حضرت رسول اكرم (ص) وجود سالمندان در بين شما باعث بركت و نعمت هاي الهي ميشود 1 (بحاراالنوار) Frailty Reza Fadayevatan, MD, MPH, PhD The University of Social Welfare and Rehabilitation Sciences 2 (USWR) Topics of Lecture What is Ageing? Where we are? Frailty Prevention of frailty Mutual responsibilities 3 ?1- What is Ageing جوانی چنين گفت روزی به پيری که چون است با پيريت زندگانی؟ بگفت اندرين نامه حرفی است مبهم (پروین) 4 که معنيش جز وقت پيری ندانی what goes around comes around تازه جوانی ز ره نيشخند پير بخنديد و بگفت ای جوان 5 گفت به پيری که کمانت به چند؟ چرخ تورا نيز دهد رايگان What is Ageing? •Progressive loss of adaptability •Increased risk of acquiring disease •Increased risk of dying •Starts age 12 6 The Story of Life: a Postcard from 19th Century Germany *Courtesy of Elizabeth Barrett-Connor 7 Why Ageing? The force of mortality Age specific mortality (per thousand) 1000 100 10 1870 1920 1950 1990 1 0.1 0 20 40 60 80 100 Age (years) 9 Why Ageing? Increased life expectancy life expectancy at birth in the 20th century 90 life expectancy (years) 80 70 60 50 40 male 30 female 20 10 0 1890 1910 1930 1950 year 1970 1990 10 Why Ageing? Trends in birth rates • Fewer births • More survivors of infancy • Decreased mortality in adult • Health improvement 11 ?2- Where we are جمعيت كل كشور در سال 70,495,782 :85 جمعيت سالمند كشور در سال 5,121,043 : 85 درصد سالمندي كشور 26/7 :درصد تعداد افراد داراي يك معلوليت يا بيشتر در استان تهران 151899 :نفر تعداد افراد 100ساله و بيشتر در استان تهران 1891 :نفر تعداد افراد 100ساله و بيشتر در شهر تهران 1138 :نفر 12 Tehran Province استان تهران: كل جمعیت13,422,366 : جمعیت سالمند973,183 : جمعیت سالمند داراى درآمد بدون كار385,200 : شهر تهران: كل جمعیت7,975,679 : جمعیت سالمند686,431: درصد سالمندی8.6 : جمعیت سالمند داراى درآمد بدون كار293,815 : 13 گروههاي سني سالمندان تهراني كه به صورت انفرادي زندگي مي كنند گروههاي سني 60-64 65-69 70-74 75به باال جمع 14 تعداد سالمندان 14561 18217 22043 34685 89506 میزان سالخوردگی در مناطق مختلف شهر تهران 15 میانگین هزینه سالمت در مناطق مختلف شهر تهران 16 هزینه تشخیص پزشکی در مناطق مختلف شهر تهران 17 روند تغییر جمعیت در ایران 1385 18 1375 1365 سال سرشماری %25.08 %39.5 %45.45 جمعیت زیر 15سال %7.27 %6.62 %5.43 جمعیت باالی 60 سال ضریب سالمندي نسبت جمعیت باالي 65سال به جمعیت زیر 15سال ضریب سالمندي در سال 1365 ضریب سالمندي در سال 1375 ضریب سالمندي در سال 1385 19 % 6.68 %10.93 %20.68 3- Frailty: Frailty is defined as: Persons with a high probability of dependency on others for daily care within the next 12 months The World Health Oranization has described frailty as the state when “awareness” of a problem arises 20 What is Frailty? (1) Elderly people are Frail when they have multiple interacting medical and psychosocial problems Frailty represents increased vulnerability which is associated with ageing These patients do not have a common pathology 21 What is Frailty? (2) Frailty may not be a disease, but there is no question that certain diseases and medical problems play a large role in it Frailty is the beginning of a cascade that leads to functional deterioration, hospitalization, institutionalization, and death 22 What is Frailty? (3) 23 Prevalence 10-25% over 65 y/o 30-45% over 85 y/o The proportion is increasing with ageing society 24 Frailty Keywords: (Frailty, Fragility, Vulnerability) Frailty in our literature Frailty in the religious context Frailty in the health sciences 25 Frailty is not disability Similarities More common with advanced age, both increase morbidity and mortality Differences Frailty always means multisystem failure; disability may be due to failure of one or more systems Frailty always unstable; disability may be stable Thus, frailty often described as “subclinical” or “preclinical” disability 26 حدیقة الحقیقه و شریعه سنایي غزنوي عمر دادم بجملگي بر باد 27 بر من آمد ز شصت صد بیداد كشكول شیخ بهائي پس از پنجه نباشد تن درستي بصر كندي پذیرد پاي سستي چو شصت آمد نشست آمد پدیدار به هشتاد و نود چون در رسیدي بسا سختي كه از گیتي كشیدي از آن جا گر به صد منزل رساني بود مرگي بصورت زندگاني 28 شکایت گفتن پیرمردی به طبیب از رنجوریها و جواب گفتن طبیب او را گفت پیری مر طبیبی را که من گفت از پیری است آن ضعف دماغ گفت از پیری است ای شیخ قدیم گفت از پیری است ای شیخ نزار گفت ضعف معده هم از پیری است گفت آری انقطاع دم بود گفت کم شد شهوتم یکبارگی گفت پایم سست شد از ره بماند گفت پشتم چون کمانی شد دوتا گفت تاریک است چشمم ای حکیم گفت ای احمق براین بر دوختی ای مدمغ عقلت این دانش نداد تو خر احمق ز اندک مایگی پس طبیبش گفت کای عمر تو شصت چون همه اجزا و اعضا شد نحیف 29 در زحیرم از دماغ خویشتن گفت بر چشمم ز ظلمت هست داغ گفت پشتم درد میآید عظیم گفت هر چه میخورم نبود گوار گفت وقت دم مرا دمگیری است چون رسد پیری دو صد علت شود گفت از پیری است این بیچارگی گفت کز پیری است در کنجت نشاند گفت از پیری است این رنج و عنا گفت از پیری است ای مرد حلیم از طبیبی تو همین آموختی که خدا هر درد را درمان نهاد بر زمین ماندی ز کوته پایگی این غضب وین خشم هم از پیری است خویشتنداری و صبرت شد ضعیف قانون ابن سینا مراحل عمر ،ازديدگاه ابن سينا: 30 اول ،سن نمو :كه آنرا سن آغازي مي نامند و این مرحله تا نزدیك سي سالگي است و شامل پنج مرحله ،مي باشد: )1سن نوباوگي و آن زماني است كه شیرخوار ،هنوز قدرت برخاستن و حركت دادن اندام را ندارد. )2سن خردسالي كه در آن طفل ،پا مي گیرد ولي هنوز استوار نیست و آن زماني است كه هنوز افتادن دندان هاي شیري و روئیدن دندان هاي دائمي ،شروع نشده است. )3سن نشوونما كه مرحله اي است بعد از نیرو گرفتن و رویش دندان هاي دائمي و پیش از بلوغ. )4سن نوجواني و آن تا زماني است كه جوش در صورت ظاهر مي شود. )5سن جواني كه بعد از نوجواني است تا زماني كه نمو متوقف مي گردد. مراحل عمر ،ازديدگاه ابن سينا دوم ،سن وقوف یا ركود :كه آنرا سن جواني ،خوانند و تا مرز سي و پنج تا چهل سالگي ادامه دارد. سوم ،سن فرازي :كه با بقاء قوه ،قرین است و آن سن نوپیران است و تا مرز شصت سالگي دوام دارد. چهارم ،سن فرودي :كه با پیدایش ناتواني قرین است و آن سن پیري است تا پایان زندگي 31 Co-morbid conditions by age percentage of women with: No illnesses 1 llness 80 2 or more illnesses 70 60 50 40 30 20 10 0 60-69 years 70-79 years 80+ years 32 Atypical disease presentations Their history: “giants” “silent” “atypical” This is determined by change in function, not by change in parameters such as cardiac index, serum level of creatinine 33 Atypical disease presentations Delirium Falls Immobility Incontinence Pressure ulcers Social breakdown 34 Risk Factors of frailty Aging Psycho Social Diseases Environment Reserve capacity Adaptability Familial physical capacity cognition nutrition sensory affective Frailty factors that are essential for interaction with environment Risk factors Functional decline 35 How does Frailty happen? • Virtually before our eyes. • Family care givers are so concerned about the “Big Staff”-cancer, MI, Stroke- and overlook the less obvious: loss of appetite, ADL, Depression. • Since Frailty is not a disease, it can slip through the cracks. 36 Approach to Illness in the Older Patient • In older adults, the presenting problem is just the “tip of the iceberg” of a pathological process, which takes careful diagnostic assessment to uncover. • For example, a certain elderly patient is having recurrent falls. Why? 37 Approach to Illness in the Older Patient • After some history taking and some simple laboratory tests, you find this patient has exercise induced hypoxia. • And why the hypoxia? Because of the true but hidden diagnosis of Congestive Heart Failure that had not been diagnosed by anyone previously and, now requires treatment. • And just where did that ice-berg come from (i.e.. Why are they in failure now? How much is reversible?)? 38 Atypical disease presentations • Their history: – “giants” – “silent” – “atypical” Illness in old age often presents atypically, or is often masked. This is determined by change in function, not by change in parameters such as cardiac index, serum level of creatinine. For example: Silent MI or Urinary Tract Infection presenting as confusion 39 Who do we see? Geriatric Syndromes • • • • • • • • • • • Confusion Falls Delirium Immobility Incontinence Pressure ulcers Social breakdown Loss of independence Depression Multiple medical problems and medications Elder abuse 40 40 The Giants of Geriatrics The Big Three ‘I’s • Intellectual failure • Instability and immobility • Incontinence 42 Use of hospitals in the final 15 years of life Himsworth R L, Goldacre M J. BMJ 1999;319:1338-9 43 Survival Rates by Age Group (65- 69 Yrs) 100% 90% 80% Percent 70% 60% Frail Non-Frail 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Years 6 7 8 9 44 Survival Rates by Age Group (70 - 74 Yrs) 100% 90% 80% Percent 70% 60% Frail Non-Frail 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Years 6 7 8 9 45 Survival Rates by Age Group (70 - 74 Yrs) 100% 90% 80% Percent 70% 60% Frail Non-Frail 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Years 6 7 8 9 46 Survival Rates by Age Group (80 - 84 Yrs) 100% 90% 80% Percent 70% 60% 50% 40% Frail Non-Frail 30% 20% 10% 0% 1 2 3 4 5 Years 6 7 8 9 47 Survival Rates by Age Group (85 Yrs & Older) 100% 90% 80% Percent 70% 60% Frail Non-Frail 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Years 6 7 8 9 48 Age is just a number “How old would you be if you didn’t know how old Satchel Paige you were?” Age is just a number 49 Fitness and Frailty BA=Biological Age CA Fitness Frailty BA CA=Chronological Age 50 Fitness and Frailty Frail Elderly BA CA BA (Biological Age) > CA (Chronological Age) 51 Fitness and Frailty Fit Elderly CA BA BA (Biological Age) < CA (Chronological Age) 52 54 55 Can Frailty Be Treated or Prevented? While some aspects of frailty are age-related and irreversible, others are not. Frailty should be seen as treatable, and as an important stage on the road to disability and serious illness. it is important to consider which therapies make sense for a frail elderly person and which are to improve the quality of life. 57 Governors’ Responsibility It is mutual Growing up gracefully 59 Growing up disgracefully 60 Aspects of responsibilities 1- Public education 2- Public facilities )work, leisure, …( 3- Public access for elderly and disabled 4- lawful community 5- Social support )family economy…( 6- Using their invaluable experience …Age friendly city 61 Lawful environment 62 63 Socially engaged 64 Age friendly city 65 Summary •Ageing is a (the) major human achievement of the 20th century •Age in just a number •Mutual responsibility of people and governing 66 Thank you for listening 67