπόδια στη διατροφική υγεία των ανθρώπων Ενθαρρύνετε τα οικογενειακά γεύματα και γεύματα με φίλους Οργανώστε βοήθεια με την προετοιμασία και παροχή φαγητού Προσφέρετε διατροφικές συμβουλές Εξετάστε τα από του στόματος συμπληρώματα δια- τροφής εάν δεν βελτιώνεται η πρόσληψη τροφής Παρακολουθήστε στενά το βάρος Εξετάστε πρόγραμμα πολυδιάστατης άσκησης Απαραίτητη η διατροφική παρέμβαση Δώστε από του στόματος συμπληρώματα διατροφής με αυξημένη πρόσληψη πρωτεΐνης (400–600 kcal/ μέρα) Προσφέρετε διατροφικές συμβουλές Παρακολουθήστε στενά το βάρος i 1 g 6.2g 6.2 i 1 Απαιτείται εξειδικευμένη φροντίδα i 1 Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας ΣΥΜΒΟΥΛΕΣ ΓΙΑ ΤΗ ΔΙΑΤΡΟΦΗ • Οι υγειονομικοί πρωτοβάθμιας φροντίδας μπορούν να δώσουν συμ- βουλές στους ηλικιωμένους και να τους ενθαρρύνουν να ακολουθή- σουν μια υγιεινή διατροφή. Όλοι οι ηλικιωμένοι μπορούν να επωφελη- θούν από αυτές τις συμβουλές, συμπεριλαμβανομένων εκείνων που βρί- σκονται σε κίνδυνο ή επηρεάζονται από την υποθρεψία, ανεξαρτήτως του εάν χρειάζονται εξειδικευμένη φροντίδα ή όχι. Είναι πιο εύκολο για τους ανθρώπους που καταγράφουν σε έναν πίνακα τι τρώνε καθημερινά – τό- σο τα γεύματα όσο και μεταξύ των γευμάτων - να ακολουθήσουν μια κα- λή δίαιτα. • Βοηθήστε τα άτομα να εντοπίσουν συγκεκριμένα τρόφιμα που είναι δια- θέσιμα τοπικά και που παρέχουν επαρκή ενέργεια (υδατάνθρακες), πρω- τεΐνες και μικροθρεπτικά στοιχεία, όπως βιταμίνες και μέταλλα. Δώστε συμβουλές σχετικά με τις κατάλληλες ποσότητες αυτών των τροφίμων. • Καθώς η απορρόφηση πρωτεϊνών μειώνεται με την ηλικία, συμβουλεύ- στε τους ηλικιωμένους να καταναλώνουν αρκετές από αυτές. Συστήνεται η πρόσληψη πρωτεϊνών 1,0–1,2 γραμμαρίων ανά κιλό σωματικού βά- ρους για υγιείς ηλικιωμένους. Ένα άτομο που ανακάμπτει από απώλεια βάρους ή αναρρώνει από μια οξεία ασθένεια ή τραυματισμό, μπορεί να χρειαστεί μέχρι και 1,5 γραμμάριο ανά κιλό σωματικού βάρους. Η νεφρι- κή λειτουργία πρέπει να παρακολουθείται, καθώς η υψηλή πρόσληψη πρωτεϊνών μπορεί να οδηγήσει σε αυξημένη ενδοσπειραματική πίεση και σπειραματική υπερδιήθηση. • Προτείνετε σωματική δραστηριότητα, η οποία επιτρέπει στις πρωτεΐνες να ενσωματωθούν στους μύες, και αυξάνει την όρεξη. • Ενθαρρύνετε την έκθεση στον ήλιο για να παράξει η επιδερμίδα βιταμί- νη D. Η βιταμίνη D στα τρόφιμα δεν επαρκεί για να διατηρήσουν οι ηλικι- ωμένοι τα βέλτιστα επίπεδα. Απαιτείται εξέταση αίματος για να μετρηθεί εάν το επίπεδο βιταμίνης D ενός ατόμου είναι επαρκές. • Συχνά, οι ηλικιωμένοι δεν τρώνε επαρκώς. Για να βοηθήσετε έναν ηλι- κιωμένο να τρώει περισσότερο, προτείνετε γεύματα οικογενειακού στυλ και κοινωνικά γεύματα, ιδιαίτερα για ηλικιωμένους που ζουν μόνοι ή εί- ναι κοινωνικά απομονωμένοι. ΘΥΜΗΘΕΙΤΕ! Ο επαγγελματίας υγείας πρέπει να ενημερώσει τα μέλη της οικογένειας και άλλους φροντιστές, καθώς και τον ηλικιωμένο. ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΓΝΩΣΗ Οι εργαζόμενοι στην πρωτοβάθμια φροντίδα υγείας, στην κοι- νότητα και σε δομές, μπορούν να προσφέρουν συμβουλές και υποστήριξη για να βοηθήσουν όλους τους ηλικιωμένους να δι- ατηρήσουν μια υγιεινή διατροφή. Οι άνθρωποι με δυσθρεψία, ή υψηλό κίνδυνο για αυτήν, χρειάζονται έναν επαγγελματία με εξειδικευμένες γνώσεις για να αναζητήσει αιτίες και παράγο- ντες κινδύνου και να συντάξει ένα εξατομικευμένο πλάνο δια- τροφής. Εάν ενδείκνυται, προβείτε ή λάβετε περαιτέρω αξιολόγηση πι- θανών καταστάσεων που μπορεί να υποκρύπτουν ή να οδηγούν σε δυσθρεψία - ακόμα και αν η τρέχουσα διατροφική κατάσταση φαίνεται επαρκής. Σημάδια αυτών των πιθανών καταστάσεων περιλαμβάνουν την απώλεια βάρους, την ταχεία απώλεια βά- ρους, τον πόνο στο στόμα, τον πόνο ή τη δυσκολία κατάποσης, τον χρόνιο έμετο ή διάρροια και το κοιλιακό άλγος. ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΔΙΑΤΡΟΦΙΚΗ ΚΑΤΑΣΤΑΣΗ Υπάρχουν καλά εργαλεία διαθέσιμα για την αξιολόγηση της διατροφικής κατάστασης (11). Για παράδειγμα: Mini nutritional assessment (MNA) (8) Αξιολόγηση διατροφικού κινδύνου DETERMINE (https://www.dads.state.tx.us/providers/AAA/Forms/ standardized/NRA.pdf) Malnutrition universal screening tool (εργαλείο για την διάγνωση της δυσθρεψίας) (https://www.bapen.org.uk/pdfs/must/must_full.pdf) Seniors in the community risk evaluation for eating and nutrition questionnaire (ερωτηματολόγιο εκτίμησης κινδύνου διατροφής για ηλικιωμένους στην κοινότητα) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2536550/) Short nutritional assessment questionnaire 65+(SNAQ65+) (Σύντομο ερωτηματολόγιο αξιολόγησης διατροφής για άτομα άνω των 65 ετών) (http://www.fightmalnutrition.eu/toolkits/summary- screening-tools) Το μονοπάτι φροντίδας πιο πάνω χρησιμοποιεί το Mini nutritional assessment (MNA). Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΤΗΝ ΔΙΑΤΡΟΦΙΚΗ ΚΑΤΑΣΤΑΣΗ ΣΥΝΘΕΣΗ ΜΑΖΑΣ ΣΩΜΑΤΟΣ ΚΑΙ ΓΗΡΑΝΣΗ Συνήθως, μετά από περίπου την ηλικία των 70 ετών, η μυϊκή μάζα μπο- ρεί να μειωθεί, με σημαντικές και δυνητικά επιβλαβείς επιπτώσεις στη ζωτικότητα. Τόσο η ανεπαρκής διατροφή όσο και η ανεπαρκής σωματι- κή άσκηση οδηγούν στην απώλεια μυϊκής μάζας και δύναμης. Ταυτόχρονα, η λιπώδης μάζα μπορεί να αυξηθεί. Το σωματικό βάρος μπορεί να μειωθεί ή να παραμείνει το ίδιο, αποκρύπτοντας έτσι αυτές τις πιθανές επιβλαβείς αλλαγές. Επομένως, ένα υποσιτισμένο άτομο μπορεί να έχει χάσει κρίσιμο άπαχο σωματικό ιστό αλλά να εξακολου- θεί να έχει ΔΜΣ στο αποδεκτό ή ακόμη και στο υπέρβαρο φάσμα. Ένας εκπαιδευμένος μη ειδικός μπορεί να αξιολογήσει αξιόπιστα τη μυ- ϊκή λειτουργία και, συνεπώς, την πρωτεϊνική δυσθρεψία, με ένα εργα- λείο όπως ένα δυναμόμετρο χειρός για τη μέτρηση της δύναμης λαβής. Αυτό το εργαλείο μετράει πόσο δυνατά μπορεί να το σφίξει ένα άτομο με το ένα χέρι. Η χαμηλή δύναμη λαβής υποδηλώνει την ανάγκη για άσκη- ση και για μια δίαιτα που θα περιλαμβάνει περισσότερη πρωτεΐνη. • την περιφέρεια του βραχίονα και μηρού Τα περισσότερα εργαλεία αξιολόγησης διατροφής ρωτούν για: • την πρόσληψη τροφής και υγρών • πρόσφατη απώλεια βάρους (όπως και στην ερώτηση εντοπι- σμού περιστατικού) • την κινητικότητα • πρόσφατο ψυχολογικό στρες ή οξεία ασθένεια • ψυχολογικά προβλήματα • τις συνθήκες διαβίωσης. Επίσης, καταγράφουν: • το βάρος • το ύψος • τον δείκτη μάζας σώματος (ΔΜΣ - βάρος σε κιλά/ύψος σε m2) Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗ ΔΥΣΘΡΕΨΙΑ ΣΤΟΥΣ ΗΛΙΚΙΩΜΕΝΟΥΣ Οι αισθητηριακές βλάβες (μειωμένη αίσθηση γεύσης και όσφρη- σης), η κακή στοματική υγιεινή, προβλήματα μάσησης και δυσκο- λίες κατάποσης, η απομόνωση, η μοναξιά, το χαμηλό εισόδημα και οι σύνθετες μακροχρόνιες χρόνιες παθήσεις αυξάνουν τον κίν- δυνο δυσθρεψίας στους ηλικιωμένους. 6.1 ΓΙΑ ΗΛΙΚΙΩΜΕΝΟΥΣ ΠΟΥ ΕΙΝΑΙ ΣΕ ΚΙΝΔΥΝΟ ΔΥΣΘΡΕΨΙΑΣ Ένας ηλικιωμένος σε κίνδυνο δυσθρεψίας (για παράδειγμα, με βαθμολογία MNA από 17 έως 23,5) μπορεί να επωφεληθεί από συμβουλές σχετικά με τη διατροφή (βλ. πλαίσιο στη σελίδα 35). Σε ένα άτομο σε κίνδυνο εμφάνισης δυσθρεψίας θα πρέπει επίσης, κατά προτίμηση, να παρασχεθεί μια διατροφική παρέμβαση, προ- κειμένου να προληφθεί η εμφάνιση δυσθρεψίας. 6.2 ΓΙΑ ΗΛΙΚΙΩΜΕΝΟΥΣ ΜΕ ΔΥΣΘΡΕΨΙΑ Για ένα άτομο στο οποίο διαγιγνώσκεται δυσθρεψία (για παράδειγμα, ένα σκορ MNA κάτω από 17), η διατροφική παρέμβαση θα πρέπει να ξεκινήσει αμέσως. Ο εργαζόμενος στην πρωτοβάθμια φροντίδα υγείας μπορεί να δώσει αμέσως βασικές διατροφικές συμβουλές (βλ. πλαίσιο στη σελίδα 35). Το συντομότερο δυνατόν, ένας εργαζόμενος υγείας με εξειδικευμέ- νες γνώσεις θα πρέπει επίσης να προσφέρει διατροφικές συμβουλές και, εάν απαιτείται, να συνταγογραφήσει συμπληρώματα διατροφής από του στόματος (βλ. παρακάτω). Η παρέμβαση θα πρέπει να αποτελεί μέρος ενός ολοκληρωμένου πλά- νου φροντίδας που αντιμετωπίζει τους υποκείμενους παράγοντες που συμβάλλουν στην κακή διατροφή, μαζί με άλλες παρεμβάσεις που αφο- ρούν άλλους τομείς της ενδογενούς ικανότητας, όπως η περιορισμένη κι- νητικότητα. Πιο συγκεκριμένα, η επαρκής πρόσληψη ενέργειας και πρω- τεΐνης θα καταστήσει τα προγράμματα πολυδιάστατης σωματικής άσκη- σης πιο αποτελεσματικά (βλ. κεφάλαιο 5 σχετικά με την περιορισμένη κι- νητικότητα).g Η από του στόματος συμπληρωματική θρέψη Η από του στόματος συμπληρωματική θρέψη (OSN) παρέχει επιπρόσθε- τη υψηλής ποιότητας πρωτεΐνη, θερμίδες και επαρκείς ποσότητες βιταμι- νών και μετάλλων. Απαιτείται εξειδικευμένη γνώση για την ανάπτυξη ενός πλάνου για την από του στόματος συμπληρωματική θρέψη, που να προ- σαρμόζεται στις ανάγκες, τις προτιμήσεις και τους σωματικούς περιορι- σμούς ενός ατόμου. Η αξιολόγηση επιτρέπει την επιλογή της καλύτερης συμπληρωματικής μεθόδου - είτε μέσω τροφών πλούσιων σε θρεπτικά συ- στατικά, είτε μέσω χαπιών συμπληρωμάτων βιταμινών ή μετάλλων, είτε 5 Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας μέσω εξειδικευμένων εμπορικών προϊόντων ή μη εμπορικών διατρο- φικών σκευασμάτων. Ο εργαζόμενος υγείας στην κοινότητα μπορεί να υποστηρίξει και να παρακολουθήσει το άτομο που λαμβάνει από του στόματος συμπληρωματική θρέψη (βλ. το πλαίσιο). Εξέταση αίματος Το εξατομικευμένο διατροφικό πρόγραμμα βασίζεται στα αποτελέ- σματα εξετάσεων αίματος. Μια εξέταση αίματος μπορεί να εντοπίσει συγκεκριμένες ελλείψεις βιταμινών και μετάλλων. Συγκεκριμένα διατροφικά συμπληρώματα από το στόμα ή ενέσεις μπορούν να αντιμετωπίσουν αυτές τις ελλεί- ψεις. Για παράδειγμα, δισκία ή ενέσεις απαιτούνται για να αντιμετω- πιστούν οι ανεπάρκειες σε βιταμίνη D και B12, οι οποίες είναι συχνές. Η από του στόματος συμπληρωματική θρέψη πρέπει να συνταγο- γραφείται μόνο όταν ένα άτομο δεν μπορεί να καταναλώσει επαρ- κείς θερμίδες και κανονικά τρόφιμα πλούσια σε θρεπτικά συστατι- κά, ή όταν αποτελεί μια προσωρινή στρατηγική, συμπληρωματική των φυσιολογικών διατροφικών στρατηγικών για την αύξηση της θερμιδικής πρόσληψης. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ ΓΙΑ ΤΗΝ ΑΠΟ ΤΟΥ ΣΤΟΜΑΤΟΣ ΣΥΜΠΛΗΡΩΜΑΤΙΚΗ ΘΡΕΨΗ 3 Η τροφή έχει προτεραιότητα. Εκτός εάν η ανάγκη για από του στόματος συ- μπληρωματική θρέψη είναι επείγουσα, πρώτα θα πρέπει να δοκιμαστούν βελτιώσεις στη δίαιτα, αν αυτό είναι εφικτό, και πιο συχνά γεύματα. 3 Η από του στόματος συμπληρωματική θρέψη προστίθεται στην τροφή. Δεν πρέπει να αντικαθιστά την τροφή. Ένα άτομο που λαμβάνει από του στόμα- τος συμπληρωματική θρέψη πρέπει να κατανοήσει την ανάγκη να συνεχί- σει να τρέφεται όσο το δυνατόν καλύτερα. 3 Οι άνθρωποι χρειάζονται οδηγίες για το πώς να αναμειγνύουν την από του στόματος συμπληρωματική θρέψη, πόση να παίρνουν κάθε φορά και πό- τε να την παίρνουν. 3 Η από του στόματος συμπληρωματική θρέψη πρέπει να λαμβάνεται ανά- μεσα στα γεύματα, όχι κατά τη διάρκεια των γευμάτων. 3 Οι άνθρωποι συχνά χρειάζονται συνεχή υποστήριξη και ενθάρρυνση (από μέλη της οικογένειας, φροντιστές και επαγγελματίες υγείας) για να συ- νεχίσουν να παίρνουν την από του στόματος συμπληρωματική θρέψη, και για να συνεχίσουν να τρώνε όσο το δυνατόν καλύτερα. 3 Μετά από ένα διάστημα, ένα άτομο μπορεί να κουραστεί από τη γεύση και την υφή ενός είδους από του στόματος συμπληρωματικής θρέψης. Η ποι- κιλία γεύσεων και μια αλλαγή από καιρό σε καιρό μπορεί να βοηθήσει. 3 Το βάρος πρέπει να παρακολουθείται και να καταγράφεται τακτικά. 3 Ιδανικά, ο στόχος θα πρέπει να είναι να σταματήσει η από του στόματος συ- μπληρωματική θρέψη μόλις περάσει ο κίνδυνος της δυσθρεψίας και η δί- αιτα πια παρέχει επαρκή θρέψη. ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Ζωτικότητα Μονοπάτια φροντίδας για τη διαχείριση της δυσθρεψίας6.3 ΣΑΡΚΟΠΕΝΙΑ ΚΑΙ ΕΥΠΑΘΕΙΑ Η σαρκοπενία και η ευπάθεια είναι καταστάσεις που μπορεί να σχε- τίζονται με την κακή διατροφή. Οι παρεμβάσεις στον τρόπο ζωής, συ- μπεριλαμβανομένης της καλύτερης διατροφής και της σωματικής άσκησης, μπορούν να βοηθήσουν και στα δύο. Σαρκοπενία. Αυτός ο όρος περιγράφει μια γενική, αυξανόμενη απώ- λεια μυϊκής μάζας, δύναμης και λειτουργικότητας. Μπορεί να οφεί- λεται σε νόσο, κακή διατροφή ή έλλειψη σωματικής δραστηριότη- τας (για παράδειγμα, παραμονή στο κρεβάτι για μεγάλα χρονικά δια- στήματα) ή ενδέχεται να μην οφείλεται σε καμία προφανή αιτία και να σχετίζεται με τη διαδικασία γήρανσης. Ευπάθεια. Η ευπάθεια μπορεί να περιλαμβάνει απώλεια βάρους, αδυναμία μυών, χαμηλά επίπεδα σωματικής δραστηριότητας, εξά- ντληση και βραδύτητα (π.χ., αργό περπάτημα). Η ευπάθεια μπορεί να προκύψει από σωματικό ή ψυχολογικό στρες, όπως ένα τραύμα, μια νόσος ή μια απώλεια ενός αγαπημένου προσώπου. Ένα άτομο με ευπάθεια μπορεί να χάσει λειτουργικές ικανότητες και να καταστεί εξαρτημένο από φροντίδα. Οι φροντιστές και οι κοινότητες μπορούν να βοηθήσουν να ξεπερα- στούν εμπόδια στη διατροφική υγεία των ηλικιωμένων. Για παρά- δειγμα, οι κοινοτικές οργανώσεις μπορούν να διοργανώνουν κοι- νωνικές εκδηλώσεις φαγητού για τους ηλικιωμένους. Από τη μεριά τους, οι εργαζόμενοι υγείας της κοινότητας μπορεί να είναι σε θέση να διευκολύνουν την πρόσβαση στην αγορά τροφί- μων, την πρόσβαση σε βοήθεια για τη διαχείριση των οικονομικών ή την πρόσβαση σε πηγές υποστήριξης του εισοδήματος, μπορούν να διευκολύνουν τη βοήθεια για την προετοιμασία του φαγητού, ή να λαμβάνουν έτοιμα φαγητά, όπως π.χ. μέσω μιας κοινοτικής υπηρεσίας τροφοδοσίας.
Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης Οπτική Ικανότητα Η όραση είναι ένα κρίσιμο στοιχείο της ενδογενούς ικανότητας, καθώς επιτρέπει στους ανθρώπους να μετακινούνται και να αλλη- λεπιδρούν με ασφάλεια με τους ομότιμούς τους και το περιβάλ- λον. Μερικές αιτίες προβλημάτων όρασης γίνονται συνηθέστε- ρες με την ηλικία: η μυωπία και η πρεσβυωπία, ο καταρράκτης, το γλαύκωμα και η εκφύλιση της ωχράς κηλίδας. Τα προβλήματα όρασης μπορεί να προκαλέσουν δυσκολίες στη διατήρηση των οικογενειακών και άλλων κοινωνικών σχέσεων, στην πρόσβαση σε πληροφορίες, στην ασφαλή μετακίνηση (ιδιαί- τερα στο πλαίσιο της ισορροπίας και του κινδύνου πτώσεων), και στην πραγματοποίηση εργασιών με τα χέρια. Τέτοιες δυσκολίες μπορεί να οδηγήσουν σε άγχος και σε κατάθλιψη Η αξιολόγηση της όρασης είναι κρίσιμο στοιχείο της προσωποκε- ντρικής αξιολόγησης. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Με έναν απλό πίνακα οφθαλμικής εξέτασης, οι εργαζόμενοι υγείας στην πρωτοβάθμια φροντίδα και στην κοινότητα μπορούν να ελέγξουν τη σημαντική απώλεια όρασης. • Καταστάσεις που προκαλούν απώλεια όρασης σε πολλά άτο- μα μπορούν να αντιμετωπιστούν. Είναι σημαντικό να ρωτήσετε, να αξιολογήσετε ή να επιβεβαιώσετε την παρουσία κάποιας εγκατε- στημένης οφθαλμικής πάθησης. • Τα γυαλιά οράσεως συχνά μπορούν να διορθώσουν την απώλεια της κοντινής και της μακρινής όρασης. • Βοηθητικές συσκευές (μεγεθυντικοί φακοί, τηλεσκόπια) μπο- ρούν να υποστηρίξουν όσους έχουν απώλεια όρασης που δεν μπορεί να διορθωθεί με γυαλιά. • Στο σπίτι και στην κοινότητα, απλά μέτρα όπως ο καλύτερος φω- τισμός, μπορούν να βελτιώσουν τη λειτουργική ικανότητα των ηλι- κιωμένων με απώλεια όρασης. Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης Η αποτυχία στη μακρινή όραση απαιτεί πάντα παραπομπή για ολοκληρωμένη φροντίδα ΠΡΟΒΛΗΜΑΤΑ ΟΡΑΣΗΣ (14) Δυσχέρεια στη μακρινή όραση: • Ήπια – οπτική οξύτητα μικρότερη από 6/12 • Μέτρια – οξύτητα μικρότερη από 6/18 • Σοβαρή – οξύτητα μικρότερη από 6/60 • Τυφλότητα – οξύτητα μικρότερη από 3/60 Δυσχέρεια στην κοντινή όραση: • Οξύτητα στην κοντινή όραση μικρότερη από Ν6 ή Μ.08 με υπάρχουσα διόρθωση Απαιτείται εξειδικευμένη φροντίδα Ν Α Ι Ν Α Ι Ν Α Ι Ο Χ Ι ΡΩΤΗΣΤΕ Δώστε οδηγίες για την καθημερινότητα με κακή όραση Υιοθετήστε προσαρμογές στο σπίτι (φωτισμός, χρώματα που κάνουν αντίθεση) για αποφυγή πτώσεων g 7.10 Απομακρύνετε επικίνδυνα αντικείμενα από τη συνήθη διαδρομή βάδισης Έχετε προβλήματα με τα μάτια σας; δυσκολία να δείτε μακριά, να διαβάσετε, κάποιο οφθαλμικό νόσημα ή λαμβάνετε στην παρούσα φάση κάποια φαρμακευτική αγωγή (π.χ. για σακχαρώδη διαβήτη, υπέρταση) ΕΛΕΓΞΤΕ ΤΗΝ ΟΠΤΙΚΗ ΟΞΥΤΗΤΑ χρησιμοποιώντας τον απλό πίνακα οφθαμλικής εξέτασης του ΠΟΥ - Να ελέγχετε πάντα τη μακρινή όραση πριν από την κοντινή - Αν φοράει γυαλιά να ελέγχετε χωρίς αυτά - Να ελέγχετε κάθε μάτι χωριστά και μετά μαζί ΜΑΚΡΙΝΗ ΟΡΑΣΗ ΚΟΝΤΙΝΗ ΟΡΑΣΗ Ενισχύστε τις συμβουλές για την οφθαλμική φρο- ντίδα και τον τρόπο ζωής και συμβουλεύστε για το άτομο και το περιβάλλον ΑΠΟΤΥΓΧΑΝΕΙ ΑΠΟΤΥΓΧΑΝΕΙ ΕΠΑΝΑΞΙΟΛΟΓΗΣΤΕ... Επαναλάβετε τον έλεγχο ετησίως ακόμα και εν τη απουσία οπτικής δυσχέρειας Δώστε γυαλιά πρεσβυωπίας Λύνουν το προβλήμα τα απλά γυαλιά από το φαρμακείο; ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΟΠΤΙΚΗ ΔΥΣΧΕΡΕΙΑ ΚΑΙ ΤΑ ΟΦΘΑΛΜΙΚΑ ΝΟΣΗΜΑΤΑ Θεραπεύστε τα οφθαλμικά νοσήματα Διαχειριστείτε την οπτική δυσχέρεια Αναθεωρήστε και επικαιροποιήστε τη συνταγή για γυαλιά ή δώστε καινούρια Εξετάστε το ενδεχόμενο αποκατάστασης των οφθαλμών περιλαμβανομένων βοηθημάτων όπως μεγεθυντικοί φακοί γραφείου και κινητοί ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ g 7.4 g 7.5 - ΥΠΕΡΤΑΣΗ Διαχειριστείτε τους παράγοντες καρδιαγγειακού κινδύνου Παραπομπή σε εξειδικευμένη οφθαλ- μολογική φροντίδα για ετήσιο έλεγχο του αμφιβληστροειδούς Αναθεώρηση φραμακευτικής αγωγής για να αποφευχούν ανεπιθύμητες ενέργειες που αφορούν τα μάτια g 7.9 - ΣΑΚΧΑΡΩΔΗΣ ΔΙΑΒΗΤΗΣ - ΧΡΗΣΗ ΣΤΕΡΟΕΙΔΩΝ ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ Αν ένα άτομο έχει εγκατεστημένη οφθαλμική νόσο ή ανα- γνωρίζεται ως πιθανό να έχει οφθαλμική νόσο, τότε ένας ειδικός στην φροντίδα των ματιών αποφασίζει τη συχνό- τητα και τον τύπο της εξέτασης. 1. ΕΞΕΤΑΣΤΕ ΤΗΝ ΟΠΤΙΚΗ ΟΞΥΤΗΤΑ ΣΤΗΝ ΠΡΩΤΟΒΑΘΜΙΑ ΦΡΟΝΤΙΔΑ • Μια απλή εξέταση διαλογής για την απώλεια όρασης θα πρέπει να γίνεται τουλάχιστον μια φορά το χρόνο σε άτομα ηλικίας μεγαλύτε- ρα των 50 ετών. • Η διαλογή μπορεί να πραγματοποιηθεί με τη χρήση του απλού πί- νακα οφθαλμικής εξέτασης του ΠΟΥ για να ελεγχθούν τόσο η κο- ντινή, όσο και η μακρινή όραση. Για οδηγίες δείτε δεξιά. • Ένας πάροχος πρωτοβάθμιας φροντίδας υγείας μπορεί να κάνει την διαλογή. Δεν απαιτείται επίσημη εκπαίδευση στην αξιολόγηση της οφθαλμικής φροντίδας υγείας (13). • Αν τα γυαλιά από το φαρμακείο λύνουν το πρόβλημα της όρασης του ατόμου μπορεί να μην απαιτείται αναλυτική εξέταση. 4. ΥΓΙΕΙΝΗ ΟΡΑΣΗΣ Η υγιεινή της όρασης αφορά τόσο το περιβάλλον όσο και το άτομο. Περιβαλλοντολογικοί παράγοντες και συμπεριφορές μπορούν να δι- ευκολύνουν τη λειτουργία της όρασης (για παράδειγμα ο φωτισμός, το κοντράστ, η χρήση χρωμάτων), ή να είναι καταστροφικές (για πα- ράδειγμα η επί μακρόν παρακολούθηση ηλεκτρονικών μέσων, η πα- ρατεταμένη χρήση της κοντινής όρασης). Η προσωπική υγιεινή περι- λαμβάνει το σύνολο των συμπεριφορών υγιεινής οφθαλμών, όπως είναι το συχνό πλύσιμο των χεριών, η αποφυγή του τριψίματος των ματιών, η χρήση μόνο ήπιου σαπουνιού για τα βλέφαρα και η αποφυ- γή καλλυντικών για τα μάτια. ΕΞΕΤΑΣΤΕ ΤΗΝ ΚΟΝΤΙΝΗ ΟΡΑΣΗ ΜΕ ΤΟΝ ΑΠΛΟ ΠΙΝΑΚΑ ΟΦΘΑΛΜΙΚΗΣ ΕΞΕΤΑΣΗΣ ΤΟΥ Π.Ο.Υ. 7.3 Επιτρέψτε στο άτομο να κρατήσει τον πίνακα οφθαλμικής εξέτασης όσο κο- ντά επιθυμεί. Εξετάστε από τα μεγαλύτερα στα μικρότερα Ε. Εάν το άτομο αναγνωρίσει την κατεύθυνση τουλάχιστον τριών από τα τέσσε- ρα μεγαλύτερα Ε ΠΕΡΝΑΕΙ τον έλεγχο διαλογής της κοντινής όρασης. Εάν όχι, ελέγξτε αν βοηθούν τα γυαλιά από το φαρμακείο. Εάν δεν είναι σε θέση να δει τουλάχιστον τρία από τα μεγαλύτερα Ε, φορώντας τα γυαλιά πρεσβυωπίας (ΑΠΟΤΥΓΧΑΝΕΙ τον έλεγχο διαλογής της κοντινής όρασης) απαιτείται αξιολόγηση των προβλημάτων όρασης και πιθανής οφθαλμικής νόσου. Το μεσαίο μέγεθος είναι παρεμφερές με το μέγεθος του κειμένου των βιβλίων. Το μικρότερο μέγεθος είναι παρεμφερές με τα ψιλά γράμματα βιβλίων και περιοδικών (δεν απαιτείται να μπορεί να τα δει). Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης ΕΞΕΤΑΣΤΕ ΤΗ ΜΑΚΡΙΝΗ ΟΡΑΣΗ ΜΕ ΤΟΝ ΑΠΛΟ ΠΙΝΑΚΑ ΟΦΘΑΛΜΙΚΗΣ ΕΞΕΤΑΣΗΣ ΤΟΥ Π.Ο.Υ. Δείξτε από κοντά στο άτομο πώς να κάνει τη δοκιμασία με το Ε δείχνοντας τη φορά του Ε. Εξετάστε ξεκινώντας από τα μικρά Ε προς τα μεγάλα Ε. 1. Εξετάστε με τα 4 μικρά Ε στα 3 μέτρα. 7.1 Η όραση είναι 6/18 ή καλύτερη αν μπορεί να αναγνωριστεί η κατεύθυνση τουλάχιστον τριών από τα τέσσερα Ε (ΠΕΡΝΑΕΙ τον έλεγχο όρασης σε από- σταση). Αν δεν μπορεί να δει τουλάχιστον τρία από τα μικρά Ε (ΑΠΟΤΥΓΧΑΝΕΙ στη δο- κιμασία ελέγχου μακρινής όρασης) απαιτείται αξιολόγηση των προβλη- μάτων όρασης και πιθανής οφθαλμικής νόσου. Οι παρακάτω επιπρόσθετοι έλεγχοι μπορούν να βοηθήσουν στην εκτίμηση της οπτικής οξύτητας. 2. Εξετάστε με τα μεγάλα Ε στα 3 μέτρα. 7.2 Εάν μπορεί να δει τα Ε, η όραση είναι 6/60 Εάν δεν μπορεί να δει τουλάχιστον τρία από τα μεγάλα Ε στα 3 μέτρα 3. Εξετάστε με τα μεγάλα Ε στο 1,5 μέτρο. 7.2 Εάν μπορεί να δει τουλάχιστον τρία από τα τέσσερα Ε, η όραση είναι 3/60 7.1 ΑΠΛΟΣ ΠΙΝΑΚΑΣ ΟΦΘΑΛΜΙΚΗΣ ΕΞΕΤΑΣΗΣ ΤΟΥ ΠΟΥ (ΤΕΣΣΕΡΑ ΜΙΚΡΑ Ε ΓΙΑ ΜΑΚΡΙΝΗ ΟΡΑΣΗ) • Τα μικρά Ε είναι 1,3 εκ. Χ 1,3 εκ. σε απόσταση 1,3 εκ. το ένα από το άλλο • Τονισμένα μαύρα Ε σε λευκό χαρτί Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης 7.2 ΑΠΛΟΣ ΠΙΝΑΚΑΣ ΟΦΘΑΛΜΙΚΗΣ ΕΞΕΤΑΣΗΣ ΤΟΥ ΠΟΥ (ΤΕΣΣΕΡΑ ΜΕΓΑΛΑ Ε ΓΙΑ ΜΑΚΡΙΝΗ ΟΡΑΣΗ) • Τα μεγάλα Ε είναι 4,2 εκ. Χ 4,2 εκ. σε απόσταση 4,5 εκ. το ένα από το άλλο • Τονισμένα μαύρα Ε σε λευκό χαρτί 7.3 ΑΠΛΟΣ ΠΙΝΑΚΑΣ ΟΦΘΑΛΜΙΚΗΣ ΕΞΕΤΑΣΗΣ ΤΟΥ ΠΟΥ (ΚΟΝΤΙΝΗ ΟΡΑΣΗ) Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης 7.4 ΑΞΙΟΛΟΓΗΣΤΕ ΓΙΑ ΠΡΟΒΛΗΜΑΤΑ ΟΡΑΣΗΣ ΚΑΙ ΟΦΘΑΛΜΙΚΑ ΝΟΣΗΜΑΤΑ • Η ξαφνική ή ταχέως εξελισσόμενη απώλεια όρασης σε ένα ή και στα δυο μάτια, απαιτεί μια βασική εξέταση των οφθαλμών και της όρασης και παραπομπή για εξειδικευμένη οφθαλμική φροντίδα. • Ένας επαγγελματίας της πρωτοβάθμιας φροντίδας μπορεί να δει τα μάτια κάποιου. Αν υπάρχουν αλλαγές, όπως ερυθρότητα, εκκρί- σεις, ουλές, ενεργός πόνος, δυσανεξία στο φως του ηλίου ή καταρ- ράκτης, τότε το άτομο θα πρέπει να εξεταστεί από έναν επαγγελμα- τία οφθαλμικής φροντίδας (οφθαλμίατρο, οπτομέτρη). • Ένας επαγγελματίας πρωτοβάθμιας φροντίδας μπορεί να εξετά- σει τα μάτια για σημεία κοινών οφθαλμικών νόσων. Αυτή η εξέταση δεν είναι σε γενικές γραμμές πλήρης και απαιτείται περαιτέρω εξέ- ταση από κάποιον ειδικό. Εάν η κατάσταση του οφθαλμού που ανα- φέρθηκε επιμένει, τότε συστήνεται εξειδικευμένη οφθαλμική φρο- ντίδα. • Τα γυαλιά πρεσβυωπίας βοηθούν πολλούς ηλικιωμένους να δουν κοντινά αντικείμενα. Για κάποιους, ωστόσο, τα γυαλιά πρεσβυωπί- ας δεν είναι η απάντηση. Για παράδειγμα άτομα που δεν μπορούν να δουν κοντά, ή που έχουν αστιγματισμό χρειάζονται να τους συνταγο- γραφηθούν γυαλιά οράσεως από έναν επαγγελματία οφθαλμικής φροντίδας μετά από εξέταση. • Μια τυπική διαγνωστική εξέταση περιλαμβάνει έναν εκπαιδευμένο επαγγελματία που χρησιμοποιεί μια σχισμοειδή λυχνία για να εξε- τάσει το μάτι με λεπτομέρεια. Αυτό το εργαλείο μπορεί να χρησιμο- ποιηθεί, για παράδειγμα, για να ανιχνευθεί καταρράκτης και μπο- ρεί να βοηθήσει στην απόφαση για το εάν χρειάζεται χειρουργείο. Η εξέταση του αμφιβληστροειδούς και του οπτικού νεύρου απαιτεί τη χρήση άλλων εργαλείων, και μερικές φορές τη λήψη εικόνων για να ανιχνευθούν πρώιμες αλλαγές και για να καθοδηγηθεί η θερα- πεία που θα αποτρέψει την απώλεια όρασης. Η εξέταση του αμφι- βληστροειδούς σε τακτικά διαστήματα είναι ιδιαίτερα σημαντική για άτομα με σακχαρώδη διαβήτη Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης ΑΞΙΟΛΟΓΗΣΤΕ ΓΙΑ ΠΡΟΒΛΗΜΑΤΑ ΟΡΑΣΗΣ ΚΑΙ ΟΦΘΑΛΜΙΚΑ ΝΟΣΗΜΑΤΑ Καταρράκτης Ο καταρράκτης είναι μια θόλωση του φακού του ματιού, που εμποδίζει την καθαρή όραση και σχετίζεται συχνά με την διαδικασία της γήρανσης. Ο καταρράκτης παραμένει η κύρια αιτία τυφλότητας. Η μείωση του καπνίσματος και της έκθεσης στο υπεριώδες φως μπορεί να αποτρέψουν ή να καθυστερήσουν την εμφάνιση καταρράκτη. Ο σακχαρώ- δης διαβήτης και η παχυσαρκία είναι επιπρόσθετοι παρά- γοντες κινδύνου. Τα προβλήματα όρασης και η τυφλότητα από καταρράκτη, μπορούν να αποφευχθούν καθώς το χειρουργείο για κα- ταρράκτη είναι ασφαλές και μπορεί να αποκαταστήσει την όραση. 7.5 ΓΥΑΛΙΑ ΠΡΕΣΒΥΩΠΙΑΣ Πολλοί άνθρωποι 50 ετών και άνω έχουν δυσκολία να δουν ή να δια- βάσουν σε κοντινή απόσταση. Μπορούν συχνά να επωφεληθούν από τη χρήση γυαλιών πρεσβυωπίας (που λέγονται και «διαβάσματος»). Απλά γυαλιά πρεσβυωπίας είναι διαθέσιμα με μικρό κόστος. Είναι συχνά διαθέσιμα σε διαφορετική ισχύ μεγέθυνσης. Τα γυαλιά πρε- σβυωπίας κάνουν απλώς τα κοντινά αντικείμενα να φαίνονται μεγα- λύτερα. Όταν το πρόβλημα δεν διορθώνεται με απλά γυαλιά πρεσβυ- ωπίας, συστήνεται πλήρης οφθαλμολογικός και οπτικός έλεγχος. Εάν είναι εφικτό, όλα τα άτομα άνω των 50 ετών θα πρέπει να εξετά- ζονται από έναν επαγγελματία οφθαλμικής φροντίδας σε τακτά δια- στήματα. Οι απλοί έλεγχοι της όρασης και της ανάγνωσης δεν υπο- καθιστούν τον πλήρη οφθαλμολογικό έλεγχο που γίνεται από έναν επαγγελματία οφθαλμικής φροντίδας. 7.6 ΜΗ ΑΝΑΣΤΡΕΨΙΜΗ ΧΑΜΗΛΗ ΟΡΑΣΗ Πολλοί άνθρωποι έχουν χαμηλή όραση, η οποία δεν διορθώνεται επαρκώς με την συνταγογράφηση γυαλιών. Για αυτά τα άτομα, βο- ηθήματα όρασης – μεγεθυντικοί φακοί γραφείου ή κινητοί – παρέ- χουν μεγαλύτερη μεγέθυνση από τα γυαλιά. Μπορεί να κάνουν εφι- κτές τις ενέργειες που περιλαμβάνουν την κοντινή όραση, όπως το διάβασμα ενός βιβλίου ή μιας εφημερίδας, την αναγνώριση των χρημάτων, την ανάγνωση ετικετών και την επιθεώρηση μικρών αντικειμένων ή επιμέρους στοιχείων μεγαλύτερων αντικειμένων. Εργαζόμενοι σε υπηρεσίες υγείας ή αποκατάστασης στην κοινότη- τα μπορούν να βοηθήσουν τα άτομα να αποκτήσουν αυτά τα βοηθή- ματα. Αποκατάσταση όρασης. Ένα άτομο με μη αναστρέψιμη χαμηλή όραση θα επωφεληθεί από ολοκληρωμένες υπηρεσίες αποκατά- στασης της όρασης, που περιλαμβάνουν ψυχολογική υποστήριξη, καθώς και προσανατολισμό, κινητικότητα και εκπαίδευση σε δρα- στηριότητες της καθημερινής ζωής. Επαγγελματίες οφθαλμικής φροντίδας και αποκατάστασης μπορούν να εκπαιδεύσουν άτομα με χαμηλή όραση σε δεξιότητες που ενισχύουν την οπτική λειτουργι- κότητα – δεξιότητες όπως η ενημερότητα η εστίαση, ο έλεγχος του χώρου και η ανίχνευση. Αυτές οι δεξιότητες χρειάζονται συνήθως για την αποτελεσματική χρήση των μεγεθυντικών φακών, αλλά μπορεί να είναι επίσης χρήσιμες και σε άλλες περιστάσεις. Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΑ ΠΡΟΒΛΗΜΑΤΑ ΟΡΑΣΗΣ 7.7 ΑΡΤΗΡΙΑΚΗ ΥΠΕΡΤΑΣΗ Η αρτηριακή υπέρταση είναι ένας σημαντικός παράγοντας κινδύνου για νοσήματα του αμφιβληστροειδούς και για γλαύκωμα. 7.8 ΣΑΚΧΑΡΩΔΗΣ ΔΙΑΒΗΤΗΣ Ένα άτομο με σακχαρώδη διαβήτη θα πρέπει να κάνει οφθαλμολογι- κή εξέταση που διενεργείται από ειδικό της οφθαλμικής φροντίδας κάθε χρόνο, για να ελέγχει για την παρουσία διαβητικής αμφιβλη- στροειδοπάθειας 7.9 ΧΡΗΣΗ ΣΤΕΡΟΕΙΔΩΝ Σε κάποιους ανθρώπους η μακροχρόνια λήψη θεραπείας με στε- ροειδή μπορεί να αυξήσει την πίεση στο βολβό του ματιού (ενδο- φθάλμια πίεση) ή να οδηγήσει σε καταρράκτη. Αυτή η αυξημένη πί- εση μπορεί να οδηγήσει σε απώλεια της όρασης, που περιλαμβά- νει βλάβη στο οπτικό νεύρο και μπορεί να καταλήξει σε τυφλότητα αν δεν αντιμετωπιστεί. Καθένας που λαμβάνει μακροχρόνια θερα- πεία με στεροειδή χρειάζεται τακτικό οφθαλμολογικό έλεγχο και μέτρηση της ενδοφθάλμιας πίεσης. Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΑΝΤΙΜΕΤΩΠΙΣΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ 7.10 ΠΡΟΣΑΡΜΟΓΕΣ ΓΙΑ ΚΑΚΗ ΟΡΑΣΗ Πέρα από την παροχή βοηθημάτων, απλές αλλαγές μπορούν να δι- ευκολύνουν τα άτομα με κακή όραση να διατηρήσουν τις δραστηρι- ότητες τους, και με αυτό τον τρόπο να διατηρήσουν την ποιότητα της ζωής τους. Οι αλλαγές μπορούν να γίνουν στο σπίτι και στα συνηθι- σμένα μέρη που μετακινείται το άτομο προκειμένου να γίνουν οι συ- νηθισμένες ενέργειες και δραστηριότητες αναψυχής ασφαλέστερες και ευκολότερες. Ακολουθούν παραδείγματα. Βελτιώστε τον φωτισμό. Ο καλός φωτισμός είναι ιδιαίτερα σημαντι- κός για την κοντινή όραση. Το φως είναι καλύτερο να έρχεται από το πλάι του ατόμου (χωρίς να δημιουργεί σκιά). Μειώστε την αντανάκλαση - αντηλιά. Το εντονότερο φως είναι συνή- θως καλύτερο. Αλλά η αντηλιά ή η αντανάκλαση του έντονου φωτός μπορεί να ενοχλούν κάποιους ανθρώπους. Απομακρύνετε εμπόδια. Κίνδυνοι όπως τα έπιπλα και άλλα σκληρά αντικείμενα, μπορούν να μετακινηθούν μακριά από τη συνηθισμένη διαδρομή βάδισης του ατόμου. Αν χρειάζονται εκεί, θα πρέπει να πα- ραμένουν πάντα στο ίδιο σημείο. Υπάρχουν πολλοί τρόποι για να βοηθήσετε άτομα με χαμηλή όραση να απολαύσουν μια καλύτερη λειτουργικότητα. Τα μέλη της οικογέ- νειας τους και οι φροντιστές μπορούν να βοηθήσουν. Η προσαρμογή σε τοπικό επίπεδο αυτών των οδηγιών για να καθοριστεί το από πού μπορεί κάποιος να προμηθευτεί βοηθήματα και υπηρεσίες είναι ανα- γκαία ανάλογα με το πλαίσιο. Δημιουργήστε αντίθεση (κοντράστ). Η καλή αντίθεση μέσα και ανάμε- σα στα αντικείμενα κάνει πιο εύκολο το να ιδωθούν, να εντοπιστούν ή να παρακαμφθούν. Παραδείγματα είναι η σήμανση στην άκρη των σκαλο- πατιών με σημάδια υψηλού κοντράστ (ιδιαίτερα για όσους έχουν μονό- φθαλμη όραση), χρωματιστά πιάτα για να φαίνεται το φαγητό, και χρή- ση μαύρου στυλό για το γράψιμο. Τα άτομα με κακή όραση, τα μέλη της οικογένειας και οι φροντιστές μπορούν να χρωματίσουν τις χειρολαβές και τα εργαλεία της κουζίνας, για να τα κάνουν πιο ορατά και ασφαλή – παράδειγμα η περιτύλιξη της λαβής ενός μαχαιριού με έντονα χρωματι- σμένη κολλητική ταινία ή ο χρωματισμός αυτής. Χρησιμοποιήστε την πιο ευανάγνωστη γραμματοσειρά. Προκειμένου για εκτυπωμένο υλικό και για οθόνες σε υπολογιστές και τηλέφωνα, μεγάλα γράμματα της γραμματοσειράς sans serif, που ξεχωρίζουν από το ομοιόμορφο χρωματικό υπόβαθρο, είναι ευκολότερο να διαβαστούν. Διαλέξτε οικιακά αντικείμενα με μεγαλύτερη γραμματοσειρά και καλή αντίθεση (κοντράστ). Υπάρχουν συχνά αντικείμενα διαθέσιμα σε κατα- στήματα, που χρησιμοποιούν μεγαλύτερα γράμματα και καλό κοντράστ. Παραδείγματα τέτοιων διαθέσιμων προϊόντων είναι ρολόγια τοίχου και χειρός, και βιβλία με μεγάλα γράμματα. Μπορούν να αγοραστούν η να κατασκευαστούν για λόγους αναψυχής, μεγάλα ταμπλό και κομμάτια επιτραπέζιων παιχνιδιών, τράπουλες με μεγάλους αριθμούς και σύμ- βολα. Χρησιμοποιήστε βοηθήματα ακοής και όρασης. Πολλά αντικείμενα στα καταστήματα έχουν πλέον δυνατότητα ομιλίας, όπως ομιλούντα τη- λέφωνα, θερμόμετρα και ζυγαριές. Πολλά κινητά τηλέφωνα και υπο- λογιστές έχουν τώρα λειτουργίες μετατροπής κειμένου σε ομιλία. Οπτική Ικανότητα Μονοπάτια Φροντίδας για τη διαχείριση των προβλημάτων όρασης ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής Ακουστική Ικανότητα Η σχετιζόμενη με την ηλικία απώλεια ακοής μπορεί να είναι η πιο κοινή αισθητηριακή διαταραχή στους ηλικιωμένους. Η απώλεια της ακοής που δεν έχει αντιμετωπιστεί, παρεμβαίνει στην επικοι- νωνία και μπορεί να οδηγήσει σε κοινωνική απομόνωση. Οι περι- ορισμοί άλλων ικανοτήτων, όπως η έκπτωση της γνωστικής λει- τουργίας, μπορούν να επιδεινώσουν περαιτέρω αυτές τις κοινωνι- κές συνέπειες. Η απώλεια ακοής συνδέεται με πολλά άλλα ζητή- ματα υγείας, περιλαμβανομένης της έκπτωσης της γνωστικής λει- τουργίας και τον κίνδυνο άνοιας, την κατάθλιψη και το άγχος, την κακή ισορροπία, τις πτώσεις, νοσηλείες και πρώιμο θάνατο. Ως εκ τούτου η αξιολόγηση της ακοής είναι ένα βασικό κομμάτι της παρακολούθησης της ενδογενούς ικανότητας του ηλικιωμένου στην κοινότητα. Η αξιολόγηση της ακοής σε μεγαλύτερο βάθος εί- ναι επίσης βασικό κομμάτι μιας πλήρους αξιολόγησης της υγείας και των αναγκών κοινωνικής φροντίδας ενός ηλικιωμένου. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Επαγγελματίες πρωτοβάθμιας φροντίδας στην κοινότητα και σε δομές μπορούν να κάνουν έλεγχο διαλογής για την απώλεια ακοής με απλό φορητό εξοπλισμό ή με μια δοκιμασία ψιθυρι- στής φωνής. • Απλές ενέργειες στο σπίτι και στην κοινότητα μπορούν να μειώ- σουν τις επιπτώσεις της απώλειας ακοής. Οι στρατηγικές επικοι- νωνίας για να κάνουν ευκολότερη την ακοή, περιλαμβάνουν την καθαρή ομιλία, την κατά μέτωπο επικοινωνία με το άτομο που έχει απώλεια ακοής, και τη μείωση του θορύβου του περιβάλ- λοντος. • Η βελτίωση αυτής καθ’ αυτής της ακοής περιλαμβάνει βοηθή- ματα ακοής, όπως ακουστικά και κοχλιακά εμφυτεύματα. Η χο- ρήγηση τους απαιτεί εξειδικευμένη γνώση και εξοπλισμό. Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής Απαιτείται εξειδικευμένη φροντίδα Ν Α Ι Ο Χ Ι ΕΛΕΓΞΤΕ ΤΗΝ ΑΚΟΗ ΡΩΤΗΣΤΕ ΓΙΑ: Κώφωση (Ακοομετρία: ≥ 81 dB) Μέτρια έως σοβαρή απώλεια ακοής (Ακοομετρία: 36–80 dB) Φυσιολογική ακουστική ικανότητα (Ακοομετρία: ≤35dB) ΠΑΡΑΓΟΝΤΕΣ ΚΙΝΔΥΝΟΥ (όπως έκθεση σε θόρυβο και ωτοτοξικά φάρμακα) ΠΟΝΟΣ ΣΤΟ ΑΥΤΙ ΙΣΤΟΡΙΚΟ ενεργού ωτόρροιας, απότομης έναρξης ή ταχείας προοδευτικής απώλειας ακοής ΖΑΛΗ ΧΡΟΝΙΑ ΜΕΣΗ ΩΤΙΤΙΔΑ ΑΜΦΟΤΕΡΟΠΛΕΥΡΗ ΑΠΩΛΕΙΑ ΑΚΟΗΣ - Δοκιμασία ψιθυριστής φωνής: Μπορεί να ακούσει ψίθυρο ή - Ακοόγραμμα διαλογής: 35db ή λιγότερο για να περάσει ή - Αυτοματοποιημένη δοκιμασία αναγνώρισης ψηφίων σε θόρυβο σε εφαρμογή κινητού ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΑΚΟΥΣΤΙΚΗ ΙΚΑΝΟΤΗΤΑ g 8.1 (Διαγνωστική ακοομετρία) Ενισχύστε τις γενικές συμβουλές για τη φροντίδα των αυτιών ή τη συνήθη φροντίδα i 3 i 2 ΠΕΡΝΑ ΑΠΟΤΥΓΧΑΝΕΙ (σε όλους) (σε οποιονδήποτε) Χορηγήστε βοηθήματα ακοής g 8.4 Αν δεν υπάρχουν διαθέσιμα βοηθήματα ακοής ενημερώστε για τη χειλεανάγνω- ση και τη νοηματική καθώς και για άλλες στρατηγικές επικοινωνίας g 8.5 Παράσχετε συναισθηματική υποστήριξη και βοή- θεια με τη διαχείριση του συναισθματικού φορτίου Παράσχετε ακουστικά βοήθήματα στο σπίτι (τηλέφωνα, κουδούνια) ΑΞΙΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Προσφέρετε στα άτομα με απώλεια ακο- ής, στα μέλη της οικογένειάς τους και στους φροντιστές τους στρατηγικές ώστε να παρα- μείνουν συνδεδεμένοι και να διατηρήσουν τις σχέσεις τους Εκτιμήστε και χορηγήστε ακουστικό βοήθημα g 8.4 (ακουστικό βαρυκοΐας ή κοχλιακό εμφύτευμα) Παραπέμψτε για εξειδικευμένη ακουστική φροντίδα Ενισχύστε τις γενικές συμβουλές για τη φροντίδα των αυτιών ή τη συνήθη φροντίδα ΕΠΑΝΑΞΙΟΛΟΓΗΣΤΕ μια φορά τον χρόνο i 2 ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ Εκτίμηση του ατόμου με σοβαρή απώλεια ακοής/κώφωση Προσαρμογή ακουστικού βοηθήματος Διαχείριση των υποκείμενων προβλημάτων που προκαλούν ή συμβάλλουν στην απώλεια ακοής. Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής ΓΕΝΙΚΕΣ ΟΔΗΓΙΕΣ ΓΙΑ ΤΗΝ ΦΡΟΝΤΙΔΑ ΤΩΝ ΑΥΤΙΩΝ • ΜΗ βάζετε βρώμικα δάκτυλα μέσα στα αυτιά ή μην ξεχνάτε να πλύ- νετε τα χέρια πριν από χειρισμούς τροφίμων, και μην τρώτε με βρώ- μικα χέρια • ΠΑΝΤΑ να πλένετε τα χέρια σας αφού πάτε στην τουαλέτα • ΜΗΝ κολυμπάτε ή πλένεστε σε βρώμικα νερά • ΜΗ βάζετε τίποτα μέσα στα αυτιά σας: - Ζεστό ή κρύο λάδι - Φυτικά σκευάσματα - Υγρά όπως η κηροζίνη 3. ΔΟΚΙΜΑΣΙΑ ΨΙΘΥΡΙΣΤΗΣ ΦΩΝΗΣ Σταθείτε σε απόσταση ίση με το μήκος ενός βραχίονα πίσω από το άτομο στη μια του πλευρά Ζητήστε από το άτομο, ή από κάποιο βοηθό, να κλείσει το αυτί από την άλλη πλευρά πιέζοντας τον τράγο (ο τράγος είναι η προς τα εμπρός προβολή του αυτιού που καλύπτει εν μέρει το άνοιγ- μα του.) Εκπνεύστε και στη συνέχεια ψιθυρίστε απαλά τέσσερις λέξεις. Χρησιμοποιήστε οποιεσδήποτε κοινές, μη σχετιζόμενες λέξεις. Ζητήστε από το άτομο να επαναλάβει τις λέξεις σας. Οι λέξεις θα πρέπει να λέγονται μία-μία και να περιμένετε κάθε φορά την απά- ντηση. Αν το άτομο επαναλάβει περισσότερες από τρεις λέξεις και είστε σίγουρος/η ότι μπορεί να σας ακούσει καθαρά, τότε το πιθα- νότερο είναι το άτομο να έχει φυσιολογική ακοή σε αυτό το αυτί. Μετακινηθείτε στην άλλη πλευρά και ελέγξτε το άλλο αυτί. Χρησιμοποιήστε διαφορετικές λέξεις. 1. ΕΞΕΤΑΣΗ ΑΚΟΗΣ Η αρχική αξιολόγηση χρησιμοποιεί μια από τις τρεις πιθανές δοκιμασίες ΔΟΚΙΜΑΣΙΑ ΨΙΘΥΡΙΣΤΗΣ ΦΩΝΗΣ Η δοκιμασία ψιθυριστής φωνής είναι ένα εργαλείο διαλογής που μπορεί να βοηθήσει να προσδιοριστεί αν το άτομο έχει κανονική ακοή ή χρειάζε- ται διαγνωστική ακοομετρία. ΑΚΟΟΜΕΤΡΙΑ ΔΙΑΛΟΓΗΣ (15) Χρησιμοποιήστε την εάν έχετε τον εξοπλισμό. Η ακοομετρία διαλογής χορηγεί καθαρούς τόνους στο φάσμα της ομιλίας (500 με 4000 Hz) στα ανώτερα όρια της φυσιολογικής ακοής. Το αποτέ- λεσμα σημειώνεται ως περνάει ή παραπέμπεται. Μια καταγραφή 35 dB ή χαμηλότερη υποδεικνύει φυσιολογική ακοή. Με μια σύντομη ειδική εκ- παίδευση, ένας μη ειδικός μπορεί να ελέγξει την ακοή με ακρίβεια με αυ- τή τη δοκιμασία. ΑΥΤΟΜΑΤΗ ΔΟΚΙΜΑΣΙΑ ΑΝΑΓΝΩΡΙΣΗΣ ΨΗΦΙΩΝ ΣΕ ΘΟΡΥΒΟ ΣΕ ΕΦΑΡΜΟΓΗ ΚΙΝΗΤΟΥ Μια αυτοματοποιημένη δοκιμασία αυτοελέγχου με ψηφία σε θόρυβο, μπορεί να χρησιμοποιηθεί για να προσδιοριστεί αν χρειάζεται διαγνωστι- κή ακοομετρία. Διαθέσιμη σε εφαρμογή κινητού - Για παράδειγμα: https://www.who.int/deafness/hearWHO (δωρεάν στα Αγγλικά) hearZA: https://www.hearza.co.za/ (δωρεάν στα Αγγλικά) uHear: http://unitron.com/content/unitron/nz/en/professional/ practice-support/uhear.html (δωρεάν στα Αγγλικά, Γαλλικά, Γερμανικά και Ισπανικά για χρήστες iPhone ) Διαθέσιμη ως υπηρεσία του διαδικτύου - για παράδειγμα: Από την HearCom: http://hearcom.eu/prof/ DiagnosingHearingLoss/SelfScreenTests/ThreeDigitTest_en.html (δωρεάν στα Ολλανδικά, Αγγλικά, Γερμανικά, Πολωνικά και Σουηδικά) Ψιθυρίστε λέξεις που είναι οικείες στο άτομο. Για παράδειγμα: - εργοστάσιο - ψάρι - ουρανός - ποδήλατο - φωτιά - κήπος - αριθμός - κίτρινο Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής ΑΞΙΟΛΟΓΗΣΤΕ ΤΗΝ ΑΚΟΥΣΤΙΚΗ ΙΚΑΝΟΤΗΤΑ 8.1 ΤΡΕΙΣ ΔΟΚΙΜΑΣΙΕΣ ΓΙΑ ΤΗΝ ΠΛΗΡΗ ΑΞΙΟΛΟΓΗΣΗ Η αξιολόγηση της ακοής μπορεί να περιλαμβάνει τρεις δοκιμασί- ες με εξειδικευμένο εξοπλισμό – έναν διαγνωστικό ακοογράφο για τους καθαρούς τόνους, και την ομιλητική ακοομετρία, και ένα τυμπα- νόμετρο για να γίνει η αξιολόγηση του μέσου ωτός. Αυτές οι δοκιμασί- ες μπορεί να βοηθήσουν να αναγνωριστεί η ανάγκη για αποκατάστα- ση. Για τη διενέργεια αυτών των δοκιμασιών χρειάζεται εξειδικευμένη εκπαίδευση. Ακοομετρία καθαρού τόνου. Η ακοομετρία καθαρού τόνου ενός ατό- μου εξετάζει την ικανότητά του να ακούει ήχους σε διαφορετικές συ- χνότητες καθαρού τόνου. Περιλαμβάνει την αναπαραγωγή ενός προ-ηχογραφημένου ήχου ολοένα και δυνατότερα, μέχρι το άτομο να τον ακούσει – κατώφλι της ακοής. Εξετάζει την αέρινη αγωγιμότητα και την οστέινη αγωγιμότητα των ήχων για να αξιολογήσει τα κατώφλια ακοής σε συχνότητες από 125 Hz (πολύ χαμηλή) μέχρι 8000 Hz (πο- λύ υψηλή). Αυτός ο έλεγχος βοηθάει να προσδιοριστεί ο βαθμός και ο τύπος της απώλειας ακοής. Ομιλητική ακοομετρία. Οι ηλικιωμένοι επωφελούνται από έναν επι- πλέον έλεγχο – την ομιλητική ακοομετρία. Σε αυτή τη δοκιμασία μια σειρά από προ-ηχογραφημένες απλές λέξεις αναπαράγονται με αυξα- νόμενη ένταση και ζητείται από το άτομο να επαναλάβει τις λέξεις όταν τις ακούει. Αυτή η δοκιμασία διασταυρώνει τα αποτελέσματα της ακοο- μετρίας καθαρού τόνου. Βοηθάει να προσδιοριστεί εάν η αναγνώριση της ομιλίας είναι συμβατή με τα αποτελέσματα της ακοομετρίας καθα- ρού τόνου, να διαπιστωθεί εάν υπάρχει ασυμφωνία στην αντίληψη της ομιλίας που δεν προβλέπεται από την ακοομετρία καθαρού τόνου, ή να αναγνωριστεί σε ποιο αυτί θα γίνει η εφαρμογή του ακουστικού βο- ηθήματος εάν χρειάζεται μόνο ένα. Τυμπανομετρία. Τέλος, η τυμπανομετρία, εξετάζει τη συμμόρφωση (ή κινητικότητα) του τυμπάνου. Αυτή η δοκιμασία μπορεί να υποστηρίξει το αποτέλεσμα της ακοομετρίας καθαρού τόνου και της ομιλητικής για να προσδιοριστεί ο τύπος του προβλήματος ακοής. ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗΝ ΑΠΩΛΕΙΑ ΑΚΟΗΣ Τόσο οι στρατηγικές επικοινωνίας όσο και τα ακουστικά βοηθήμα- τα θα πρέπει να ληφθούν υπ’ όψιν για την αντιμετώπιση της απώλει- ας ακοής. Η καλύτερη προσέγγιση για τη διαχείριση της απώλειας ακοής θα πρέπει να αποφασιστεί με βάση το πόρισμα της πλήρους αξιολόγη- σης της ενδογενούς ικανότητας του ατόμου. Οποιαδήποτε έκπτωση της γνωστικής λειτουργίας, οποιαδήποτε απώλεια της κινητικής ικα- νότητας ή απώλεια δεξιοτήτων στα χέρια και στα πόδια, καθώς και η υποστήριξη που υπάρχει από την οικογένεια και την κοινότητα, θα πρέπει να ληφθούν υπ’ όψιν. 8.2 ΓΙΑ ΑΤΟΜΑ ΜΕΓΑΛΥΤΕΡΗΣ ΗΛΙΚΙΑΣ ΜΕ ΜΕΤΡΙΑ ΩΣ ΣΟΒΑΡΗ ΑΠΩΛΕΙΑ ΑΚΟΗΣ • Εξηγήστε στα άτομα με απώλεια ακοής και στις οικογένειες τους, το όφελος από τα βοηθήματα ακοής, όπως τα ακουστικά, από πού μπορούν να τα προμηθευτούν και πώς να τα χρησιμοποιήσουν. Μόλις κάποιο άτομο αποκτήσει ακουστικό βαρηκοΐας, ο εργαζόμε- νος υγείας μπορεί να υποστηρίξει και ενθαρρύνει τη χρήση του. • Η ακοομοετρία από μόνη της δεν θα πρέπει να καθορίσει αν ένα άτομο έχει ανάγκη ακουστικού. Οι περισσότεροι άνθρωποι με απώ- λεια ακοής παραπονούνται σχετικά με τη δυσκολία που έχουν να επικοινωνήσουν όταν υπάρχει θόρυβος στο περιβάλλον. Το άτομο θα πρέπει να αξιολογηθεί για τη συνολική του ανάγκη πριν από τη σύσταση για χρήση ακουστικού βαρηκοΐας. • Δώστε ξεκάθαρες οδηγίες σε άτομα με απώλεια ακοής, στις οικογέ- νειες τους και στους φροντιστές για στρατηγικές επικοινωνίας που μπορούν να βελτιώσουν την λειτουργική ικανότητα. g 8.5 • Κάποια φάρμακα μπορεί να προκαλέσουν βλάβη στο έσω αυτί, οδη- γώντας στην απώλεια της ακοής και/ή στην απώλεια της ισορροπί- ας. Αυτά περιλαμβάνουν αντιβιοτικά, όπως η στρεπτομυκίνη και η γενταμυκίνη, και ανθελονοσιακά, όπως η κινίνη και η χλωροκίνη. Υπάρχουν και άλλα φάρμακα που επίσης μπορούν να επηρεάσουν την ακοή. Η μείωση αυτών των φαρμάκων, αν αυτό είναι εφικτό, μπο- ρεί να αποτρέψει περαιτέρω απώλεια της ακοής. 8.3 ΓΙΑ ΑΤΟΜΑ ΜΕΓΑΛΥΤΕΡΗΣ ΗΛΙΚΙΑΣ ΜΕ ΚΩΦΩΣΗ Ένας ηλικιωμένος με μεγάλο βαθμό απώλειας ακοής (σοβαρή ή βα- θιά) ή που δεν επωφελείται από τις παρεμβάσεις που αναφέρθηκαν παραπάνω, θα χρειαστεί εξειδικευμένη φροντίδα ακοής, όπως η το- ποθέτηση ακουστικού βαρηκοΐας. Η χορήγηση βοηθημάτων ακοής απαιτεί εξειδικευμένες δεξιότητες για τον έλεγχο, τη συνταγογρά- φηση και την προσαρμογή. Άλλα σημεία συναγερμού για τη λήψη εξειδικευμένης φροντίδας ακοής. Καταστάσεις που μπορεί να κρύβονται στην απώλεια ακοής, χρειάζονται εξειδικευμένη διάγνωση και διαχείριση. Αυτές περιλαμβάνουν: • Πόνο στο αυτί • Χρόνια μέση ωτίτιδα (φλεγμονή του μέσου ωτός) • Αιφνίδια ή ταχέως εξελισσόμενη απώλεια ακοής • Ζάλη με μετρίου βαθμού έως σοβαρή απώλεια ακοής • Ενεργό ωτόρροια • Παρουσία παραγόντων κινδύνου, όπως η έκθεση σε θόρυβο και η λήψη φαρμάκων που μπορούν να βλάψουν την ακοή. Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής 8.4 ΒΟΗΘΗΜΑΤΑ ΑΚΟΗΣ Ακουστικά βαρηκοΐας. Τα ακουστικά βαρηκοΐας είναι συνήθως η καλύτερη τεχνολογία για τους ηλικιωμένους με απώλεια ακοής. Τα ακουστικά κάνουν τους ήχους πιο δυνατούς. Είναι συνήθως αποτε- λεσματικά στους περισσότερους ανθρώπους και είναι βολικά για- τί φοριούνται πάνω ή μέσα στο αυτί. Είναι σημαντικό να εξηγηθεί στο άτομο ότι το ακουστικό δεν θεραπεύει την απώλεια ακοής. Κοχλιακά εμφυτεύματα. Τα κοχλιακά εμφυτεύματα μπορούν να βο- ηθήσουν κάποιον με μεγάλο βαθμό απώλειας ακοής που δεν έχει ωφεληθεί από τη χρήση ακουστικού. Το κοχλιακό εμφύτευμα τοπο- θετείται χειρουργικά στο αυτί. Μετατρέπει τους ήχους σε ηλεκτρι- κούς παλμούς και τους στέλνει στα νεύρα του αυτιού. Θα πρέπει να γίνει προσεκτική αξιολόγηση του ατόμου για να διαπιστωθεί αν ένα κοχλιακό εμφύτευμα θα βοηθήσει. Εάν η τοποθέτηση κοχλιακού εμ- φυτεύματος δεν είναι διαθέσιμη ή εφικτή, τότε ο ηλικιωμένος και η οικογένεια του θα πρέπει να ενημερωθούν σχετικά με τη χειλεανά- γνωση και τη νοηματική και να εκπαιδευτούν σε αυτές. Κυκλώματα επαγωγής ήχου και προσωπικοί ενισχυτές ήχου. Τα κυκλώματα επαγωγής ήχου και οι προσωπικοί ενισχυτές ήχου εί- ναι επίσης αποτελεσματικά μέσα. Ένα κύκλωμα επαγωγής ήχου, ή ακουστικό κύκλωμα, είναι ένα καλώδιο ή καλώδια τοποθετημένα σε έναν χώρο (για παράδειγμα σε μια αίθουσα συνεδριάσεων ή σε κάποιο γκισέ υπηρεσίας). Τα καλώδια στέλνουν σήματα από ένα μι- κρόφωνο και ενισχυτή σε συγκεκριμένους τύπους ακουστικών βα- ρηκοΐας. Οι κατευθυντήριες οδηγίες του ΠΟΥ για τα ακουστικά και τις υπηρεσίες ακοής για τις αναπτυσσόμενες χώρες, προσφέρουν καλύτερη καθοδήγηση. http://apps.who.int/iris/handle/10665/43066 Ακουστική Ικανότητα Μονοπάτια φροντίδας για τη διαχείριση της απώλειας ακοής ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Η ελαχιστοποίηση των επιπτώσεων της απώλειας ακοής μπορεί να βοηθήσει στη διατήρηση της ανεξαρτησίας και να μειώσει την ανά- γκη του ηλικιωμένου να βασίζεται σε κοινοτικές υπηρεσίες για την αντιμετώπιση καθημερινών αναγκών. Τα μέλη της οικογένειας, οι φροντιστές και η κοινότητα μπορούν όλοι να βοηθήσουν. Η απώλεια ακοής οδηγεί σε ψυχολογική δυσφορία και κοινωνική απομόνωση. Για αυτόν τον λόγο η ακοολογική αποκατάσταση δίνει πια μεγαλύτερη έμφαση στην εξέταση ψυχολογικών παραγόντων, προσαρμοσμένων στους στόχους του ηλικιωμένου και των φροντι- στών του. • Η τακτική κοινωνική αλληλεπίδραση δύναται να μειώσει τον κίν- δυνο έκπτωσης γνωστικών λειτουργιών, κατάθλιψης και άλλων συνεπειών της απώλειας ακοής που αφορούν συναισθήματα και συμπεριφορές. Σε περιόδους ιδιαίτερης ψυχικής δυσφορίας τα κοινωνικά υποστηρικτικά δίκτυα μπορούν να βοηθήσουν. • Οι σύντροφοι και τα μέλη της οικογένειας μπορούν να βοηθήσουν στην πρόληψη της μοναξιάς και της απομόνωσης. Ενδέχεται να χρειάζονται συμβουλές για το πώς θα το κάνουν αυτό. Για παρά- δειγμα, θα πρέπει να συνεχίσουν να επικοινωνούν με το άτομο που έχει απώλεια ακοής και να οργανώνουν δραστηριότητες που κρα- τούν το άτομο μέσα σε ένα κοινωνικό δίκτυο. Βλ. το πλαίσιο στα δε- ξιά για συμβουλές σχετικά με το πώς πρέπει να μιλάει κάποιος σε ένα άτομο με απώλεια ακοής. g 8.5 • Λύσεις που αφορούν το περιβάλλον στο σπίτι μπορεί να περιλαμ- βάνουν την εγκατάσταση κουδουνιών και τηλεφώνων που να ακούγονται σε όλο το σπίτι. 8.5 ΣΤΡΑΤΗΓΙΚΕΣ ΕΠΙΚΟΙΝΩΝΙΑΣ ΓΙΑ ΜΕΛΗ ΤΗΣ ΟΙΚΟΓΕΝΕΙΑΣ ΚΑΙ ΦΡΟΝΤΙΣΤΕΣ Οι επαγγελματίες υγείας μπορούν να συμβουλεύσουν τα μέλη της οικογένειας και τους φροντιστές να ακολουθούν ορισμένες απλές πρακτικές όταν μιλάνε σε ένα άτομο με απώλεια ακοής (14). 3 Επιτρέψτε στο άτομο να βλέπει το πρόσωπό σας όταν μιλάτε. 3 Βεβαιωθείτε ότι υπάρχει αρκετό φως στο πρόσωπό σας ώστε να βοηθηθεί ο ακροατής να διαβάσει τα χείλη σας. 3 Τραβήξτε την προσοχή του ατόμου προτού μιλήσετε. 3 Προσπαθήστε να αποφύγετε τους περισπασμούς, ειδικά τους δυνατούς θορύβους και τους θορύβους του περιβάλ- λοντος. 3 Μιλάτε καθαρά και πιο αργά. Μη φωνάζετε. 3 Μην παραιτείστε από το να μιλάτε με ανθρώπους που έχουν δυσκολία στην ακοή. Αυτό θα τους απομονώσει και θα οδη- γήσει σε κατάθλιψη. Αυτές οι στρατηγικές είναι βοηθητικές είτε χρησιμοποιεί είτε δεν χρησιμοποιεί το άτομο βοηθήματα ακοής.
Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Ψυχολογική ικανότητα Ο όρος «καταθλιπτική συμπτωματολογία» (ή κακή διάθεση) αναφέρεται σε ηλικιωμένους που παρουσιάζουν δύο ή περισσότερα συμπτώματα κατάθλι- ψης ταυτοχρόνως, διαρκώς ή κατά το μεγαλύτερο διάστημα τις τελευταίες δυο εβδομάδες τουλάχιστον, αλλά δεν πληρούν τα κριτήρια για τη διάγνωση μεί- ζονος κατάθλιψης. Η καταθλιπτική συμπτωματολογία είναι πιο κοινή σε ηλικι- ωμένους που αντιμετωπίζουν μακροχρόνια προβλήματα υγείας και αναπηρί- ας και βρίσκονται σε κοινωνική απομόνωση, και σε εκείνους που είναι οι ίδιοι φροντιστές με αυξημένες ευθύνες φροντίδας. Αυτά τα ζητήματα πρέπει να λη- φθούν υπ’ όψιν ως μέρος μιας συνολικής προσέγγισης στη διαχείριση των κα- ταθλιπτικών συμπτωμάτων. Η καταθλιπτική συμπτωματολογία αποτελεί μια σημαντική πτυχή της ψυχο- λογικής ικανότητας, αλλά είναι μία μόνο από τις διαστάσεις της. Υπάρχουν κι άλλες πτυχές, όπως το άγχος, τα χαρακτηριστικά της προσωπικότητας, η ικα- νότητα αντιμετώπισης προβλημάτων και η κατάκτηση αυτής της ικανότητας. Αυτές οι πτυχές απαιτούν περίπλοκες μετρήσεις. Το παρόν κεφάλαιο παρέχει καθοδήγηση για την πρόληψη και τη διαχείριση της καταθλιπτικής συμπτωματολογίας στους ηλικιωμένους. Περαιτέρω κα- θοδήγηση για παρεμβάσεις στην κατάθλιψη βρίσκονται στον οδηγό παρέμβα- σης του ΠΟΥ mhGAP, στο https://apps.who.int/iris/ handle/10665/250239 ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Κάνοντας ορισμένες ερωτήσεις, ο επαγγελματίας πρωτοβάθμιας φρο- ντίδας στην κοινότητα μπορεί να εντοπίσει όσους έχουν καταθλιπτικά συμπτώματα και να διακρίνει την καταθλιπτική συμπτωματολογία από την κατάθλιψη. • Με τη χρήση βραχέων δομημένων ψυχολογικών παρεμβάσεων, εκ- παιδευμένοι και εποπτευόμενοι μη εξειδικευμένοι επαγγελματίες υγείας μπορούν να βοηθήσουν άτομα με καταθλιπτική συμπτωματο- λογία εντός της κοινότητας και στο πλαίσιο άλλων δομών πρωτοβάθ- μιας φροντίδας. • Η κατάθλιψη απαιτεί συνολική και συνήθως εξειδικευμένη θεραπεία. • Έκπτωση σε άλλους τομείς της ενδογενούς ικανότητας, όπως είναι η ακοή ή η κινητικότητα, μπορεί να βλάψει τις λειτουργικές ικανότητες, να μειώσει την κοινωνική συμμετοχή και να συμβάλλει στην καταθλι- πτική συμπτωματολογία. Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Απαιτείται εξειδικευμένη φροντίδα οι ηλικιωμένοι χρησιμοποιούν διάφορους όρους για τη κακή διάθεση, όπως θλίψη, κατάθλιψη, ψυχολογική πτώση κ.λπ. Ν Α Ι Ο Χ Ι ΕΛΕΓΞΤΕ ΓΙΑ ΚΑΤΑΘΛΙΠΤΙΚΗ ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ Ελαττώστε το στρες και ενδυναμώστε την κοινωνική στήριξη Παρακινήστε τους ηλικιωμένους ώστε να παραμέινουν κινητικοί και κοινωνικώς δικτυωμένοι Ενισχύστε τη λειτουργικότητα στις καθημερινές δραστηριότητες Ενθαρρύνετε τη συμμετοχή σε προγράμματα άσκησης και ανάπτυξης δεξιοτήτων μέσα στην κοινότητα Εντοπίστε και αντιμετωπίστε τη μοναχικότητα και τον κοινωνικό αποκλεισμό (εξετάστε παρεμβάσεις βασισμένες στην τεχνολογία) ΡΩΤΗΣΤΕ Στη διάρκεια των τελευταίων δύο εβδομάδων σας ενόχλησε Η αίσθηση ότι είστε πεσμένος, καταθλιμμένος ή απελπισμένος; * ΚΑΤΑΘΛΙΠΤΙΚΑ ΣΥΜΠΤΩΜΑΤΑ (0 - 2 επιπλέον συμπτώματα) ΚΑΤΑΘΛΙΨΗ (≥ 3 επιπλέον συμπτώματα) Η έλλειψη ενδιαφέροντος ή ευχαρίστησης να κάνετε πράγματα; Ενισχύστε γενικές συμβουλές υγείας και τρόπου ζωής ή τη συνήθη φροντίδα Ο Χ Ι (σε όποιο από τα παραπάνω) (σε όλα) ΠΟΛΥΦΑΡΜΑΚΙΑ ΠΟΝΟΣ ΑΝΑΙΜΙΑ, ΔΥΣΘΡΕΨΙΑ ΥΠΟΘΥΡΕΟΕΙΔΙΣΜΟΣ Ο Χ Ι ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΔΙΑΘΕΣΗ i 1 Προσφέρετε βραχείες δομημένες ψυχολογικές παρεμβάσεις: g 9.1 - γνωσιακή συμπεριφορική Θεραπεία - συμβουλευτική ή θεραπεία στην επίλυση προβλημάτων - συμπεριφορικη ενεργοποίηση - Θεραπεία ανασκόπησης ζωής Πολυδιάστατη άσκηση g9.2 Εξάσκηση ενσυνειδητότητας g9.3 Αντιμετωπίστε την κατάθλιψη Οι ηλικιωμένοι με διάγνωση μείζονος κατάθλιψης συνήθως χρειάζονται εξειδικευμένη φροντίδα. Θα πρέπει να ενημερωθούν και να τους παρασχεθεί θεραπεία σύμφωνα με τις προτάσεις του οδηγού παρέβασης του ΠΟΥ mhGAP https://apps.who.int/iris/handle/10665/250239 - Μείζων απώλεια τους τελευταίους 6 μήνες - Ιστορικό μανίας - Έκπτωση γνωστικών λειτουργιών - Απώλεια ακοής - Οπτική δυσχέρεια - Αναπηρία οφειλόμενη σε ασθένεια ή τραυματισμό ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ g9.4 - 9.7 ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Αναθεωρήστε τη φαρμακευτική αγωγή όπως αντικαταθλιπτικά, αντιισταμινικά αντιψυχωτικά Συνολική διαχείριση των καταστάσεων g Αξιολογήστε και διαχειριστείτε τον πόνο 6 Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων ΚΑΤΑΘΛΙΠΤΙΚΗ ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ Εάν ένα άτομο έχει τουλάχιστον ένα από τα βασικά και ένα ή δύο από τα επιπρόσθετα συμπτώματα, πιθανώς να έχει καταθλιπτική συμπτωματολογία. Εάν ένα άτομο έχει περισσότερα από δύο συ- μπτώματα, πιθανώς να πληροί τα κριτήρια για τη διάγνωση κατα- θλιπτικής διαταραχής. Είναι σημαντικό να διακρίνετε την καταθλι- πτική συμπτωματολογία από την καταθλιπτική διαταραχή καθώς η αντιμετώπισή των δύο διαφέρει. • Η έκπτωση γνωστικών λειτουργιών και η άνοια μπορεί να συνδέ- ονται με την καταθλιπτική συμπτωματολογία και πρέπει επίσης να αξιολογηθούν. Άτομα με άνοια προσέρχονται συχνά σε επαγ- γελματίες υγείας με παράπονα για τη διάθεσή τους ή προβλήμα- τα συμπεριφοράς, όπως η απάθεια, η απώλεια ελέγχου των συ- ναισθημάτων ή η δυσκολία διεκπεραίωσης συνηθισμένων ερ- γασιακών, οικιακών ή κοινωνικών δραστηριοτήτων. • Ταυτοχρόνως, η έκπτωση σε άλλους τομείς της ενδογενούς ικα- νότητας, όπως οι αισθητηριακοί και οι κινητικοί, μπορεί να μει- ώσει τη λειτουργική ικανότητα και την κοινωνική συμμετοχή και έτσι να συμβάλει στην καταθλιπτική συμπτωματολογία. • Οι παρεμβάσεις για την έκπτωση σε άλλους τομείς ενδογενών ικανοτήτων, όπως οι γνωστικές ικανότητες ή η ακοή, πιθανώς να είναι πιο αποτελεσματικές εάν συγχρόνως αντιμετωπιστεί και η καταθλιπτική συμπτωματολογία. Αυτό είναι κάτι που πρέπει να εξετάζεται όταν διαμορφώνεται το εξατομικευμένο πλάνο φρο- ντίδας. ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΦΡΟΝΤΙΔΑ • Η διαχείριση της κατάθλιψης απαιτεί μια πιο διεξοδική και συνήθως εξειδικευμένη προσέγγιση, προκειμένου να διαμορφωθεί ένα εξατομικευμένο πλάνο φροντίδας. • Προκειμένου να διαχειριστούν τα καταθλιπτικά συμπτώματα, οι επαγγελματίες υγείας χρειάζονται ιδιαίτερη εκπαίδευση στις βραχείες δομημένες ψυχολογικές παρεμβάσεις. • Ορισμένες συνδεόμενες παθήσεις, όπως ο υποθυρεοειδισμός, πιθανώς να απαιτούν εξειδικευμένη διάγνωση και θεραπεία. ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΔΙΑΘΕΣΗ Εάν ένα άτομο αναφέρει τουλάχιστον ένα από τα βασικά συμπτώ- ματα – αίσθηση ότι είναι πεσμένο, καταθλιμμένο ή απελπισμένο και ότι έχει ελάχιστο ενδιαφέρον ή ευχαρίστηση να κάνει πράγ- ματα – προχωρήστε σε περαιτέρω αξιολόγηση της διάθεσης. Μπορούν να χρησιμοποιηθούν εναλλακτικές λέξεις εάν ένα άτο- μο δεν είναι εξοικειωμένο με αυτές των δυο ερωτήσεων της διε- ρεύνησης. ΡΩΤΗΣΤΕ: «Στη διάρκεια των τελευταίων δυο εβδομάδων σας ενόχλησε κάποιο από τα παρακάτω προβλήματα;»* • Δυσκολία να κοιμηθείτε ή να παραμείνετε κοιμισμένος ή κοιμό- σασταν πάρα πολύ; • Νιώθατε κουρασμένος ή ότι δεν είχατε αρκετή ενέργεια; • Έλλειψη όρεξης ή υπερφαγία; • Αισθανόσασταν άσχημα για τον εαυτό σας ή ότι είστε αποτυχη- μένος ή ότι έχετε απογοητεύσει τον εαυτό σας ή την οικογένειά σας; • Δυσκολία να συγκεντρωθείτε σε δραστηριότητες, όπως το διά- βασμα εφημερίδας ή η παρακολούθηση τηλεόρασης; • Κινούσασταν ή μιλούσατε τόσο αργά ώστε αυτό να έχει γίνει αντιληπτό από τους άλλους; • Ήσασταν τόσο νευρικός ή ανήσυχος που περιφερόσα σταν πε- ρισσότερο από συνήθως; • Σκέψεις ότι θα ήταν καλύτερο να πεθαίνατε ή να κάνατε κακό στον εαυτό σας κατά κάποιον τρόπο; Αυτές οι ερωτήσεις υπάρχουν στο Ερωτηματολόγιο Υγείας Ασθενούς (http:// www.cqaimh.org/pdf/tool_phq9.pdf), που είναι ένα από τα εργαλεία της εκτίμησης της καταθλιπτικής συμπτωματολογίας. Ή βλ. το κεφάλαιο της κα- τάθλιψης στον οδηγό παρέμβασης mhGAP, στο https://apps.who.int/iris/ handle/10665/250239). ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗΝ ΚΑΤΑΘΛΙΠΤΙΚΗ ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Αυτές οι παρεμβάσεις συνήθως πραγματοποιούνται από επαγγελματίες υγείας με εκπαίδευση στην ψυχική υγεία. Οι εργαζόμενοι υγείας στην κοινότητα μπο- ρούν επίσης να τις πραγματοποιήσουν, εάν είναι έμπειροι και εκπαιδευμένοι στα θέματα ψυχικής υγείας των ηλικιωμένων. Δεν έχουν αναφερθεί ποτέ βλά- βες που να σχετίζονται με αυτές τις παρεμβάσεις. 9.1 ΒΡΑΧΕΙΕΣ ΔΟΜΗΜΕΝΕΣ ΨΥΧΟΛΟΓΙΚΕΣ ΠΑΡΕΜΒΑΣΕΙΣ Οι βραχείες δομημένες ψυχολογικές παρεμβάσεις, όπως η γνωσι- ακή συμπεριφορική θεραπεία, οι παρεμβάσεις επίλυσης προβλη- μάτων, η συμπεριφορική ενεργοποίηση και η θεραπεία ανασκόπη- σης της ζωής, μπορούν να μειώσουν αισθητά την καταθλιπτική συ- μπτωματολογία στους ηλικιωμένους. Οι πολυδιάστατη άσκηση και η εξάσκηση ενσυνειδητότητας μπορούν επίσης να μειώσουν τα κα- ταθλιπτικά συμπτώματα. Πολλές ψυχολογικές παρεμβάσεις μπορούν να χρησιμοποιηθούν, με τη συναίνεση και τη σύμφωνη γνώμη του ηλικιωμένου, λαμβά- νοντας υπ’ όψιν τις ανησυχίες του, όπως για παράδειγμα τις δυσκο- λίες στην επίλυση προβλημάτων. Η σωματική άσκηση πρέπει επί- σης να εξεταστεί, επιπροσθέτως με τις ψυχολογικές θεραπείες, λό- γω του θετικού αποτελέσματός της στη βελτίωση της διάθεσης (βλ. Κεφάλαιο 5 περί περιορισμένης κινητικότητας). g Δεν συστήνεται η συνταγογράφηση αντικαταθλιπτικών από τον ια- τρό της πρωτοβάθμιας φροντίδας υγείας, εάν αυτός δεν έχει εξειδι- κευμένες γνώσεις ψυχικής υγείας. Γνωσιακή συμπεριφορική θεραπεία Η γνωσιακή συμπεριφορική θεραπεία (CBT) βασίζεται στην ιδέα ότι τα συναι- σθήματα επηρεάζονται τόσο από τις πεποιθήσεις όσο και από τη συμπεριφο- ρά. Άτομα με καταθλιπτική συμπτωματολογία (ή με διαγνωσμένες ψυχικές διαταραχές) πιθανώς να έχουν μη ρεαλιστικές, διαστρεβλωμένες αρνητικές σκέψεις, οι οποίες δύνανται να οδηγήσουν σε βλαπτική συμπεριφορά εάν δεν αντιμετωπιστούν. Έτσι, η γνωσιακή συμπεριφορική θεραπεία συνήθως έχει ένα γνωσιακό κομμάτι – που βοηθάει το άτομο να αναπτύξει την ικανό- τητα να αναγνωρίζει και να αμφισβητεί τις μη ρεαλιστικές αρνητικές σκέψεις – καθώς και ένα συμπεριφορικό που ενδυναμώνει τις θετικές συμπεριφο- ρές και μειώνει τις αρνητικές. Τα βήματα μπορούν να περιλαμβάνουν (1) την αναγνώριση των προβλημάτων στη ζωή του ασθενούς, (2) την επίγνωση των σκέψεων, των συναισθημάτων και των πεποιθήσεων σχετικά με αυτά τα προβλήματα, (3) την αναγνώριση της αρνητικής ή ανακριβούς σκέψης και (4) την αναδιαμόρφωση αυτής της σκέψης σε μια πιο ρεαλιστική. Συμβουλευτική ή θεραπεία επίλυσης προβλημάτων Η προσέγγιση της επίλυσης προβλημάτων πρέπει να εξετάζεται για τα άτομα με καταθλιπτική συμπτωματολογία που βρίσκονται σε δυσφορία ή έχουν κά- ποιο βαθμό έκπτωσης στην κοινωνική τους λειτουργικότητα (όταν δεν υπάρ- χει διαγνωσμένο καταθλιπτικό επεισόδιο ή καταθλιπτική διαταραχή). Η θεραπεία επίλυσης προβλημάτων προσφέρει στο άτομα άμεση και πρα- κτική υποστήριξη. Ο επαγγελματίας υγείας που παίζει τον ρόλο του θερα- πευτή και ο ηλικιωμένος δουλεύουν μαζί για να εντοπίσουν και να απομο- νώσουν κομβικά προβληματικά σημεία που μπορεί να συμβάλλουν στην καταθλιπτική συμπτωματολογία. Μαζί τις αποδομούν σε μικρές συγκεκρι- μένες, διαχειρίσιμες εργασίες βάσει της επίλυσης προβλημάτων και με την ανάπτυξη στρατηγικών αντιμετώπισης των συγκεκριμένων προβλημάτων. 5 Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Συμπεριφορική ενεργοποίηση Η συμπεριφορική ενεργοποίηση περιλαμβάνει την ενθάρρυνση του ατόμου να συμμετάσχει σε επιβραβευτικές δραστηριότητες, ως μέ- σο μείωσης της καταθλιπτικής συμπτωματολογίας. Αυτή η προσέγγιση μπορεί να διδαχθεί πιο γρήγορα από τις περισ- σότερες άλλες, τεκμηριωμένες βάσει στοιχείων, ψυχολογικές θε- ραπείες. Μπορούν να την εμπεδώσουν μη εξειδικευμένα άτομα και έτσι η πρόσβαση στη φροντίδα για την καταθλιπτική συμπτωματολο- γία μπορεί να διευρυνθεί. Η παρέμβαση έχει μελετηθεί κυρίως ως μια παρέμβαση πολλαπλών συνεδριών που πραγματοποιείται από ειδικούς. Είναι ωστόσο δυνατόν η παρέμβαση να τροποποιηθεί ώστε να γίνει βραχεία και να διεξάγεται από εκπαιδευμένους επαγγελ- ματίες υγείας σαν μια συμπληρωματική θεραπεία ή ως μέρος ενός πρώτου βήματος μιας συνολικής προσέγγισης πρωτοβάθμιας φρο- ντίδας. Θεραπεία ανασκόπησης της ζωής Στη θεραπεία ανασκόπησης της ζωής, ένας θεραπευτής καθοδηγεί το άτομο να θυμηθεί και να αξιολογήσει το παρελθόν του, ώστε να καταλήξει σε μια αίσθηση ηρεμίας και αποδοχής σχετικά με τη ζωή του. Αυτού του τύπου η θεραπεία μπορεί να βοηθήσει τον ασθενή να δει τις πραγματικές διαστάσεις της ζωής του, ή ακόμα και να ανακτή- σει σημαντικές αναμνήσεις σχετικές με φίλους και αγαπημένα πρό- σωπα. Η θεραπεία ανασκόπησης της ζωής μπορεί να βοηθήσει στην αντιμετώπιση της κατάθλιψης στους ηλικιωμένους όπως επίσης και αυτούς που αντιμετωπίζουν προβλήματα σχετιζόμενα με το τέλος της ζωής. Οι θεραπευτές επικεντρώνουν τη θεραπεία ανασκόπησης της ζωής σε συγκεκριμένη θεματολογία της ζωής του ασθενούς ή σε ανασκόπηση συγκεκριμένων περιόδων, όπως είναι η παιδική ηλι- κία, η περίοδος που ο ασθενής ήταν γονέας, η μετάβαση στον ρόλο του παππού ή της γιαγιάς, ή τα εργασιακά του χρόνια. 9.2 ΠΟΛΥΔΙΑΣΤΑΤΗ ΣΩΜΑΤΙΚΗ ΑΣΚΗΣΗ Ένα πρόγραμμα άσκησης προσαρμοσμένο στις σωματικές ικανότη- τες και προτιμήσεις του ατόμου δύναται να μειώσει την καταθλιπτι- κή συμπτωματολογία βραχυπρόθεσμα και πιθανώς ακόμα και πιο μακροπρόθεσμα. (Βλ. κεφάλαιο 5 σχετικά με την περιορισμένη κι- νητικότητα). g 5 9.3 ΕΞΑΣΚΗΣΗ ΕΝΣΥΝΕΙΔΗΤΟΤΗΤΑΣ Η ενσυνειδητότητα αναφέρεται στη συγκέντρωση της προσοχής σε αυτό που συμβαίνει την παρούσα στιγμή, σε μια διαδικασία όπου δεν παρασύρεται κανείς από τον ειρμό των σκέψεων σχετικά με το παρελθόν, το μέλλον, τις επιθυμίες, τις ευθύνες ή τη μεταμέλεια. Αυτές οι σκέψεις μπορούν να οδηγήσουν το άτομο με καταθλιπτική συμπτωματολογία σε μια «ελεύθερη πτώση». Υπάρχουν πολλοί τύποι εξάσκησης της ενσυνειδητότητας. Μια προσέγγιση που χρη- σιμοποιείται ευρέως είναι το άτομο να κάθεται ή να είναι ξαπλωμέ- νο σιωπηλό, και να επικεντρώνει την προσοχή του στις αισθήσεις της αναπνοής. Η ενσυνειδητότητα της σωματικής κίνησης – κατά τη διάρκεια της γιόγκα επί παραδείγματι, ή του βαδίσματος – είναι επί- σης επωφελής για κάποιους ανθρώπους. ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΣΧΕΤΙΖΟΜΕΝΕΣ ΚΑΤΑΣΤΑΣΕΙΣ Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Η ύπαρξη των ακόλουθων σχετιζόμενων καταστάσεων θα καταδείκνυε ότι απαιτείται μια διαφορετική θεραπεία για την κατάθλιψη. • Μείζων απώλεια τους τελευταίους έξι μήνες. • Ιστορικό μανίας. Η μανία είναι ένα επεισόδιο ανύψωσης της διά- θεσης και αύξησης της ενέργειας και της δραστηριότητας. Τα άτο- μα που βιώνουν μανιακά επεισόδια ταξινομούνται ως πάσχοντα από διπολική διαταραχή. Το ιστορικό μανίας μπορεί να εντοπιστεί με τη διερεύνηση της ύπαρξης διάφορων συμπτωμάτων που πα- ρουσιάζονται ταυτοχρόνως, διαρκούν τουλάχιστον για μια εβδο- μάδα και είναι αρκετά έντονα ώστε να εμποδίζουν σημαντικά την εργασία και τις κοινωνικές δραστηριότητες ή απαιτούν νοσηλεία ή εγκλεισμό (βλ. τον οδηγό παρέμβασης mhGAP https://www. paho.org/mhgap/en/ bipolar_flowchart.html) . • Έκπτωση γνωστικών λειτουργιών. Η σχέση μεταξύ της κατάθλι- ψης και της έκπτωσης γνωστικών λειτουργιών είναι πολύπλοκη. Οι επιδημιολογικές μελέτες έχουν από καιρό συνδέσει την κατά- θλιψη με την ανάπτυξη της νόσου Αλτσχάιμερ. Οι γνωστικές λει- τουργίες που επηρεάζονται από την κατάθλιψη είναι η προσοχή, η μάθηση και η οπτική μνήμη, όπως επίσης και οι εκτελεστικές λει- τουργίες. Η κατάθλιψη πιθανώς να αποτελεί μια ψυχολογική από- κριση στην επίγνωση του ατόμου ότι έχει μια ήπια έκπτωση των γνωστικών του λειτουργιών, η οποία όμως δεν έχει αρχίσει ακόμα να επηρεάζει τη λειτουργικότητά του στην καθημερινότητα. • Απώλεια ακοής. Οι ηλικιωμένοι με απώλεια ακοής είναι πιθανό να αναφέρουν αίσθημα ντροπής, άγχους και απώλειας αυτοεκτί- μησης, και είναι λιγότερο πιθανό να συμμετέχουν σε κοινωνικές και σωματικές δραστηριότητες, γεγονός που οδηγεί σε κοινωνική απομόνωση, μοναξιά και, εν τέλει, κατάθλιψη (15). • Τα προβλήματα όρασης και η ύπαρξη μειζόνων οφθαλμικών ασθενειών που σχετίζονται με τη γήρανση, όπως η εκφύλιση της ωχράς κηλίδος και το γλαύκωμα συνδέονται με αυξημένο κίνδυνο κατάθλιψης (16). Άτομα με κακή λειτουργία της όρασης συχνά αναφέρουν ότι αισθάνονται δυστυχισμένα, μόνα ή ακόμα και απελπισμένα. • Αντίδραση σε αναπηρία οφειλόμενη σε ασθένεια ή τραυματισμό. Η κατάθλιψη είναι μια συχνή δευτεροπαθής πάθηση σε άτομα με αναπηρία. Άτομα που βιώνουν αναπηρία συνεπεία ασθένειας και τραυματισμού υφίστανται στρες και πρέπει να διαχειριστούν τις μεταβολές στη ζωή τους. Τα στάδια της προσαρμογής σε ένα νέο είδος αναπηρίας περιλαμβάνουν το σοκ, την άρνηση, τον θυμό/ κατάθλιψη και την προσαρμογή/αποδοχή. Οι ηλικιωμένοι με νέες αναπηρίες κινδυνεύουν να παρουσιάσουν άγχος και κατάθλιψη. Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων9.4 ΠΟΛΥΦΑΡΜΑΚΙΑ Η πολυφαρμακία μπορεί να οδηγήσει σε καταθλιπτική συμπτω- ματολογία και η καταθλιπτική συμπτωματολογία μπορεί να οδη- γήσει σε πολυφαρμακία. Η αντιμετώπιση της πολυφαρμακίας, αλλά και της καταθλιπτικής συμπτωματολογίας, είναι σημαντική προκειμένου να σπάσει ο φαύλος κύκλος. Εκτός από τα φάρμα- κα που δρουν κυρίως στο κεντρικό νευρικό σύστημα, φάρμακα με ψυχοτρόπες ιδιότητες, όπως τα αντιισταμινικά και τα αντιψυχωτι- κά, τα μυοχαλαρωτικά, και άλλα μη ψυχοτρόπα φάρμακα με αντι- χολινεργικές ιδιότητες μπορεί να συνδέονται με καταθλιπτική συ- μπτωματολογία. Η εξάλειψη περιττών, μη αποτελεσματικών φαρ- μάκων, καθώς και φαρμάκων με κοινή δράση μειώνει την πολυ- φαρμακία. 9.5 ΑΝΑΙΜΙΑ, ΔΥΣΘΡΕΨΙΑ Η αναιμία και η δυσθρεψία μπορεί να οδηγήσουν σε καταθλιπτική συμπτωματολογία λόγω ανεπάρκειας σιδήρου, βιταμινών όπως το φυλλικό οξύ και οι βιταμίνες Β6 και Β12. Η καταθλιπτική συμπτω- ματολογία μπορεί επίσης να παίξει ρόλο στην εμφάνιση αναιμίας. Η απώλεια της όρεξης και η έλλειψη ενδιαφέροντος για τη διεκπε- ραίωση καθημερινών δραστηριοτήτων (όπως είναι τα ψώνια και το μαγείρεμα) μπορούν να ελαττώσουν την ποιότητα και την ποσότητα της διατροφής στους ηλικιωμένους, διευκολύνοντας έτσι την ανά- πτυξη αναιμίας και δυσθρεψίας. Προκειμένου να αντιμετωπιστεί η καταθλιπτική συμπτωματολογία, είναι κομβικής σημασίας να αντι- μετωπιστεί η αναιμία και να βελτιωθεί η διατροφική κατάσταση (Βλ. Κεφάλαιο 6 σχετικά με τον υποσιτισμό). g 6 9.6 ΥΠΟΘΥΡΕΟΕΙΔΙΣΜΟΣ Ο υποθυρεοειδισμός είναι μια κοινή διαταραχή στους ηλικιωμέ- νους και ιδιαίτερα στις γυναίκες. Τα συμπτώματα του υποθυρεοειδι- σμού μπορεί να μην είναι συγκεκριμένα και να διαφέρουν από άτο- μο σε άτομο, αλλά είναι πιθανό να περιλαμβάνουν και καταθλιπτι- κά συμπτώματα. Ο υποθυρεοειδισμός πρέπει να αξιολογείται και να αντιμετωπίζεται από επαγγελματίες υγείας με εξειδικευμένη γνώ- ση. 9.7 ΠΟΝΟΣ Τα άτομα που αναφέρουν χρόνιο πόνο έχουν πιο συχνά καταθλιπτι- κή συμπτωματολογία. Είναι σημαντικό να γίνεται αξιολόγηση και διαχείριση του πόνου (Βλ. Κεφάλαιο 5 σχετικά με την περιορισμένη κινητικότητα). g 5 ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΟ ΚΟΙΝΩΝΙΚΟ ΚΑΙ ΦΥΣΙΚΟ ΠΕΡΙΒΑΛΛΟΝ Ψυχολογική ικανότητα Μονοπάτια φροντίδας για τη διαχείριση καταθλιπτικών συμπτωμάτων Η απώλεια ενδιαφέροντος για δραστηριότητες που παλαιότερα εν- διέφεραν το άτομο ή του ήταν ευχάριστες είναι συνήθης στην κατά- θλιψη. Τα μέλη της οικογένειας και οι φροντιστές μπορούν να προ- σφέρουν ήπια ενθάρρυνση και υποστήριξη για περισσότερη σωμα- τική δραστηριότητα και κοινωνική αλληλεπίδραση, όπως προγράμ- ματα άσκησης και ανάπτυξης δεξιοτήτων στην κοινότητα. Εάν ένα ηλικιωμένο άτομο βιώσει απώλεια μιας λειτουργίας όπως είναι η ακοή ή ο περιορισμός της κινητικής του ικανότητας, τα μέλη της οικογένειάς του και οι φροντιστές του μπορούν να δώσουν προ- σοχή στην αποφυγή της κοινωνικής του απομόνωσης. Η κοινωνική απομόνωση μπορεί να οδηγήσει σε καταθλιπτική συμπτωματολο- γία. Εξετάστε και την αξιοποίηση παρεμβάσεων που βασίζονται στην τεχνολογία για την αντιμετώπιση της μοναξιάς με τη χρήση του τη- λεφώνου και του διαδικτύου. Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη Κοινωνική φροντίδα και υποστήριξη Για τα άτομα με σημαντική απώλεια της ενδογενούς ικανότητάς τους η διατήρηση της αξιοπρέπειας είναι συχνά δυνατή μόνο με την παρο- χή φροντίδας, υποστήριξης και βοήθειας από τους άλλους. Η κοινωνι- κή μέριμνα και υποστήριξη είναι σημαντική για τη διασφάλιση μιας αξι- οπρεπούς και ουσιαστικής ζωής και περιλαμβάνει όχι μόνο βοήθεια με τις δραστηριότητες της καθημερινής ζωής. Η κοινωνική μέριμνα και υποστήριξη περιάμβάνει (Αctivities of Daily Living-ADLs) και την προσωπική φροντίδα, αλλά και τη διευκόλυνση της πρόσβασης σε κοι- νοτικές δομές και δημόσιες υπηρεσίες, τον περιορισμό της απομόνω- σης και του αισθήματος μοναξιάς, την οικονομική εξασφάλιση, την πα- ροχή κατάλληλου τόπου διαβίωσης, την προστασία από παρενοχλή- σεις και κακοποίηση, καθώς και τη συμμετοχή σε δραστηριότητες που δίνουν νόημα στη ζωή. Σχετικά με την κοινωνική φροντίδα και υποστήριξη, το περιεχόμενο της ερώτησης καθορίζει και το άτομο που θα την απαντήσει καλύτερα. Στην περίπτωση ηλικιωμένων με άνοια, ερωτήσεις σχετικά με τις καθημερι- νές δραστηριότητες και τα οικονομικά θέματα μπορούν να απαντηθούν καλύτερα από κάποιον που γνωρίζει καλά τον ηλικιωμένο, όπως ένα μέλος της οικογένειάς του, ο φροντιστής ή ένας φίλος του. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Η έκπτωση της λειτουργικής ικανότητας είναι κοινό χαρακτηριστι- κό μεταξύ των ηλικιωμένων, ειδικά εκείνων με έκπτωση της ενδογε- νούς ικανότητας, αλλά δεν είναι αναπόφευκτη. • Οι εργαζόμενοι στον τομέα της υγείας στην κοινότητα μπορούν να πραγματοποιήσουν έλεγχο για απώλεια λειτουργικής ικανότητας χρησιμοποιώντας ένα απλό ερωτηματολόγιο. • Παρεμβάσεις προσαρμοσμένες στις προτεραιότητες των ηλικιωμέ- νων μπορούν να βελτιώσουν τη λειτουργική τους ικανότητα. • Οι αποτελεσματικές παρεμβάσεις περιλαμβάνουν εκείνες που βελ- τιώνουν την ενδογενή ικανότητα, τη λειτουργικότητα και την παροχή κοινωνικής φροντίδας και υποστήριξης. Κοινωνική φροντίδα και υποστήριξη Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη Ο Χ Ι ΑΞΙΟΛΟΓΗΣΤΕ ΤΙΣ ΑΝΑΓΚΕΣ ΚΟΙΝΩΝΙΚΗΣ ΦΡΟΝΤΙΔΑΣ ΚΑΙ ΥΠΟΣΤΗΡΙΞΗΣ ΡΩΤΗΣΤΕ Αξιολογήστε και τροποποιήστε τις συνθήκες του φυσικού περιβάλλοντος για να αντισταθμιστεί ή απώλεια της ενδογενούς ικανότητας, να βελτιωθεί η κινητικότητα και να προληφθούν οι πτώσεις Εξετάστε τη χρήση υποστηρικτικών τεχνολογιών, βοηθημάτων και προσαρμογών Αξιολογήστε την υποστήριξη από τον/τη σύζυγο, την οικογένεια ή άλλους άμισθους φροντιστές, και συμπεριλάβετε μια αξιολόγηση των αναγκών του φροντιστή Αναθεωρήστε την ανάγκη για υποστήριξη από αμειβόμενους επαγγελματίες φροντίδας Οι φροντιστές και οι υπηρεσίες πρέπει να είναι διαθέσιμοι στο σπίτι, στα κέντρα ημέρας, σε μονάδες φροντίδας ΒΟΗΘΗΣΤΕ ΜΕ ΤΗΝ ΚΟΙΝΩΝΙΚΗ ΦΡΟΝΤΙΔΑ (ΠΡΟΣΩΠΙΚΗ ΒΟΗΘΕΙΑ) 1. Δυσκολεύεστε να μετακινείστε σε εσωτερικούς χώρους; 2. Δυσκολεύεστε με τη χρήση της τουαλέτας; 3. Δυσκολεύεστε να ντυθείτε μόνος/η σας; 4. Δυσκολεύεστε να χρησιμοποιήσετε το μπάνιο ή το ντους; 5. Δυσκολεύεστε με τη φροντίδα της εξωτερικής σας εμφάνισης; 6. Δυσκολεύεστε να φάτε μόνος/η σας; 7. Αντιμετωπίζετε πρόβλημα με το μέρος που ζείτε; 8. Αντιμετωπίζετε πρόβλημα με τα οικονομικά σας; 9. Αισθάνεστε μοναξιά 10. Μπορείτε να ασχοληθείτε με χόμπι, δραστηριότητες αναψυχής, εργασία, εθελοντι- σμό, υποστήριξη της οικογένειάς σας, εκπαιδευ- τικές ή πνευματικές δραστηριότητες που είναι σημαντικές για εσάς; 11. Αξιολογήστε τον κίνδυνο κακοποίησης του ηλικιωμένου Ν Α Ι Ν Α Ι Ν Α Ι Ν Α Ι Ν Α Ι ΡΩΤΗΣΤΕ ΣΥΜΠΛΗΡΩΜΑΤΙΚΕΣ ΕΡΩΤΗΣΕΙΣ Σας ανησυχεί: 1. Η ασφάλειά σας στο μέρος που μένετε; 2. Η κατάσταση του σπιτιού σας; 3. Η τοποθεσία του σπιτιού σας; 4. Το κόστος της στέγασης; 5. Η επισκευή και η συντήρηση του σπιτιού σας; 6. Η δυνατότητα να ζείτε ανεξάρτητα εκεί που είστε; ΡΩΤΗΣΤΕ ΣΥΜΠΛΗΡΩΜΑΤΙΚΕΣ ΕΡΩΤΗΣΕΙΣ 1. Γενικά πώς τα πάτε με τα οικονομικά σας στο τέλος του μήνα; 2. Είστε σε θέση να διαχειριστείτε τα χρήματά σας και τις οικονομικές σας υποθέσεις; 3. Θα θέλατε συμβουλές σχετικά με επιδόματα και βοηθήματα; Εξετάστε τρόπους βελτίωσης: - των στενών κοινωνικών σχέσεων (με σύζυγο, οικογένεια, φίλους, κατοικίδια) - της χρήσης πόρων της τοπικής κοινότητας (λέσχες, θρησκευτικές ομάδες, κέντρα ημέρας, αθλητισμό, ψυχαγωγικές δραρτηριότητες, εκπαίδευση) - των ευκαιριών συνεισφοράς (εθελοντισμός, απασχόληση) - της συνδεσιμότητας μέσω της χρήσης τεχνολογιών επικοινωνίας Εξετάστε: - προσαρμογές στο σπίτι - εναλλακτικό τόπο διαμονής - παραπομπή στην κοινωνική πρόνοια, η σε κοινοτικά προγράμματα στέγασης ή σε υπάρχοντα υποστηρικτικά δίκτυα Εξετάστε: - παραπομπή για εξειδικευμένες οικονομικές συμβουλές - συμβουλές για την ανάθεση της λήψης των οικονομικών αποφάσεων με προστασία απέναντι σε οικονομική εκμε- τάλλευση ΡΩΤΗΣΤΕ ΣΥΜΠΛΗΡΩΜΑΤΙΚΕΣ ΕΡΩΤΗΣΕΙΣ ΓΙΑ ΝΑ ΠΡΟΣΔΙΟΡΙΣΕΤΕ ΤΑ ΕΜΠΟΔΙΑ Δεν μπορείτε να ασχοληθείτε με ... λόγω: 1. κόστους, 2. απόστασης, 3. μετακίνησης, 4. έλλειψης ευκαιριών, 5. άλλο; Προσφέρετε μια λίστα τοπικών κοινοτικών υπηρεσιών διαθέσιμες για ηλικιωμένους όπως εγκαταστάσεις αναψυχής, σύλλογοι, προγράμματα εκπαίδευσης, εθελοντισμού και απασχόλησης Ενθαρρύνετε τον ηλικιωμένο να χρησιμοποιεί αυτές τις υπηρεσίες προκειμένου να αυξήσει τη συμμετοχή του Δεδομένα από την παρατήρηση της συμπεριφοράς του ηλικιωμέ- νου, της συμπεριφοράς των φροντιστών ή των συγγενών ή από ση- μάδια σωματικής κακοποίησης πρέπει να χρησιμοποιούνται για την αναγνώριση πιθανής κακοποίησης. Σε οποιαδήποτε περίπτωση άμεσης απειλής παραπέμψτε για εξειδικευ- μένη αξιολόγηση από κοινωνικό λειτουργό προγράμματα προστασίας ενηλίκων ή όργανα επιβολής του νόμου i 1 Οι εργαζόμενοι στον τομέα της υγείας θα πρέπει να γνωρίζουν πού πρέπει να παραπέμψουν έναν ηλικιωμένο για ειδική αξιολόγηση. Τα πρωτόκολλα δια- φέρουν ανάλογα με τη διαθεσιμότητα. Ο πρόεδρος της κοινότητας, ο διευθυντής του σχολείου, ο τοπικός ιερέας ή ο αρχηγός μιας θρησκευτικής ομάδας μπορούν να είναι πιο κατάλληλοι από έναν κοινωνικό λειτουργό σε ορισμένες συνθήκες. Δεδομένου ότι η παροχή ολοκληρωμένης κοινωνικής φροντίδας και υποστήριξης είναι πολυδιάστα- τη, οι τακτικές συναντήσεις των ειδικών και των υπηρεσιών είναι σημαντικές για την ενίσχυση της εμπιστοσύνης μεταξύ τους. Ακολουθούν παραδείγματα ειδικοτήτων σε διάφορους τομείς που συμμετέ- χουν στη φροντίδα των ηλικιωμένων. • Συνθήκες διαβίωσης: υπηρεσίες στέγασης, κοινωνικοί λειτουργοί, ερ- γοθεραπευτές. • Οικονομικά ζητήματα: κοινωνικοί λειτουργοί, υπηρεσίες επιδοματικής συμβουλευτικής. • Μοναξιά: κοινωνικοί λειτουργοί, εθελοντικές υπηρεσίες, ιατροί πρωτο- βάθμιας περίθαλψης • Συμμετοχικότητα: κοινωνικοί λειτουργοί, υπηρεσίες αναψυχής και απα- σχόλησης, εθελοντικές υπηρεσίες • Περιστατικά κακοποίησης: κοινωνικοί λειτουργοί, υπηρεσίες προστασί- ας ενηλίκων, αστυνομία • Δραστηριότητες καθημερινής ζωής: εργοθεραπευτές, κοινωνικοί λει- τουργοί νοσηλευτές ή διεπιστημονική ομάδα ειδικών γηριατρικής . • Κινητικότητα σε εσωτερικούς χώρους: φυσικοθεραπευτές, εργοθερα- πευτές, κοινωνικοί λειτουργοί ή διεπιστημονική ομάδας ειδικών γηρι- ατρικής • Κινητικότητα σε εξωτερικούς χώρους: φυσικοθεραπευτές, κοινωνικοί λειτουργοί, εθελοντικές υπηρεσίες μεταφοράς. ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΓΝΩΣΗ Κοινωνική φροντίδα και υποστήριξη Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη ΣΗΜΑΔΙΑ ΠΙΘΑΝΗΣ ΚΑΚΟΠΟΙΗΣΗΣ ΗΛΙΚΙΩΜΕΝΟΥ ΣΤΗ ΣΥΜΠΕΡΙΦΟΡΑ ΤΟΥ ΗΛΙΚΙΩΜΕΝΟΥ • Φαίνεται να φοβάται έναν συγγενή ή έναν επαγγελματία φρο- ντιστή. • Δεν θέλει να απαντά στις ερωτήσεις ή κοιτά με άγχος τον φροντιστή/συγγενή πριν απαντήσει. • Η συμπεριφορά του αλλάζει όταν ο φροντιστής/συγγενής ει- σέρχεται ή εξέρχεται από το δωμάτιο. • Αναφέρεται στον φροντιστή χρησιμοποιώντας όρους όπως «ισχυρογνώμων» ή συχνά «κουρασμένος» ή «δύστρο- πος», ή αναφέρει ότι γίνεται ευερέθιστος/νευρικός/πολύ αγχώδης ή ότι χάνει την ψυχραιμία του πολύ εύκολα. • Δείχνει υπερβολικό σεβασμό προς τον φροντιστή ή υπερβο- λική υποταγή σε αυτόν. ΣΤΗ ΣΥΜΠΕΡΙΦΟΡΑ ΤΟΥ ΦΡΟΝΤΙΣΤΗ/ΣΥΓΓΕΝΗ • Εμποδίζει ή αποτρέπει τον επαγγελματία υγείας και τον ηλι- κιωμένο από το να μιλήσουν κατ’ ιδίαν, ή βρίσκει λόγους να διακόπτει τη ροή της συζήτησης-αξιολόγησης (για παρά- δειγμα μπαίνοντας συνεχώς στο δωμάτιο). • Επιμένει να απαντά ο ίδιος σε ερωτήσεις που απευθύνονται στον ηλικιωμένο. • Εμποδίζει την παροχή βοήθειας στο σπίτι. • Δείχνει να δυσαρεστείται έντονα για το ότι πρέπει να φροντί- ζει τον ηλικιωμένο. • Προσπαθεί να πείσει τους επαγγελματίες ότι το ηλικιωμένο άτομο είναι «τρελό» ή ανοϊκό, ή ότι το άτομο δεν ξέρει τι λέει λόγω σύγχυσης, ενώ αυτό δεν ισχύει. • Είναι εχθρικός, κουρασμένος ή ανυπόμονος κατά τη διάρ- κεια της συνέντευξης και το ηλικιωμένο άτομο είναι πολύ ανήσυχο ή δείχνει αδιάφορο για την παρουσία του συνοδού. ΣΩΜΑΤΙΚΗ ΚΑΚΟΠΟΙΗΣΗ • Κοψίματα, εγκαύματα, μώλωπες και γρατσουνιές. • Τραυματισμοί ασύμβατοι με την εξήγηση που δόθηκε. • Τραυματισμοί που είναι απίθανο να έχουν συμβεί κατά λάθος. • Τραυματισμοί σε κρυφά σημεία. • Μώλωπες σε σχήμα δακτύλων (συχνά στα άνω άκρα του ηλικιωμένου). • Τραυματισμοί σε προστατευμένες περιοχές από έντονους χειρισμούς π.χ. μασχάλες. • Παραμελημένα τραύματα. • Πολλαπλοί τραυματισμοί σε διαφορετικά στάδια επούλωσης. • Μειωμένη ή υπερβολική χρήση φαρμάκων. ΑΞΙΟΛΟΓΗΣΤΕ & ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΑΝΑΓΚΕΣ ΚΟΙΝΩΝΙΚΗΣ ΥΠΟΣΤΗΡΙΞΗΣ Κοινωνική φροντίδα και υποστήριξη Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη 10.1 ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΗΝ ΑΝΑΓΚΗ ΓΙΑ ΑΤΟΜΙΚΗ ΦΡΟΝΤΙΔΑ ΚΑΙ ΒΟΗΘΕΙΑ ΜΕ ΤΙΣ ΚΑΘΗΜΕΡΙΝΕΣ ΔΡΑΣΤΗΡΙΟΤΗΤΕΣ (ΤΜΗΜΑ Α ΤΟΥ ΜΟΝΟΠΑΤΙΟΥ) Για να εκτιμηθεί εάν ένα άτομο έχει φτάσει στο σημείο να μην μπορεί πλέον να φροντίσει τον εαυτό του χωρίς τη βοήθεια άλλων, χρησιμο- ποιούνται έξι ερωτήσεις. Ένας ηλικιωμένος με σημαντική απώλεια της ενδογενούς ικανότητάς του μπορεί να ωφεληθεί από αυτή την αξιολό- γηση. Η μετακίνηση σε εσωτερικούς χώρους περιλαμβάνει μια σειρά από δραστηριότητες, όπως τη μετακίνηση από το κρεβάτι στην καρέκλα, το περπάτημα, τη μετάβαση στην τουαλέτα και τη χρήση της, καθώς και τη χρήση σκάλας. Η περιορισμένη κινητικότητα οδηγεί σε αυξημέ- νους κινδύνους και στην ανάγκη προσωπικής φροντίδας. Το ντύσιμο, η σίτιση, το μπάνιο και η φροντίδα της προσωπικής υγιεινής ανήκουν στις δραστηριότητες της καθημερινής ζωής (Activities of Daily Living- ADLs). Πολλοί ηλικιωμένοι δεν θέλουν να βασίζονται σε άλλους για αυτές τις δραστηριότητες, προτιμώντας να τις εκτελούν μόνοι τους. Οι ηλικιωμένοι που δυσκολεύονται με τις δραστηριότητες της καθη- μερινής ζωής, με ή χωρίς κινητικά προβλήματα, ωφελούνται από την ένταξη σε προγράμματα αποκατάστασης. Αυτά εστιάζουν στη βελτίωση των ικανοτήτων τους, αλλά πιθανώς να περιλαμβάνουν και τη χρήση υποστηρικτικών τεχνολογικών μέσων καθώς και μετατροπές στο πε- ριβάλλον που ζουν, προκειμένου να βελτιστοποιήσουν τη λειτουργική τους ικανότητα, παρά τους περιορισμούς της ενδογενούς ικανότητας. Για τις εξωτερικές μετακινήσεις μπορούν να χρησιμοποιηθούν υπηρε- σίες μεταφοράς. Εάν οι δυσκολίες παραμένουν μπορεί να ζητηθεί βο- ήθεια από τον/την σύζυγο, την οικογένεια και άλλους μη αμειβόμε- νους φροντιστές, λαμβάνοντας υπ’ όψιν και τις δικές τους ανάγκες. Εάν απαιτείται περαιτέρω υποστήριξη, μπορεί να παρασχεθεί, από εθελο- ντικές δημόσιες ή ιδιωτικές υπηρεσίες φροντίδας, κατ’ οίκον. 10.2 ΑΞΙΟΛΟΓΗΣΤΕ ΚΑΙ ΔΙΑΧΕΙΡΙΣΤΕΙΤΕ ΤΙΣ ΑΝΑΓΚΕΣ ΚΟΙΝΩΝΙΚΗΣ ΥΠΟΣΤΗΡΙΞΗΣ (ΤΜΗΜΑ Β ΤΟΥ ΜΟΝΟΠΑΤΙΟΥ) Η αξιολόγηση των αναγκών κοινωνικής υποστήριξης θα είναι επωφε- λής για έναν ηλικιωμένο, ανεξάρτητα από το επίπεδο της ενδογενούς ικανότητας και λειτουργικότητάς του. Η παροχή κοινωνικής υποστήρι- ξης θα του δώσει τη δυνατότητα να κάνει τα πράγματα που είναι σημα- ντικά για αυτόν. Αυτή περιλαμβάνει την υποστήριξη των συνθηκών δι- αβίωσης, την οικονομική εξασφάλιση, τη διαχείριση της μοναξιάς, την πρόσβαση σε κοινοτικές εγκαταστάσεις και δημόσιες υπηρεσίες, κα- θώς και την προστασία από την κακοποίηση. Β7 ΣΥΝΘΗΚΕΣ ΔΙΑΒΙΩΣΗΣ Το μέρος όπου ζει ένα ηλικιωμένο άτομο μπορεί να επηρεάσει την υγεία, την αυτονομία και την ποιότητα της ζωής του. Τα προβλήματα μπορεί να σχετίζονται με το μέγεθος και την κατάσταση του χώρου, την προσβασιμότητα και την ασφάλεια. Για τον εντοπισμό συγκεκριμένων προβλημάτων που πρέπει να αντιμετωπιστούν, μπορούν να χρησιμο- ποιηθούν συμπληρωματικές ερωτήσεις. Κοινωνική φροντίδα και υποστήριξη Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη Τα προβλήματα στις συνθήκες διαβίωσης μπορούν να μετριαστούν ει- σάγοντας νέα μέτρα ασφάλειας, έχοντας έναν αριθμό έκτακτης ανά- γκης και κάνοντας τις απαραίτητες προσαρμογές για τη διατήρηση της αυτόνομης διαβίωσης. Ενδεχομένως να υπάρχουν διαθέσιμα οικονο- μικά επιδόματα για την κάλυψη των εξόδων διαμονής, επισκευής και συντήρησης. Εάν αυτά τα μέτρα αποτύχουν, θα πρέπει να εξεταστεί το ενδεχόμενο μετεγκατάστασης σε πιο κατάλληλο χώρο. Β8 ΟΙΚΟΝΟΜΙΚΑ ΖΗΤΗΜΑΤΑ Οι οικονομικοί πόροι συνδέονται στενά με την υγεία, την ανεξαρτη- σία και την ευημερία των ηλικιωμένων. Η ένδεια μπορεί να αποτελεί εμπόδιο στην κάλυψη βασικών αναγκών ή στην πλήρη συμμετοχή σε κοινωνικές δραστηριότητες. Οι ηλικιωμένοι συχνά ανησυχούν ότι τα χρήματα θα τελειώσουν ή ότι θα καταστούν ανίκανοι να διαχειρίζονται τα οικονομικά τους. Περαιτέρω ερωτήσεις θα βοηθήσουν στον προσ- διορισμό συγκεκριμένων ζητημάτων που χρειάζονται αντιμετώπιση. Τα οικονομικά προβλήματα ενδέχεται να μετριαστούν με την παροχή συμβουλών σχετικά με τον οικονομικό προγραμματισμό και τη διαχεί- ριση χρημάτων. Μπορεί να γίνουν διευθετήσεις ώστε η διαχείριση των οικονομικών να μεταβιβαστεί σε ένα τρίτο πρόσωπο άξιο εμπιστοσύ- νης, υπό την προϋπόθεση να υπάρχει νομική προστασία για την απο- φυγή οικονομικών ατασθαλιών. Β9 ΜΟΝΑΞΙΑ Η μοναξιά είναι συχνή στους ηλικιωμένους και σχετίζεται με αυξημέ- νη πιθανότητα κατάθλιψης και πρόωρου θανάτου. Βλ. το Κεφάλαιο 9 για καθοδήγηση σχετικά με τον έλεγχο για καταθλιπτικά συμπτώματα. Το να είσαι μόνος δεν είναι το ίδιο με το να νιώθεις μοναξιά. Τα ηλικιω- μένα άτομα μπορεί νιώθουν μοναξιά ακόμα και όταν περιστοιχίζονται από άλλους, εάν η ποιότητα των σχέσεων είναι κακή. Είναι χρήσιμο να ρωτήσετε ένα μοναχικό ηλικιωμένο άτομο εάν η αυ- ξημένες κοινωνικές του επαφές με την οικογένεια και τους φίλους, ή η συναναστροφή με ανθρώπους με κοινά ενδιαφέροντα, θα βοηθού- σαν στη μείωση του αισθήματος της μοναξιάς. Οι ερωτήσεις, ωστόσο, θα πρέπει να γίνονται με τη διαβεβαίωση ότι η εχεμύθεια είναι εξα- σφαλισμένη, προκειμένου να ξεπεραστούν τυχόν φόβοι σχετικά με την αποκάλυψη της φύσης των προσωπικών σχέσεων. Ένα κατοικίδιο ζώο μπορεί να περιορίσει τη μοναξιά για πολλούς ηλι- κιωμένους. Πρέπει να ενθαρρύνεται η χρήση τοπικών κοινοτικών δο- μών, όπως σύλλογοι, χώροι λατρείας, κέντρα ημέρας και δομές αθλη- τισμού, αναψυχής ή εκπαίδευσης. Μπορούν να αναζητηθούν ευκαιρί- ες για συνεισφορά μέσω εθελοντικής ή αμειβόμενης απασχόλησης. Τα δίκτυα κοινωνικών επαφών μπορούν να ενισχυθούν μέσω της τε- χνολογίας επικοινωνιών. Πρέπει να διενεργηθεί μια γενική ανασκό- πηση αυτών των μέτρων για την καταπολέμηση της μοναξιάς. Οι αξιο- λογητές πρέπει να γνωρίζουν το εύρος των τοπικών δυνατοτήτων. Κοινωνική φροντίδα και υποστήριξη Μονοπάτια για την κοινωνική μέριμνα και υποστήριξη Β10 ΚΟΙΝΩΝΙΚΗ ΕΜΠΛΟΚΗ ΚΑΙ ΣΥΜΜΕΤΟΧΗ Ο στόχος της προσέγγισης ICOPE είναι να βοηθήσει τους ηλικιωμέ- νους να κάνουν τα πράγματα που είναι σημαντικά για αυτούς. Είναι χρήσιμο να μάθετε τι είναι σημαντικό για τον ηλικιωμένο μέσω της κατανόησης της ζωής τους, των προτεραιοτήτων και των προτιμήσε- ών του, καθώς αυτό μπορεί να βοηθήσει και στην ανεύρεση τρόπων ενίσχυσης της συμμετοχικότητας. Οι δραστηριότητες αναψυχής και εκμάθησης, τα χόμπι, η εργασία και οι πνευματικές και θρησκευτικές δραστηριότητες αποτελούν παρα- δείγματα συμμετοχής στην κοινωνία. Κάθε ηλικιωμένος είναι μονα- δικός και έχει διαφορετικές, συχνά πολύ συγκεκριμένες, προτεραιό- τητες για το τι του είναι σημαντικό. Θα πρέπει να ρωτήσετε σχετικά και να καταγράψετε τις απαντήσεις ως οδηγό για το εξατομικευμένο πλά- νο φροντίδας. Περαιτέρω ερωτήσεις πρέπει να γίνουν για τον εντοπισμό τυχόν εμποδίων, όπως το κόστος, η προσβασιμότητα και οι ευκαιρίες. Οι αξιολογητές θα πρέπει να γνωρίζουν για τη διαθεσιμότητα των τοπι- κών εγκαταστάσεων αναψυχής και των συλλόγων, των δομών εκπαί- δευσης ενηλίκων, τις υπηρεσίες εθελοντισμού και επαγγελματικής απασχόλησης, και να συζητούν με το ηλικιωμένο άτομο, εάν ενδια- φέρεται για αυτά. Η μετακίνηση μπορεί να είναι ένα σημαντικό ζήτη- μα και πρέπει να αναζητηθούν κατάλληλες υπηρεσίες. Οι χρεώσεις για ορισμένες από αυτές τις υπηρεσίες ενδεχομένως να επιδοτού- νται, προκειμένου να επιτραπεί σε ηλικιωμένους και σε άτομα με μει- ωμένο εισόδημα να συμμετέχουν περισσότερο. Β11 ΚΑΚΟΠΟΙΗΣΗ ΗΛΙΚΙΩΜΕΝΩΝ Πολλοί εξαρτώμενοι από τη φροντίδα ηλικιωμένοι είναι ευάλωτοι στην κακοποίηση, ενώ περίπου ένας στους έξι ηλικιωμένους βιώ- νει κάποια μορφή κακοποίησης - αριθμός υψηλότερος απ’ ό,τι είχε παλαιότερα εκτιμηθεί (20). Η κακοποίηση μπορεί να λάβει πολλές μορφές, συμπεριλαμβανομένης της παραμέλησης, της ψυχολογι- κής, σωματικής ή σεξουαλικής κακοποίησης και της οικονομικής εκ- μετάλλευσης. Πληροφορίες από την παρατήρηση της συμπεριφοράς του ηλικιω- μένου, των φροντιστών ή των συγγενών του, καθώς και σημάδια σω- ματικής κακοποίησης, θα πρέπει να αξιολογούνται, προκειμένου να εντοπιστεί πιθανή κακοποίηση. Εάν υπάρχει οποιαδήποτε υπόνοια κακοποίησης, θα χρειαστεί εξειδικευμένη αξιολόγηση και διαχείριση. Θα πρέπει να ενημερώσετε τον ηλικιωμένο για τις ανη- συχίες σας και για το ότι πρόκειται ζητήσετε βοήθεια από ειδικούς. Θα πρέπει να καταγράψετε τις ανησυχίες σας και το ότι έχετε ενημερώ- σει το ηλικιωμένο άτομο για την παραπομπή σε βοήθεια από ειδικό. Εάν εντοπίσετε οποιαδήποτε άμεση απειλή, θα πρέπει να παραπέμ- ψετε για εξειδικευμένη αξιολόγηση μέσω κοινωνικού λειτουργού, υπηρεσιών προστασίας ενηλίκων ή των αρχών. i 1 Μονοπάτια για την υποστήριξη του φροντιστή Υποστήριξη του φροντιστή Όταν η έκπτωση της ενδογενούς ικανότητας και της λειτουργικότητας καθιστά ένα άτομο εξαρτώμενο από άλλους για φροντίδα, η ευθύνη συχνά πέφτει στον/στη σύζυγο, κάποιο άλλο μέλος της οικογένειας, ή ένα άλλο άτομο στο νοικοκυριό. Ανάλογα με τις ανάγκες του ηλικιωμέ- νου, το βάρος της παροχής φροντίδας μπορεί να επηρεάσει δυσμενώς την ευημερία του φροντιστή. Οι επαγγελματίες υγείας ή οι κοινωνικοί λειτουργοί στην κοινότητα μπορούν να παρακολουθούν τους φροντιστές και να προσπαθούν να εξασφαλίσουν ότι και οι ίδιοι θα λαμβάνουν τη φροντίδα που χρειάζο- νται για τη δική τους υγεία και ότι υποστηρίζονται στο έργο τους. ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ • Η φόρτιση και το άγχος που συνοδεύει τη φροντίδα των ηλικιωμένων με σημαντική απώλεια της ενδογενούς ικανότητας και της λειτουργι- κότητας, μπορεί να επιβαρύνουν την υγεία των μελών της οικογένειας και των φίλων που έχουν τον ρόλο του φροντιστή. Επιπλέον, μπορεί να τους αναγκάσει, ιδιαίτερα τις γυναίκες, να σταματήσουν να εργάζονται. • Ο εντοπισμός φροντιστών που οι ίδιοι χρειάζονται βοήθεια, είναι ση- μαντικό μέρος της αξιολόγησης ηλικιωμένων με μειωμένη λειτουργι- κότητα. • Μια γκάμα παρεμβάσεων – ανάπαυλα της φροντίδας (μέσω της προ- σωρινής παροχής φροντίδας από κάποιο άλλο άτομο ή φορέα), παρο- χή συμβουλευτικής, εκπαίδευση, οικονομική υποστήριξη και ψυχολο- γική παρέμβαση – μπορεί να βοηθήσει τον φροντιστή να διατηρήσει μια ικανοποιητική και υγιή σχέση φροντίδας με τον ηλικιωμένο. • Ορισμένες φορές η σχέση φροντίδας γίνεται κακοποιητική. Ένας ερ- γαζόμενος στην κοινότητα ενδεχομένως να δει σημάδια κακοποίησης κατά τη διάρκεια της αξιολόγησης του ηλικιωμένου ή του φροντιστή. Σε αυτό το σημείο είναι απαραίτητη η παραπομπή σε ειδικό. Υποστήριξη του φροντιστή Μονοπάτια για την υποστήριξη του φροντιστή Απαιτείται εξειδικευμένη φροντίδα Ν Α Ι Ν Α Ι Ν Α Ι Ν Α Ι ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΔΙΑΘΕΣΗ ΤΟΥ ΦΡΟΝΤΙΣΤΗ ΡΩΤΗΣΤΕ ΡΩΤΗΣΤΕ ΡΩΤΗΣΤΕ ΕΠΑΝΑΞΙΟΛΟΓΗΣΤΕ ΚΑΘΕ 6 ΜΗΝΕΣ Ο Χ Ι Ο Χ Ι Ο Χ Ι Εξετάστε την υποστήριξη για τους φροντιστές όπως εκπαίδευση, καθοδήγηση, διάλειμμα από τα καθήκοντά τους μέσω αξιοποίησης κέ- ντρων ημέρας, εμπλοκής της κοινότητας στην φροντίδα, ένα υποστηρικτικό δίκτυο (ιδέες δί- νονται στο iSupport στο https://www.isupportfordementia.org) Ο ρόλος σας ως φροντιστής για τον/ την (...) έχει αρνητικό αντίκτυπο στη ζωή σας; Νιώθετε ότι δεν έχετε υποστήριξη στον ρόλο σας ως φροντιστής; Διαχειριστείτε την κατάθλιψη: Βλ. τον οδηγό mhGAP https://apps.who.int/iris/ handle/10665/250239 Στη διάρκεια των δυο τελευταίων εβδομάδων σας ενόχλησε: - η αίσθηση ότι είστε πεσμένος, καταθλιμμένος ή απελπισμένος; - η έλλειψη ενδιαφέροντος ή ευχαρίστησης να κάνετε πράγματα; Αντιμετωπίζετε απώλεια εισοδή- ματος η/και επιπρόσθετα έξοδα λόγω των αναγκών της φροντίδας; Διερευνήστε τις τοπικές επιλογές οικονομικής στήριξης. Ενισχύστε τον δεσμό με το επίσημο μακροχρόνιο σύστημα φροντίδας και κοινοτικής υποστήριξης όπως εθελοντικές οργανώσεις Αντιμετωπίστε την πίεση με υποστήριξη και ψυχοεκπαίδευση Παράσχετε συμβουλευτική για την επίλυση προβλημάτων Παράσχετε γνωσιακή συμπεριφορική θεραπεία (σε οποιαδήποτε από τις δυο ερωτήσεις) (σε οποιαδήποτε από τις δυο ερωτήσεις) (και στις δυο ερωτήσεις) ΟΤΑΝ ΑΠΑΙΤΕΙΤΑΙ ΕΞΕΙΔΙΚΕΥΜΕΝΗ ΓΝΩΣΗ • Για τη θεραπεία της κατάθλιψης. • Για την παροχή συμβουλευτικής επίλυσης προβλημάτων ή γνωσιακής συμπεριφορικής θεραπείας σε φροντιστές με συμπτώματα κατάθλιψης. • Όταν υπάρχει υποψία κακοποιητικής σχέσης. Υποστήριξη του φροντιστή Μονοπάτια για την υποστήριξη του φροντιστή Ο ΚΙΝΔΥΝΟΣ ΚΑΚΟΠΟΙΗΣΗΣ Η αμφίδρομη σχέση μεταξύ του ατόμου που λαμβάνει τη φροντίδα και του φροντιστή είναι πολύπλοκη. Υγιείς και ικανοποιημένοι φροντιστές είναι ικανοί να παρέχουν αξιοσημείωτη υποστήριξη, αλλά μερικές φο- ρές η σχέση φροντίδας μπορεί να γίνει ανεπιθύμητη για τον έναν ή και τους δύο συμμετέχοντες. Αυτό μπορεί να προκαλέσει σύγκρουση και να καταστήσει τον ηλικιωμένο ευάλωτο σε κακοποίηση. Η κακοποίηση μπορεί να πάρει τη μορφή της παραμέλησης, της οικονομικής εκμετάλ- λευσης ή της σωματικής, συναισθηματικής ή σεξουαλικής κακοποίη- σης. Παραμέληση μπορεί να προκύψει και λόγω άγνοιας, έλλειψης δε- ξιοτήτων στη φροντίδα ή έλλειψης εξωτερικής υποστήριξης και επίβλε- ψης. Η κακοποίηση μπορεί να μην αναφερθεί στον επαγγελματία υγείας ούτε από τον ηλικιωμένο, ούτε από τον φροντιστή του. Οι πληροφορίες από την παρατήρηση της συμπεριφοράς του ηλικιωμέ- νου, του φροντιστή του ή των συγγενών του καθώς και πιθανά σημάδια σωματικής κακοποίησης, θα πρέπει να χρησιμοποιούνται για τον εντοπι- σμό πιθανής κακοποίησης (βλ. Κεφάλαιο 10 σχετικά με την κοινωνική φροντίδα και υποστήριξη). Παράγοντες που αυξάνουν την πιθανότητα κακοποιητικής σχέσης είναι: • η κακή μακροχρόνια σχέση • το ιστορικό οικογενειακής βίας • η δυσκολία του φροντιστή να παρέχει σταθερά το επίπεδο ή το είδος της φροντίδας που απαιτείται και • τα προβλήματα σωματικής ή ψυχικής υγείας του φροντιστή, ιδιαίτερα η κατάθλιψη και, κυρίως όσον αφορά τους άνδρες, η κατάχρηση αλκοόλ και ουσιών. Η πιθανότητα ύπαρξης κακοποίησης δεν σχετίζεται αποκλειστικά με τη φύση της παρεχόμενης φροντίδας ή ακόμη και με παράγοντες που σχε- τίζονται συχνά με το άγχος που νιώθει ο φροντιστής, όπως οι προκλήσεις που θέτει η συμπεριφορά ενός ατόμου με άνοια. Εάν υπάρχει υποψία κακοποιητικής σχέσης, απαιτείται λεπτομερέστε- ρη αξιολόγηση από ειδικό, ακολουθώντας τα κατά τόπους πρωτόκολλα παραπομπής. * Αυτές οι ερωτήσεις υπάρχουν στο Ερωτηματολόγιο Υγείας Ασθενούς (http://www.cqaimh.org/pdf/tool_phq9.pdf), που εί- ναι ένα από τα εργαλεία της εκτίμησης της καταθλιπτικής συμπτωματολογίας. Ή βλ. το κεφάλαιο της κατάθλιψης στον οδηγό πα- ρέμβασης mhGAP, στο https://apps.who.int/iris/handle/10665/250239). ΑΞΙΟΛΟΓΗΣΤΕ ΤΗ ΔΙΑΘΕΣΗ ΤΟΥ ΦΡΟΝΤΙΣΤΗ Aν ένα άτομο αναφέρει τουλάχιστον ένα από τα βασικά συμπτώματα – να νιώθει «πεσμένο», καταθλιμμένο, απελπισμένο και ελάχιστο ενδιαφέ- ρον ή ευχαρίστηση να κάνει οτιδήποτε – προχωρήστε σε περαιτέρω αξιο- λόγηση της διάθεσής του. Εάν ένα άτομο δεν είναι εξοικειωμένο με τις λέξεις στις δύο ερωτήσεις διαλογής, μπορούν να χρησιμοποιηθούν εναλλακτικοί όροι. ΡΩΤΗΣΤΕ: «Στη διάρκεια των τελευταίων δυο εβδομάδων σας ενόχλησε κάποιο από τα παρακάτω προβλήματα;»* • Δυσκολία να κοιμηθείτε ή να παραμείνετε κοιμισμένος, ή κοιμόσασταν πάρα πολύ; • Νιώθατε κουρασμένος ή ότι δεν είχατε αρκετή ενέργεια; • Έλλειψη όρεξης ή υπερφαγία; • Αισθανόσασταν άσχημα για τον εαυτό σας ή ότι είστε αποτυχημένος ή ότι έχετε απογοητεύσει τον εαυτό σας ή την οικογένειά σας; • Δυσκολία να συγκεντρωθείτε σε δραστηριότητες όπως το διάβασμα της εφημερίδας ή την παρακολούθηση της τηλεόρασης; • Κινούσασταν ή μιλούσατε τόσο αργά ώστε αυτό να έχει γίνει αντιληπτό από τους άλλους; • Ήσασταν τόσο νευρικός ή ανήσυχος που κινούσασταν περισσότερο από συνήθως; • Σκέψεις ότι θα ήταν καλύτερο να πεθαίνατε ή να κάνατε κακό στον εαυ- τό σας κατά κάποιον τρόπο; Υποστήριξη του φροντιστή Μονοπάτια για την υποστήριξη του φροντιστή 11.1 ΡΩΤΗΣΤΕ ΤΟΝ ΦΡΟΝΤΙΣΤΗ Το μονοπάτι στη σελίδα 74 προσφέρει καθοδήγηση στη συζήτηση με το φροντιστή. Σύμφωνα με αυτό, γίνονται ερωτήσεις στον κάθε φρο- ντιστή σχετικά με τρεις τομείς: 1. Το βάρος της φροντίδας (δύο ερωτήσεις) που δυνητικά οδηγεί στο σχεδιασμό πρακτικών στρατηγικών για την υποστήριξη των φροντι- στών. 2. Τα δύο βασικά συμπτώματα της κατάθλιψης που δυνητικά απαιτούν πλήρη αξιολόγηση για κατάθλιψη (βλ. Κεφάλαιο 9 σχετικά με τα συμπτώματα της κατάθλιψης). 3. Το οικονομικό κόστος της φροντίδας που μπορεί να οδηγήσει στην εύρεση τοπικών πηγών οικονομικής στήριξης και οργανωμένης κοινωνικής μέριμνας, όπου είναι διαθέσιμη. Κατά τη διάρκεια της συζήτησης με τον φροντιστή, ο επαγγελματίας υγείας αναζητά σημάδια εξάντλησης, θυμού, απογοήτευσης ή έλλει- ψης σεβασμού. Επίσης, ο φροντιστής μπορεί να ερωτηθεί εάν χρειά- ζεται περαιτέρω υποστήριξη από κάποιον πάροχο κοινωνικής φροντί- δας. Με την πάροδο του χρόνου το βάρος της φροντίδας συσσωρεύε- ται και η επαναξιολόγηση κάθε έξι μήνες κρίνεται απαραίτητη. Η αξιολόγηση του ρόλου του φροντιστή και της επίδρασής του καλύ- τερα να γίνεται μακριά από το ηλικιωμένο άτομο, προκειμένου να πε- ριοριστεί η αμηχανία ή ο δισταγμός του φροντιστή να μιλήσει ανοιχτά και να πει τα πάντα. Τα λεγόμενα του ηλικιωμένου και του φροντιστή μπορεί να διαφέρουν για ποικίλους λόγους, μεταξύ των οποίων είναι και πιθανά προβλήματα μνήμης του ηλικιωμένου. Επομένως, η αξιο- λόγηση θα πρέπει γίνει υπό το πρίσμα της αποκτηθείσας γνώσης από την πλήρη αξιολόγηση της ενδογενούς ικανότητας του ηλικιωμένου. 11.2 ΠΡΟΣΦΕΡΕΤΕ ΥΠΟΣΤΗΡΙΞΗ ΣΤΟΝ ΦΡΟΝΤΙΣΤΗ Κατάλληλα εκπαιδευμένοι επαγγελματίες και αμειβόμενοι φροντι- στές θα πρέπει να υποστηρίζουν τους μη αμειβόμενους φροντιστές, επικουρούμενοι και εποπτευόμενοι από τις υπηρεσίες υγείας και κοι- νωνικής φροντίδας. Οι εργαζόμενοι στον τομέα της υγείας και της κοι- νωνικής φροντίδας, επαγγελματίες και εθελοντές, μπορούν να δη- μιουργήσουν στην κοινότητα ένα δίκτυο διαχείρισης των διαθέσιμων πόρων για την υποστήριξη των μη αμειβόμενων φροντιστών. Το iSupport είναι ένα διαδικτυακό εκπαιδευτικό πρόγραμμα του ΠΟΥ που μπορεί να βοηθήσει τους φροντιστές ατόμων με άνοια να πα- ρέχουν καλή φροντίδα και να φροντίζουν τους εαυτούς τους– βλ. το https://www.isupportfordementia.org. Η υποστήριξη εστιάζει στον κύριο φροντιστή στην οικογένεια. Προκειμένου να κατανοήσει τις ανάγκες του φροντιστή, ο επαγγελ- ματίας υγείας μπορεί να τον ρωτήσει ποια καθήκοντα εκτελούνται, με ποιο τρόπο και πόσο συχνά, αναζητώντας πτυχές της φροντίδας για τις οποίες ο φροντιστής μπορεί να λάβει ενίσχυση μέσω συμβουλών, πρακτικής υποστήριξης ή καινοτόμων τεχνολογιών (βλ. πλαίσιο στη σελίδα 77). Η υποστήριξη θα πρέπει να αντικατοπτρίζει τις επιλογές του φροντιστή και να δίνει έμφαση στη βελτιστοποίηση της ευημερί- ας του. Υποστήριξη του φροντιστή Μονοπάτια για την υποστήριξη του φροντιστήΟι επαγγελματίες υγείας και οι κοινωνικοί λειτουργοί μπορούν: • να παρέχουν στον φροντιστή εκπαίδευση και υποστήριξη σε συ- γκεκριμένες δεξιότητες – για παράδειγμα, τη διαχείριση της δύ- σκολης συμπεριφοράς • να εξετάσουν το ενδεχόμενο παροχής ή σχεδιασμού πρακτικής υποστήριξης, όπως ένα διάλειμμα από τη φροντίδα, και • να διερευνήσουν εάν το άτομο με περιορισμένη λειτουργικότητα πληροί τις προϋποθέσεις για κοινωνικά επιδόματα ή οικονομική υποστήριξη από κρατικές ή μη πηγές. Δώστε συμβουλές. Αναγνωρίστε ότι η φροντίδα ηλικιωμένου μπορεί να είναι εξαιρετικά ματαιωτική και αγχωτική. Μπορεί επίσης να πε- ριπλέκεται από αισθήματα πένθους για την απώλεια της μέχρι πρό- τινος σχέσης του ηλικιωμένου και του φροντιστή, ιδιαίτερα εάν είναι ο/η σύζυγός του. Ενθαρρύνετε τους φροντιστές να σέβονται την αξιοπρέπεια των ηλι- κιωμένων, με το να τους εμπλέκουν όσο το δυνατόν περισσότερο στη λήψη αποφάσεων για τη ζωή και τη φροντίδα τους. Κανονίστε το διάλειμμα από τη φροντίδα. Μπορεί κάποιο άλλο άτο- μο προσωρινά να επιβλέπει και να φροντίζει τον ηλικιωμένο, όταν η φροντίδα γίνει επιβαρυντική ή κουραστική; Αυτό θα μπορούσε να είναι ένα άλλο μέλος της οικογένειας ή ένα άτομο εκπαιδευμένο στην κοινωνική φροντίδα είτε επαγγελματίας είτε εθελοντής. Το δι- άλειμμα – κατά το οποίο η φροντίδα θα παρέχεται από κάποιον άλ- λον, όπως π.χ. ένα κέντρο ημέρας - μπορεί να ανακουφίσει τον κύριο φροντιστή, ώστε να ξεκουραστεί ή να πραγματοποιήσει άλλες δρα- στηριότητες. Τα κέντρα ημέρας είναι ένα είδος κοινοτικής υπηρεσίας στήριξης που παρέχουν προσωπική φροντίδα (λούσιμο, σίτιση, ξύρισμα, βα- σική σωματική φροντίδα), προγράμματα αποκατάστασης, ψυχαγω- γικές και κοινωνικές δραστηριότητες, γεύματα και μετακινήσεις, για πολλές ώρες την ημέρα και για αρκετές φορές την εβδομάδα. Επίσης παρέχουν υπηρεσίες στήριξης και για τους φροντιστές, όπως επισκέψεις κατ’ οίκον, οικογενειακές δραστηριότητες, ομάδες υπο- στήριξης και εκπαίδευσης. Η ανάπαυλα από τη φροντίδα μπορεί να βοηθήσει στη διατήρηση μιας υγιούς και βιώσιμης σχέσης φροντιστή-ηλικιωμένου. Περίοδοι μακριά από τον συνήθη φροντιστή δεν είναι επιβλαβείς για τον ωφε- λούμενο. Προσφέρετε ψυχολογική υποστήριξη. Προσπαθήστε να αντιμετω- πίσετε το ψυχολογικό στρες του φροντιστή με υποστήριξη και συμ- βουλευτική επίλυσης προβλημάτων, ιδιαίτερα όταν η φροντίδα είναι πολύπλοκη και εκτενής και η καταπόνηση του φροντιστή μεγάλη. ΚΑΙΝΟΤΟΜΕΣ ΥΠΟΣΤΗΡΙΚΤΙΚΕΣ ΤΕΧΝΟΛΟΓΙΕΣ Καινοτόμες υποστηρικτικές τεχνολογίες υγείας, όπως η απο- μακρυσμένη παρακολούθηση και υποστηρικτικά ρομπότ, αποτελούν πολλά υποσχόμενα μέσα για την ενίσχυση της λει- τουργικότητας των ηλικιωμένων, τη βελτίωση της ποιότητας ζωής των ίδιων και των φροντιστών τους, την αύξηση των επι- λογών, της ασφάλειας, της ανεξαρτησίας, της αίσθησης ελέγ- χου και της υποβοήθησης των ηλικιωμένων να παραμείνουν στο περιβάλλον τους. Η χρήση αυτών των τεχνολογιών θα πρέπει να βασίζεται στις ανάγκες και τις προτιμήσεις των ηλι- κιωμένων ή των φροντιστών τους και απαιτούν κατάλληλη εκ- παίδευση. Προσοχή πρέπει να δοθεί στην ανάπτυξη χρηματο- δοτικών μηχανισμών έρευνας και ανάπτυξης και στη διασφά- λιση του δίκαιου καταμερισμού τους. Παραδείγματα καινοτόμων υποστηρικτικών τεχνολογιών: • Κοινωνικά υποστηρικτικό ρομπότ PARO. Αυτό το ρο- μποτικό κατοικίδιο (φώκια) προσφέρει συντροφικό- τητα (22). http://www.parorobots.com • Hybrid Assistive Limb (HAL) οσφυϊκού τύπου. Αυτή η τεχνολογία δίνει στους φροντιστές τους ρομποτι- κούς μυς που χρειάζονται για να σηκώσουν και να με- τακινήσουν τους ασθενείς από το κρεβάτι στην καρέ- κλα και το μπάνιο. https://www.cyberdyne.jp/english/ products/Lumbar_CareSupport.html ΑΝΑΠΤΥΞΤΕ ΕΝΑ ΕΞΑΤΟΜΙΚΕΥΜΕΝΟ ΠΛΑΝΟ ΦΡΟΝΤΙΔΑΣ ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ 3 Η προσωποκεντρική φροντίδα είναι η ολιστική, προ- σαρμοσμένη στο άτομο φροντίδα, που υποστηρίζεται από συνεργατικές σχέσεις μεταξύ των εργαζομένων στον τομέα της υγείας και των ηλικιωμένων, με τη συμ- μετοχή της οικογένειας και των φίλων που τους υπο- στηρίζουν. 3 Διεπιστημονικές ομάδες μπορούν να βοηθήσουν τους ηλικιωμένους να καθορίσουν τους στόχους τους. 3 Οι παρεμβάσεις που υποστηρίζουν την εξατομικευμένη φροντίδα πρέπει να συμφωνούνται υπό το πρίσμα των προτεραιοτήτων και των στόχων των ηλικιωμένων. 3 Η τακτική και διαρκής παρακολούθηση είναι απαραίτη- τη για την επίτευξη των στόχων. Το πλάνο εξατομικευμένης φροντίδας είναι μια ανθρωποκεντρι- κή προσέγγιση που απομακρύνεται από τις παραδοσιακές, επι- κεντρωμένες στη νόσο, μεθόδους, και εστιάζει αντίθετα στις ανά- γκες, τις αξίες και τις προτιμήσεις των ηλικιωμένων. Μόλις αυ- τές εκφραστούν, το εξατομικευμένο πλάνο φροντίδας καθοδηγεί όλες τις πτυχές της υγειονομικής και κοινωνικής φροντίδας και στηρίζει ρεαλιστικούς προσωποκεντρικούς στόχους. ΒΗΜΑΤΑ ΓΙΑ ΤΗΝ ΑΝΑΠΤΥΞΗ ΤΟΥ ΕΞΑΤΟΜΙΚΕΥΜΕΝΟΥ ΠΡΟΓΡΑΜΜΑΤΟΣ ΦΡΟΝΤΙΔΑΣ 1. Αναθεωρήστε τα ευρήματα και συζητήστε τις ευκαιρίες βελτί- ωσης της λειτουργικότητας, της υγείας και της ευημερίας των ηλικιωμένων Σε συνεργασία με τους ηλικιωμένους και τα μέλη της οικογένειάς τους ή τους φροντιστές τους (εάν είναι σκόπιμο), οι διεπιστημονι- κές ομάδες θα προβούν τώρα σε μια ανασκόπηση των αποτελε- σμάτων της προσωποκεντρικής αξιολόγησης και των παρεμβά- σεων που προτείνονται στα μονοπάτια φροντίδας. Η αξιολόγηση αυτή θα αποφέρει μια λίστα προτεινόμενων παρεμβάσεων, που μπορούν να συμπεριληφθούν στο πλάνο φροντίδας και να συζη- τηθούν με τον ασθενή. Σε αυτή τη διαδικασία, η εφαρμογή ICOPE app μπορεί να βοηθήσει τον λειτουργό υγείας. Οι διεπιστημονικές ομάδες μπορεί να περιλαμβάνουν όλους όσοι εμπλέκονται στη φροντίδα του ηλικιωμένου, όπως ιατροί πρωτοβάθμιας φροντί- δας, ειδικευμένοι ιατροί, νοσηλευτές, εργαζόμενοι παροχής φρο- ντίδας στην κοινότητα, κοινωνικοί λειτουργοί, θεραπευτές (φυσι- κοθεραπευτές, εργοθεραπευτές, λογοθεραπευτές, ψυχολόγοι/ ψυχοθεραπευτές), αμειβόμενοι ή μη φροντιστές, φαρμακοποιοί και εθελοντές. 2. Προσωποκεντρική στοχοθεσία Η προσωποκεντρική στοχοθεσία για την ταυτοποίηση, τον ορισμό και την προτεραιοποίηση των στόχων αποτελεί ένα βασικό στοι- χείο της ανάπτυξης ενός πλάνου φροντίδας. Είναι σημαντικό η δι- επιστημονική ομάδα να εμπλέκει τον ηλικιωμένο στη διαδικα- σία λήψης αποφάσεων σχετικά με τη φροντίδα του, καθώς και να κατανοεί και να σέβεται τις ανάγκες, αξίες, προτιμήσεις και προ- τεραιότητές του. Η προσέγγιση αυτή μπορεί πραγματικά να μετα- σχηματίσει τον τρόπο με τον οποίον οι επαγγελματίες υγείας σχε- τίζονται με τους ασθενείς τους στη σημερινή εποχή. Οι στόχοι της φροντίδας υπερβαίνουν τη μείωση της επιβάρυν- σης εξαιτίας ιατρικών προβλημάτων και εστιάζουν σε ό,τι μπορεί να βοηθήσει τους ηλικιωμένους να υλοποιούν τις επιθυμίες τους, όπως το να γερνάνε ανεξάρτητοι και ασφαλείς στο περιβάλλον τους, να διατηρούν την προσωπική τους εξέλιξη, να συμπεριλαμ- βάνονται και να συνεισφέρουν στην κοινότητά τους, διατηρώντας παράλληλα την αυτονομία και την υγεία τους. Επιπλέον των μέ- σο-μακροπρόθεσμων στόχων (6 με 12 μήνες), προτείνεται να συ- μπεριλαμβάνονται και πιο βραχυπρόθεσμοι στόχοι (εντός τριμή- νου), ως μόχλευση για πιο άμεση βελτίωση, με σκοπό τη διατήρη- ση της κινητοποίησης και της συμμετοχής του ηλικιωμένου. 3. Συμφωνήστε αναφορικά με τις παρεμβάσεις. Οι παρεμβάσεις που προτείνεται να περιληφθούν στο πλάνο φρο- ντίδας, μετά την διεπιστημονική και προοσωποκεντρική αξιολόγη- ση, θα χρειαστεί να έχουν: α) Συναίνεση εκ μέρους του ηλικιωμένου β) Εναρμόνιση με τους στόχους, τις ανάγκες, τις προτιμήσεις και τις προτεραιότητες του ηλικιωμένου γ) Προσαρμογή στο φυσικό και κοινωνικό περιβάλλον του ηλικιωμένου. Τέλος, οι προτεινόμενες παρεμβάσεις θα πρέπει να συζητηθούν και να συμφωνηθούν μία προς μία με τον ηλικιωμένο και τον επαγ- γελματία υγείας ή τον κοινωνικό λειτουργό, προτού ενταχθούν στο τελικό πλάνο φροντίδας. 4. Οριστικοποιήστε και κοινοποιήστε το σχέδιο φροντίδας. Ο επαγγελματίας της υγείας θα πρέπει τώρα να καταγράψει τα απο- τελέσματα των συζητήσεων στο πλάνο φροντίδας και να το κοινο- ποιήσει στον ηλικιωμένο, τα μέλη της οικογένειάς του, τους φρο- ντιστές και οποιουσδήποτε άλλους μπορεί να εμπλέκονται στη φροντίδα του, κατόπιν συγκατάθεσης. Η εφαρμογή ICOPE για το κι- νητό μπορεί να υποστηρίξει αυτήν τη διαδικασία, παρέχοντας σε όλους τους ενδιαφερόμενους μία περίληψη του πλάνου φροντί- δας, που θα περιλαμβάνει τους πρώτους σε προτεραιότητα στό- χους και τα προβλήματα που έχουν εντοπιστεί. 5. Παρακολούθηση και επανεξέταση. Η παρακολούθηση και η τακτική επανεξέταση της υλοποίησης του σχεδίου φροντίδας είναι ουσιώδης για την επίτευξη των συμφωνη- μένων στόχων. Παρέχει τη δυνατότητα να παρακολουθείται η πρό- οδος και διευκολύνει την πρώιμη ανίχνευση δυσκολιών συμμε- τοχής στις παρεμβάσεις, δυσμενών επιπτώσεων των παρεμβάσε- ων και αλλαγών στη λειτουργική κατάσταση του ωφελούμενου. Βοηθά επίσης στη διατήρηση μιας αποδοτικής σχέσης μεταξύ του ηλικιωμένου και των παρόχων της φροντίδας του. Η διαδικασία επανεξέτασης περιλαμβάνει, αλλά δεν περιορίζεται σε: • διασφάλιση της επιτυχούς υλοποίησης του σχεδίου φροντίδας, βήμα προς βήμα, • επανάληψη της προσωποκεντρικής αξιολόγησης και καταγρα- φή κάθε μεταβολής, • σύνοψη των αποτελεσμάτων, των εμποδίων, και των επιπλοκών της υλοποίησης των παρεμβάσεων υγείας και κοινωνικής φρο- ντίδας, • εντοπισμό αλλαγών και νέων αναγκών, • συμφωνία για την εξεύρεση λύσεων για τις αλλαγές και τις νέ- ες ανάγκες που έχουν προκύψει, συμπεριλαμβανομένης της υι- οθέτησης νέων παρεμβάσεων, όπου είναι απαραίτητο, και της αναθεώρησης και βελτίωσης του πλάνου κατά περίπτωση, και • επανάληψη του κύκλου. ΤΟΜΕΙΣ ΛΕΙΤΟΥΡΓΙΚΗΣ ΙΚΑΝΟΤΗΤΑΣ ΗΛΙΚΙΩΜΕΝΩΝ 1. Να ικανοποιούνται βασικές ανάγκες, όπως η οικονομική ασφάλεια, η στέγαση και η προσωπική ασφάλεια. 2. Να μαθαίνουν, να αναπτύσσονται και να λαμβάνουν αποφά- σεις. Αυτό περιλαμβάνει προσπάθειες για συνεχή μάθηση και εφαρμογή γνώσεων, εμπλοκή στην επίλυση προβλημάτων, διατήρηση της προσωπικής ανάπτυξης και ικανότητα λήψης αποφάσεων. 3. Να είναι κινητικοί, πράγμα απαραίτητο ώστε να μπορούν να κά- νουν πράγματα στο σπίτι, να έχουν πρόσβαση στα καταστήματα, στις υπηρεσίες και στις κοινοτικές εγκαταστάσεις και να συμ- μετέχουν σε κοινωνικές, οικονομικές και πολιτιστικές δραστη- ριότητες. 4. Να δημιουργούν και να διατηρούν ένα ευρύ φάσμα σχέσεων, συμπεριλαμβανομένων των σχέσεων με τα παιδιά τους και άλ- λα τα μέλη της οικογένειάς τους, των απλών, ανεπίσημων κοι- νωνικών σχέσεων με φίλους, γείτονες, ή συναδέλφους καθώς και των επίσημων σχέσεων με εργαζομένους στην κοινοτική φροντίδα. 5. Να συνεισφέρουν, πράγμα που συνδέεται στενά με τη συμ- μετοχή τους σε κοινωνικές και πολιτιστικές δραστηριότητες, όπως για παράδειγμα: η βοήθεια σε φίλους και γείτονες, η κα- θοδήγηση συνομήλικων και νεότερων ατόμων και η φροντίδα των μελών της οικογένειας και της κοινότητας. ΠΩΣ ΘΑ ΥΛΟΠΟΙΗΣΕΤΕ ΤΗΝ ΠΡΟΣΩΠΟΚΕΝΤΡΙΚΗ ΣΤΟΧΟΘΕΣΙΑ ΤΑΥΤΟΠΟΙΗΣΤΕ ΤΟΥΣ ΣΤΟΧΟΥΣ Αναγνωρίστε στόχους σε συνεργασία με τον ηλικιωμένο, τα μέλη της οικογένειάς του και τους φροντιστές του (23): • ΕΡΩΤΗΣΗ 1 Παρακαλώ εξηγήστε τα πράγματα που έχουν για εσάς τη μεγαλύτερη σημασία σε κάθε τομέα της ζωής σας. • ΕΡΩΤΗΣΗ 2 Παρακαλώ πείτε μου μερικούς συγκεκριμένους στό- χους που έχετε στη ζωή σας; • ΕΡΩΤΗΣΗ 3 Πείτε μου κάποιους συγκεκριμένους στόχους που έχετε σχετικά με την υγεία σας; • ΕΡΩΤΗΣΗ 4 Βασιζόμενοι στους στόχους για τη ζωή και για την υγεία που μόλις συζητήσαμε, μπορείτε να επιλέξετε τρεις στους οποίους θα θέλατε να επικεντρωθούμε τους επό- μενους τρεις μήνες; Και κάποιους αντίστοιχα για τους επόμενους έξι έως δώδεκα μήνες; ΟΡΙΣΤΕ ΤΟΥΣ ΣΤΟΧΟΥΣ: Οι στόχοι μπορούν να προσαρμοστούν στις ανάγκες των ηλικιωμένων και στη δική τους αντίληψη των προβλημά- των. • ΕΡΩΤΗΣΗ 5 Πάνω σε ποιο στοιχείο του πρώτου, δεύτερου ή τρίτου στόχου θα θέλατε να εργαστούμε κατά τη διάρκεια των επόμενων τριών μηνών; Τι θα θέλατε να δουλέψουμε για τους επόμενους έξι ή δώδεκα μήνες; • ΕΡΩΤΗΣΗ 6 Τι κάνετε αυτήν τη στιγμή σχετικά [με τον τομέα του στό- χου]; • ΕΡΩΤΗΣΗ 7 Ποιο θα ήταν ένα για εσάς το ιδανικό αλλά ταυτόχρονα και εφικτό στοιχείο στην επίτευξη αυτού του στόχου; ΠΡΟΤΕΡΑΙΟΠΟΙΗΣΤΕ ΤΟΥΣ ΣΤΟΧΟΥΣ Η συμφωνία σχετικά με την προτεραιότητα των στόχων της φροντίδας, μεταξύ των ηλικιωμένων και των παρόχων, θα αποφέρει καλύτερα αποτελέσματα. • ΕΡΩΤΗΣΗ 8 Από τους στόχους που συζητήσαμε, για ποιον είστε πιο πρόθυμος να εργαστείτε κατά τους επόμενους τρεις μή- νες - είτε μόνος σας, είτε με βοήθεια από τον [γιατρό XX και την ομάδα του]; Και για ποιόν τους επόμενους έξι έως δώδεκα μήνες; Πηγή: προσαρμοσμένη από το πρωτότυπο από το (http://healthtapestry.ca) ΠΩΣ ΜΠΟΡΟΥΝ ΤΑ ΣΥΣΤΗΜΑΤΑ ΥΓΕΙΑΣ ΚΑΙ ΜΑΚΡΟΧΡΟΝΙΑΣ ΦΡΟΝΤΙΔΑΣ ΝΑ ΥΠΟΣΤΗΡΙΞΟΥΝ ΤΗΝ ΥΛΟΠΟΙΗΣΗ ΤΗΣ ΠΡΟΣΕΓΓΙΣΗΣ ICOPE ΤΟΥ ΠΟΥ ΣΗΜΕΙΑ ΚΛΕΙΔΙΑ 3 Η αποτελεσματική εφαρμογή της προσέγγισης ICOPE απαιτεί ένα ολοκληρωμένο πλαίσιο που συνδέει τις υπηρεσίες υγείας και κοινωνικής πρόνοιας. 3 Η βελτιστοποίηση των ενδογενών και των λειτουρ- γικών ικανοτήτων των ηλικιωμένων ξεκινά από την κοι- νότητα, με τους εργαζόμενους εκεί. Τα συστήματα υγεί- ας και κοινωνικής πρόνοιας θα πρέπει να ενισχύουν τη φροντίδα που επικεντρώνεται στο επίπεδο της κοινότη- τας. 3 Το εξατομικευμένο πλάνο φροντίδας βρίσκεται στο επίκεντρο της προσέγγισης ICOPE. Για την εκτέλεση και τη διαχείριση αυτών των πλάνων, οι εργαζόμενοι ενδε- χομένως να χρειαστούν ειδική εκπαίδευση στη διαχεί- ριση περιστατικών. Η παγκόσμια έκθεση του Παγκόσμιου Οργανισμού Υγείας για τη γή- ρανση και την υγεία έθεσε μια νέα κατεύθυνση για τα συστήματα υγεί- ας και μακροχρόνιας φροντίδας (1). Τα καλεί να επικεντρωθούν στη βελτιστοποίηση των ενδογενών ικανοτήτων των ηλικιωμένων, στο- χεύοντας στη διατήρηση και βελτίωση των λειτουργικών τους ικα- νοτήτων. Οι κατευθυντήριες οδηγίες του Παγκόσμιου Οργανισμού Υγείας σχετικά με παρεμβάσεις σε επίπεδο κοινότητας για τη διαχείρι- ση της έκπτωσης των ενδογενών ικανοτήτων των ηλικιωμένων, που δημοσιεύτηκαν το 2017, μεταφράζουν αυτήν τη νέα κατεύθυνση σε μια πρακτική προσέγγιση για την αξιολόγηση και τη φροντίδα σε επί- πεδο κοινότητας (2). Συνολικά, προωθούν μια προσωποκεντρική, ολοκληρωμένη υγειονομική και κοινωνική υποστήριξη και φροντί- δα. Η προσέγγιση αυτή ξεκινά με μια προσωποκεντρική αξιολόγηση των υγειονομικών και κοινωνικών αναγκών, την οποία μπορεί να φέ- ρει σε πέρας ένας εργαζόμενος σε επίπεδο κοινότητας. Αυτό το κεφάλαιο αναδεικνύει μερικές βασικές σκέψεις που πρέπει να ληφθούν υπ’ όψιν για την εφαρμογή της προσέγγισης ICOPE. Οι οδηγίες ICOPE του ΠΟΥ προς τα συστήματα και τις υπηρεσίες για την εφαρμογή της προσέγγισης ICOPE, θα αναφερθούν λεπτομερώς στο θέμα αυτό. (https://apps.who.int/iris/handle/10665/325669) ΠΑΡΑΜΕΤΡΟΙ ΚΛΕΙΔΙΑ ΓΙΑ ΤΗΝ ΕΦΑΡΜΟΓΗ ΣΕ ΕΘΝΙΚΟ ΕΠΙΠΕΔΟ Ο προγραμματισμός για την ενσωμάτωση της προσέγγισης ICOPE στα συστήματα υγείας και μα- κροπρόθεσμης φροντίδας θα πρέπει να διέπεται από: • εφαρμοσιμότητα - οικονομική και οργανωτική • βιωσιμότητα - αποδοτικότητα και ικανότητα του εργατικού δυναμικού • συνοχή - ευθυγράμμιση με πολιτικές που υποστηρίζουν την υγιή γήρανση • απαρτίωση - διασυνδέσεις μεταξύ υπηρεσιών υγείας και κοινωνικής πρόνοιας. 13.1 ΕΘΝΙΚΗ ΥΠΟΣΤΗΡΙΞΗ ΤΗΣ ΕΦΑΡΜΟΓΗΣ Ως ένα πρώτο βήμα, τόσο οι συστάσεις του ΠΟΥ, όσο και το παρόν εγχειρίδιο, θα πρέπει να προσαρμοστούν στο τοπικό πλαίσιο, την κουλτούρα και τη γλώσσα, ώστε να είναι κατάλληλα για τους ερ- γαζόμενους στον τομέα της υγείας και της κοινωνικής φροντίδας, τους φροντιστές και τους ίδιους τους ηλικιωμένους. Μία συμπερι- ληπτική διαδικασία προσαρμογής μπορεί να βοηθήσει στην ενσω- μάτωση αυτής της νέας προσέγγισης. Η υλοποίηση της προσέγγισης ICOPE θα απαιτήσει συνεχή συνερ- γασία σε όλα τα επίπεδα και τα στάδια μεταξύ όλων των εμπλεκόμε- νων φορέων, συμπεριλαμβανομένων των φορέων χάραξης πολι- τικής, των επαγγελματιών υγείας, των εργαζομένων στην κοινωνι- κή πρόνοια, των ερευνητών, των κοινοτήτων και των ηλικιωμένων. Η γνώση των τοπικών συνθηκών θα υποστηρίξει τη μετάφραση των παγκόσμιων οδηγιών σε ένα εφικτό και αποδεκτό σχεδιασμό υπη- ρεσιών. Η προαγωγή της υγιούς γήρανσης απαιτεί τη συμμετοχή τόσο του το- μέα της υγείας, όσο και του τομέα της κοινωνικής πρόνοιας. Οι δύο αυτοί τομείς θα είναι σε θέση να υιοθετήσουν και να εφαρμόσουν καλύτερα την προσέγγιση ICOPE, όταν οι εθνικές πολιτικές στηρί- ξουν την ενοποιημένη προσέγγιση υγείας και κοινωνικής πρόνοι- ας. Κεντρικές πολιτικές αποφάσεις θα καθορίσουν πώς θα λειτουρ- γεί η σύνδεση μεταξύ της υγειονομικής περίθαλψης και της κοινω- νικής πρόνοιας σε εθνικό, περιφερειακό και κοινοτικό επίπεδο. Κίνητρα και επιβράβευση, μηχανισμοί χρηματοδότησης και η πα- ρακολούθηση της απόδοσης, μπορούν να ενισχύσουν τη μετατόπι- ση της προτεραιότητας, όσον αφορά τη φροντίδα των ηλικιωμένων, προς τη βελτιστοποίηση των ενδογενών ικανοτήτων και της λει- τουργικότητάς τους. Τα πληροφοριακά συστήματα θα πρέπει να εί- ναι προσανατολισμένα στην παρακολούθηση της πορείας της μετά- βασης σε εθνικό και τοπικό επίπεδο. 13.2 ΑΠΑΙΤΗΣΕΙΣ ΣΕ ΕΠΙΠΕΔΟ ΠΡΟΫΠΟΛΟΓΙΣΜΟΥ ΚΑΙ ΑΝΘΡΩΠΙΝΟΥ ΔΥΝΑΜΙΚΟΥ Οι προϋποθέσεις της εφαρμογής της προσέγγισης ICOPE πρέπει να αναλυθούν για να προσδιοριστεί πού θα χρειαστούν επιπλέον επεν- δύσεις - για παράδειγμα, στην εκπαίδευση των εργαζομένων στον τομέα της υγείας, τη χρήση τεχνολογιών και την προσαρμογή των πληροφοριακών συστημάτων υγείας. Συγκεκριμένα, οι κοινοτικοί εργαζόμενοι στην υγεία και την κοινωνική πρόνοια και οι ομάδες πρωτοβάθμιας φροντίδας θα χρειαστεί να υποστηριχθούν για να κα- τανοήσουν και να εφαρμόσουν τη νέα προσέγγιση. Οι εθνικές και το- πικές επαγγελματικές ενώσεις μπορούν να διαδραματίσουν σημα- ντικό ρόλο σε αυτό, ως μέρος μιας συμμετοχικής διαδικασίας, που εμπλέκει όλους τους ενδιαφερόμενους φορείς. 13.3 ΑΠΑΡΤΙΩΣΗ ΥΓΕΙΟΝΟΜΙΚΗΣ ΚΑΙ ΚΟΙΝΩΝΙΚΗΣ ΦΡΟΝΤΙΔΑΣ ΚΑΙ ΥΠΟΣΤΗΡΙΞΗΣ Όλες οι παρεμβάσεις ολοκληρωμένης φροντίδας θα πρέπει να ακο- λουθούν τις αρχές μετάφρασης της γνώσης, τις οποίες ο ΠΟΥ ορίζει από το 2005 ως «τη σύνθεση, ανταλλαγή και εφαρμογή της γνώσης από τους αντίστοιχους ενδιαφερόμενους φορείς, με σκοπό να επιτα- χυνθούν τα οφέλη από την παγκόσμια και τοπική καινοτομία στην ενί- σχυση των συστημάτων υγείας και τη βελτίωση της υγείας των ανθρώ- πων». Το πλαίσιο μετάφρασης της γνώσης του ΠΟΥ για τη γήρανση και την υγεία του 2012, αναπτύχθηκε ειδικά για να εφαρμοστούν αυτές οι αρχές στη φροντίδα των ηλικιωμένων με πολλαπλές συννοσηρότητες και/ή δυσκολίες στην πρόσβαση στις υπηρεσίες υγείας (24). Το πλαίσιο του ΠΟΥ για ολοκληρωμένες και προσωποκεντρικές υπη- ρεσίες το 2016, προτείνει βασικές προσεγγίσεις για να διασφαλιστεί μια υψηλής ποιότητας ολοκληρωμένη φροντίδα (6). Ένα σημαντι- κό στοιχείο της ολοκληρωμένης φροντίδας είναι η ενισχυμένη δια- χείριση των περιστατικών, με σκοπό την υποστήριξη του σχεδιασμού, του συντονισμού και της παρακολούθησης των πλάνων φροντίδας, τα οποία πιθανότατα εκτείνονται σε πολλαπλούς τομείς υγείας και κοινω- νικής πρόνοιας. Οι εργαζόμενοι στον τομέα της υγείας και της κοινω- νικής πρόνοιας μπορεί να χρειαστούν ειδική εκπαίδευση στη διαχεί- ριση των περιστατικών, καθώς και στις κλινικές πτυχές των συστάσε- ων ICOPE. Το πλαίσιο του ΠΟΥ για την εφαρμογή της προσέγγισης ICOPE τονί- ζει τις κύριες ενέργειες που είναι αναγκαίες, σε επίπεδο υπηρεσιών και συστημάτων, για την υλοποίηση του ICOPE (25). Οι οδηγίες καλύ- πτουν τις ενέργειες (σελίδα 84) που πρέπει να ακολουθήσουν οι διοι- κήσεις υπηρεσιών και συστημάτων, προκειμένου να παρέχουν υπηρε- σίες ολοκληρωμένης φροντίδας. Το πλαίσιο προτείνει συγκεκριμένες ενέργειες, ανάλογα με την έκταση των υπαρχουσών υπηρεσιών υγεί- ας και κοινωνικής πρόνοιας. 13.4 ΕΥΘΥΓΡΑΜΜΙΣΗ ΤΟΠΙΚΩΝ ΥΠΗΡΕΣΙΩΝ ΥΓΕΙΑΣ ΚΑΙ ΚΟΙΝΩΝΙΚΗΣ ΠΡΟΝΟΙΑΣ ΓΙΑ ΤΗΝ ΥΠΟΣΤΗΡΙΞΗ ΤΗΣ ΕΦΑΡΜΟΓΗΣ Οι παρεμβάσεις ICOPE θα πρέπει να εφαρμόζονται στοχεύοντας στην υποστήριξη της γήρανσης στο χώρο διαμονής του ατόμου. Αυτό σημαί- νει ότι οι υπηρεσίες υγείας και κοινωνικής πρόνοιας θα πρέπει να πα- ρέχονται, έτσι ώστε οι ηλικιωμένοι να μπορούν να ζουν στο σπίτι τους και στην κοινότητά τους με ασφάλεια, αυτονομία και άνεση. Οι παρεμ- βάσεις σχεδιάζονται με σκοπό να παρέχονται μέσω μοντέλων φροντί- δας που δίνουν προτεραιότητα στην πρωτοβάθμια και την κοινοτική φροντίδα. Αυτό περιλαμβάνει την έμφαση σε παρεμβάσεις στο σπίτι, στην εμπλοκή της κοινότητας και σε ένα πλήρως απαρτιωμένο σύστη- μα παραπομπής. Αυτή η εστίαση μπορεί να επιτευχθεί μόνο με την αναγνώριση και την υποστήριξη του κρίσιμου ρόλου που παίζουν οι εργαζόμενοι στην κοι- νότητα, στην αύξηση της πρόσβασης στην πρωτοβάθμια φροντίδα υγείας και στην ομοιόμορφη παροχή υπηρεσιών υγείας. Οι οδηγίες του ΠΟΥ για την υποστήριξη των προγραμμάτων υγείας σε επίπεδο κοινό- τητας καταθέτουν επιστημονικά τεκμηριωμένες προτάσεις και συστά- σεις σχετικά με την επιλογή, την εκπαίδευση, τις βασικές δεξιότητες, την επίβλεψη και την αποζημίωση των εργαζομένων στον τομέα της υγείας σε επίπεδο κοινότητας(26). ΠΕΡΙΛΗΨΗ ΔΡΑΣΕΩΝ ΠΛΑΙΣΙΟΥ ΕΦΑΡΜΟΓΗΣ ICOPE ΕΝΕΡΓΕΙΕΣ ΓΙΑ ΤΙΣ ΥΠΗΡΕΣΙΕΣ 3Εμπλέξτε και ενδυναμώστε τους ανθρώπους και τις κοι- νότητες. Εμπλέξτε τους ηλικιωμένους, τις οικογένειές τους και την κοινωνία των πολιτών στην παροχή υπηρε- σιών. Υποστηρίξτε και εκπαιδεύστε τους φροντιστές. 3Υποστηρίξτε τον συντονισμό των υπηρεσιών που πα- ρέχονται από διεπιστημονικές ομάδες. Εντοπίστε τους ηλικιωμένους της κοινότητας που χρειάζονται φρο- ντίδα, πραγματοποιήστε ολοκληρωμένες αξιολογή- σεις και αναπτύξτε ολοκληρωμένα πλάνα φροντίδας. Εγκαθιδρύστε δίκτυα συνεργασίας μεταξύ των εργαζο- μένων στον τομέα της υγείας και της κοινωνικής πρό- νοιας. 3Προσανατολίστε τις υπηρεσίες προς την κοινοτική φρο- ντίδα. Παρέχετε αποτελεσματική και αποδεκτή φροντί- δα, με εστίαση στη λειτουργική ικανότητα των ωφελού- μενων μέσω των εργαζομένων και των υπηρεσιών της κοινότητας, με την υποστήριξη επαρκών υποδομών. ΕΝΕΡΓΕΙΕΣ ΓΙΑ ΤΑ ΣΥΣΤΗΜΑΤΑ 3Ενισχύστε τα συστήματα διακυβέρνησης και λογοδοσί- ας. Εμπλέξτε τους ενδιαφερόμενους φορείς στην ανά- πτυξη πολιτικής και υπηρεσιών. Αναπτύξτε πολιτική και κανονισμούς που να υποστηρίζουν την ολοκληρωμέ- νη φροντίδα και την αντιμετώπιση της κακοποίησης των ηλικιωμένων. Επαναβεβαιώνετε και βελτιώνετε συνε- χώς την ποιότητα των υπηρεσιών. Ελέγχετε τακτικά την ισότιμη και δίκαιη κατανομή των υπηρεσιών παροχής φροντίδας. 3 Προωθήστε την ενδυνάμωση των συστημάτων: Αναπτύξτε τις ικανότητες του εργατικού δυναμικού, τη χρηματοδότηση και τη διαχείριση των ανθρώπινων πό- ρων. Χρησιμοποιήστε την τεχνολογία για την ανταλλα- γή πληροφοριών μεταξύ των παρόχων των υπηρεσιών. Συλλέξτε και αναφέρετε τα δεδομένα για τις ενδογενείς ικανότητες και τη λειτουργικότητα των ηλικιωμένων. Χρησιμοποιήστε τις ψηφιακές τεχνολογίες προκειμένου να υποστηρίξετε την αυτοδιαχείριση των ωφελουμένων. Όταν απαιτείται εξειδικευμένη φροντίδα, ένα δίκτυο υγειονομικών σε δευτεροβάθμιο και τριτοβάθμιο επίπεδο πρέπει να υποστηρίζει το έργο των εργαζομένων στην κοινότητα. Πρέπει να καθοριστούν σαφή κριτήρια και πρωτόκολλα παραπομπής, μετά από συμφωνία μεταξύ όλων των ενδιαφερομένων μερών σε λειτουργικό επίπεδο, και ακολούθως αυτά να παρακολουθούνται με σκοπό τη διασφάλι- ση της ποιότητας. Οι ρυθμίσεις για τον επανέλεγχο πρέπει να είναι σαφείς, για να εξασφαλιστεί ότι τα πλάνα φροντίδας παραμένουν κατάλληλα και ότι η παροχή υγειονομικής περίθαλψης και υποστή- ριξης είναι αποτελεσματική. Η τακτική παρακολούθηση και η υπο- στήριξη μπορεί να είναι ιδιαίτερα σημαντικές μετά από μείζονες αλλαγές στην υγεία του ατόμου, ή εάν ο ηλικιωμένος βιώνει ένα μείζον γεγονός στη ζωή του, όπως η αλλαγή κατοικίας ή ο θάνατος συζύγου ή φροντιστή. 13.5 ΕΜΠΛΟΚΗ ΤΩΝ ΚΟΙΝΟΤΗΤΩΝ ΚΑΙ ΥΠΟΣΤΗΡΙΞΗ ΤΩΝ ΦΡΟΝΤΙΣΤΩΝ Οι εργαζόμενοι στη φροντίδα έχουν ανάγκη ενίσχυσης από επιπρό- σθετους πόρους εντός της κοινότητας. Η πιο ενεργός και άμεση συμ- μετοχή των κοινοτήτων και των γειτονιών στη φροντίδα και την υπο- στήριξη των ηλικιωμένων, μπορεί να απαιτήσει τόσο τοπική οργάνω- ση, όσο και πολιτική βούληση, ειδικά για την προώθηση του εθελο- ντισμού και τη διευκόλυνση της συνεισφοράς των ηλικιωμένων με- λών της κοινότητας. Οι σύλλογοι και οι ενώσεις ηλικιωμένων είναι οι φυσικοί σύμμαχοι σε αυτήν την προσπάθεια. Ταυτόχρονα, το σύστημα υγείας φέρει ευθύνη απέναντι στους εταί- ρους του στην υποστήριξη της υγιούς γήρανσης - τις κοινότητες, τις κοινοτικές οργανώσεις, τα μέλη της οικογένειας και άλλους μη αμει- βόμενους φροντιστές των ηλικιωμένων. Αυτή η ευθύνη περιλαμβά- νει την προσοχή στην υγεία και την ευεξία των φροντιστών, όπως συ- ζητείται στο Κεφάλαιο 11, και την αμοιβαία υποστήριξη, συνεργασία και συντονισμό με τις κοινότητες και τις κοινοτικές οργανώσεις για τη δημιουργία ενός υγιούς περιβάλλοντος για την υγιή γήρανση. ΒΙΒΛΙΟΓΡΑΦΙΑ 1. World report on ageing and health. Geneva: World Health Organization (WHO); 2015 (https://iris.who.int/ handle/10665/186463, accessed 2 April 2019). 2. Integrated care for older people: Guidelines on community-level interventions to manage declines in intrinsic capacity. Geneva: WHO; 2017 (https://iris.who.int/handle/10665/258981, accessed 2 April 2019). 3. 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Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H..Impact of a disease management program upon caregivers of.chron- ically critically ill patients. Chest. 2005;128(6):3925–36. doi:.10.1378/chest.128.6.3925. 22. Liang A, Piroth I, Robinson H, MacDonald B, Fisher M, Nater UM,.et al. A pilot randomized trial of a companion robot for people.with dementia living in the community. J Am Med Dir Assoc..2017;18(10):871–8. doi: 10.1016/j.jamda.2017.05.019. 23. Javadi D, Lamarche L, Avilla E, Siddiqui R, Gaber J, Bhamani M,.et al. Feasibility study of goal setting discussions between older. adults and volunteers facilitated by an eHealth application:.de- velopment of the Health TAPESTRY approach. Pilot Feasibility. Stud. 2018;4:184. doi: 10.1186/s40814-018-0377-2. 24. Knowledge translation. Geneva: WHO; no date (https://www. who.int/ageing/projects/knowledge_translation, accessed 2 April 2019). 25. Integrated care for older people: Guidance for systems and services. Geneva: WHO; 2019 (https://apps.who.int/iris/ handle/10665/325669, accessed June 2019). 26. Community-based health workers (CHWs). Geneva: WHO; no date (https://www.who.int/hrh/community, accessed 2 April 2019). www.who.int/ageing/health-systems/icope Department of Ageing and Life Course World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ageing@who.int Αυτή η μετάφραση δεν δημιουργήθηκε από τον Παγκόσμιο Οργανισμό Υγείας (ΠΟΥ). Ο ΠΟΥ δεν είναι υπεύθυνος για το περιεχόμενο ή την ακρίβεια αυτής της μετάφρασης. Η πρωτότυπη αγγλική έκδοση είναι η δεσμευτική και έγκυρη έκδοση. Μετάφραση: Αναστασία Κουτσούρη, Ελένη Ζίγκιρη, Γιώργος Σούλης, Παναγιώτα Καρύδη, Αθανάσιος Κορομηλιάς, Έκτορας Τσουγκαράκης, Αθηνά Μανιάτη, Ελευθέριος Μπουρνουσούζης. Έτος έκδοσης 2024