Evaluation gériatrique en vue d’une promontofixation

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1 Evaluation gériatrique en vue d’une promontofixation
F. PUISIEUX

2 Recherche bibliographique
Geriatric assessment AND Sacral colpopexy Colpopexy Surgery of prolapse ….. = 0 référence !!!!!

3 Elderly AND colpoplexy,….
Richter HE et al. The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse. J Am Geriatr Soc. 2007;55: “ Conclusion: Outcomes of prolapse surgery were comparable between older and younger women except that older women had slightly longer hospital stays” Ben-Ami I et al. Perioperative morbidity and mortality of gynecological oncologic surgery in elderly women. Int J Gynecol Cancer. 2006;16:452-7. “Conclusion: Chronological age by itself should not be a contraindication for the treatment of elderly women with gynecological malignancy since it is a poor predicting factor for perioperative morbidity.” J Am Geriatr Soc Jun;55(6): Links The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse.Richter HE, Goode PS, Kenton K, Brown MB, Burgio KL, Kreder K, Moalli P, Wright EJ, Weber AM; Pelvic Floor Disorders Network. Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35233, USA. OBJECTIVES: To compare perioperative morbidity and 1-year outcomes of older and younger women undergoing surgery for pelvic organ prolapse (POP). DESIGN: Prospective ancillary analysis. SETTING: Academic medical centers in National Institutes of Health, National Institute of Child Health and Human Development Colpopexy and Urinary Reduction Study. PARTICIPANTS: Women with POP and no symptoms of stress incontinence. INTERVENTION: Abdominal sacrocolpopexy with randomization to receive Burch colposuspension for treatment of possible occult incontinence or not. MEASUREMENTS: Perioperative complications and Pelvic Organ Prolapse Quantification and quality-of-life (QOL) questionnaires (Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Medical Outcomes Study Short-Form Health Survey (SF-36) preoperatively, immediately postoperatively, and 6 weeks and 3 and 12 months postoperatively). RESULTS: Three hundred twenty-two women aged 31 to 82 (21% aged > or =70), 93% white. Older women had higher baseline comorbidity (P<.001) and more severe POP (P=.003). Controlling for prolapse stage and whether Burch was performed, there were no age differences in complication rates. Older women had longer hospital stays (3.1+/-1.0 vs 2.7+/-1.5 days, P=.02) and higher prevalence of incontinence at 6 weeks (54.7% vs 37.2%, P=.005). At 3 and 12 months, there were no differences in self-reported incontinence, stress testing for incontinence, or prolapse stage. Improvements from baseline were significant on all QOL measures but with no age differences. CONCLUSION: Outcomes of prolapse surgery were comparable between older and younger women except that older women had slightly longer hospital stays Int J Gynecol Cancer Jan-Feb;16(1): Links Perioperative morbidity and mortality of gynecological oncologic surgery in elderly women.Ben-Ami I, Vaknin Z, Schneider D, Halperin R. Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. The study compares the perioperative morbidity and mortality rates of elderly (> or =70 years) and younger (< 70 years) patients. The study cohort consisted of 171 women undergoing explorative laparotomy due to uterine or ovarian cancer. Clinical data included patients' age, comorbidities, chronic use of medications, body mass index (kg/m(2)), past and current surgical procedures, surgical FIGO stage, histologic type and number of dissected lymph nodes, optimal versus nonoptimal debulking, occurrence of perioperative complications, and postoperative hospital stay (days). Participants were divided to 108 (63.2%) patients with uterine cancer and 63 (36.8%) patients with ovarian cancer. Women having uterine cancer were further subdivided to those <70 years of age (72 women, 66.7%) and those > or =70 years of age (36 women, 33.3%). Women with ovarian cancer were subdivided to those <70 years of age (48 women, 76.2%) and those > or =70 years of age (15 women, 23.8%). Excluding the occurrence of postoperative ileus and poorly controlled hypertension in the elderly subgroup of women with uterine cancer, the rate of early postoperative complications was similar between the two subgroups. Chronological age by itself should not be a contraindication for the treatment of elderly women with gynecological malignancy since it is a poor predicting factor for perioperative morbidity.

4 Elderly AND colpoplexy,….
Toglia MR et al. Morbidity and mortality rates of elective gynecologic surgery in the elderly woman. Am J Obstet Gynecol. 2003;189:1584-7: “Conclusion: Postoperative complications occurred infrequently among elderly women who underwent gynecologic surgery. Although age alone is not a contraindication to elective surgery, there may be increased risks for geriatric women.” Parker DY, et al. Gynecological surgery in octogenarians and nonagenarians. Am J Obstet Gynecol. 2004;190: “Conclusion: Successful gynecologic surgical outcomes with minimal morbidity are achievable in octogenarian patients and nonagenarian patients with optimization of co-medical conditions and careful perioperative treatment. Age should not be the sole determinant in the decision-making process” Am J Obstet Gynecol Dec;189(6):1584-7; discussion Links Morbidity and mortality rates of elective gynecologic surgery in the elderly woman.Toglia MR, Nolan TE. Division of Gynecology, Riddle Memorial Hospital, Suite 3404, Outpatient Pavilion, 1098 West Baltimore Pike, Media, PA 19073, USA. OBJECTIVE: The purpose of this study was to report perioperative morbidity and mortality rates in elderly women who undergo gynecologic surgery. STUDY DESIGN: The charts of 54 consecutive women ages 70 to 85 years who underwent major gynecologic surgery between June 1998 and November 2002 were reviewed retrospectively. RESULTS: The mean age was 76.7 years. Fifty procedures (92.6%) were performed for pelvic organ prolapse and/or urinary incontinence. Forty-nine of the procedures were performed vaginally, and 27 of the procedures (50%) were performed with the use of general anesthesia. Postoperative cardiac complications occurred in five patients (10%), including three myocardial infarctions, two of which were fatal. Other complications included benign cardiac arrhythmias in two patients, slow return of gastrointestinal function in five patients (9.3%), and transient mental status changes in four patients (7.4%). The mean length of stay was 4 days. CONCLUSION: Postoperative complications occurred infrequently among elderly women who underwent gynecologic surgery. Although age alone is not a contraindication to elective surgery, there may be increased risks for geriatric women. Am J Obstet Gynecol May;190(5): Links Gynecological surgery in octogenarians and nonagenarians.Parker DY, Burke JJ 2nd, Gallup DG. Department of Obstetrics and Gynecology, Memorial Health University Medical Center, Savannah, GA 31403, USA. OBJECTIVE: The study analyzed morbidity and mortality rates among octogenarian and nonagenarian patients who underwent operations for gynecologic indications. STUDY DESIGN: A retrospective chart review was performed for patients, aged >or=80 years, who underwent gynecologic procedures between January 1, 1995, and September 30, Information obtained included a complete medical history, type of surgical procedure, length of hospital stay, and discharge disposition. Simple demographic statistics were used. RESULTS: Sixty-two patients (mean age, 83.6 years) were identified. Seventy-seven operative procedures, 49 major and 28 minor, were performed. All patients were discharged home, except 2, who were discharged to nursing homes. Sixteen patients, who underwent minor procedures, were discharged the same day, and 6 patients were admitted for "23" hour stays. There were 11 perioperative complications and no perioperative deaths. CONCLUSION: Successful gynecologic surgical outcomes with minimal morbidity are achievable in octogenarian patients and nonagenarian patients with optimization of co-medical conditions and careful perioperative treatment. Age should not be the sole determinant in the decision-making process

5 Balance Avantages / Risques

6 Pour mener à bien cette évaluation
La connaissance de sa pathologie, de l’âge chronologique du patient et du désir du malade sont nécessaires mais insuffisants. L’état physique, fonctionnel, mental et thymique, l’autonomie et la motivation sont des paramètres aussi importants

7 Si le patient est atteint d’une maladie d’Alzheimer ou d’une maladie apparentée,
↑ confusion post-opératoire ↑ risque de chutes ↑ risque infectieux ↓ compliance aux traitements ↑ durée de séjour intra-hospitalier ↑ mortalité On peut réduire le risque par une prise en charge adaptée. Mais, une maladie d’Alzheimer sur deux n’est pas diagnostiquée !!

8 Intérêt d’une évaluation gériatrique multidimensionnelle ou standardisée (CGA des anglo-saxons)
Elle permet avec des outils validés d’apprécier l’état fonctionnel, la comorbidité, l’état cognitif, thymique, psychologique et nutritionnel du patient et sa situation sociale. Elle est utile pour prédire de la survie et/ou les complications des traitements. Elle permet de mesurer l’autonomie du patient et de déterminer les besoins en aides humaines, matérielles et financières. Les échelles permettent aussi de décrire la population âgée incluse dans les essais cliniques et de comparer les résultats.

9 CGA: les dimensions Médicale Fonctionnelle Psychologique Sociale
Interdisciplinaire Médicale Psychologique Fonctionnelle Sociale « La gériatrie n’est pas faite pour le solitaire » Pr. Roger DUFRESNE Faculté de Médecine de Sherbrooke

10 Joe Restivo, humoriste américain
« Ne demandez jamais à une personne âgée comment elle va s’il vous reste autre chose à faire le même jour. » Joe Restivo, humoriste américain

11 La CGA n’est pas utile pour toutes les personnes âgées
VIGOUREUX FRAGILES DEPENDANTS Cibles de la gériatrie

12 Outils standardisés et validés
Dimension Outil d’évaluation Corrélation Etat fonctionnel Autonomie ADL et IADL Espérance de vie Tolérance au stress Comorbidité Indices de comorbidité Cognition MMS Dépendance Thymie GDS Motivation Etat nutritionnel MNA Polymédication Nombre de médicaments Risque d’interactions Syndromes gériatriques: confusion, chute, incontinence…

13 Survie et perte d’autonomie
Quatre niveaux: (0) patients qui marchent sans aide, indépendants pour les ADL, continents (1) incontinents urinaires seulement (2) besoin d’aide pour se déplacer ou pour ou une ADL (ou deux si incontinence) ou incontinence urinaire ou fécale (3) dépendance totale pour se déplacer ou pour ou une ou plusieurs ADL (ou trois si incontinence) ou incontinence urinaire et fécale ou démence Rockwood et al. Lancet 1999

14 Sujets âgés fragiles à haut risque d’institutionnalisation
Effectiveness of a geriatric evaluation unit. A randomized clinical trial Rubenstein LZ et al, N Engl J Med 1984; 311: Sujets âgés fragiles à haut risque d’institutionnalisation 63 dans groupe intervention 60 dans le groupe contrôle A 1 an: ↓ Mortalité (24% vs 48%) ↓ NH admission (27% vs 47%; 26 vs 56 days) ↓ Rehospitalisations (35% vs 50%; 17 vs 23 days) ↓ Coût ($22,000 vs $28,000 /année de survie) ↑ ADL (42% vs 24% amélioration) ↑ Thymie (42% vs 24% amélioration)

15 Randomized trial of impact of model of integrated care and case management for older people living in community Bernabei R et al. BMJ 1998;316:1348–51 Randomised trial of impact of model of integrated care and case management for older people living in community Roberto Bernabei, Francesco Landi, Giovanni Gambassi, Antonio Sgadari, Giuseppe Zuccala, Vincent Mor, Laurence Z Rubenstein, PierUgo Carbonin BMJ 1998;316:1348–51 Abstract Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 (r1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P < 0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P < 0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

16 Randomized trial of impact of model of integrated care and case management for older people living in community Bernabei R et al. BMJ 1998;316:1348–51

17 Randomized trial of impact of model of integrated care and case management for older people living in community Bernabei R et al. BMJ 1998;316:1348–51

18 L’adhésion du personnel soignant aux recommandations a été de 96 %.
Prévention du syndrome confusionnel dans un service de médecine interne gériatrique A. Gentric, et al. Revue de médecine interne 2007;28:589–593 Critère d’évaluation principal: comparaison de l’incidence du syndrome confusionnel avant et après la mise en oeuvre d’une stratégie préventive. Critère secondaire: adhésion du personnel soignant au protocole de prévention. Avant intervention, 367 patients ont été admis (moyenne d’âge : 84,6 ± 6,2 ans). Incidence du syndrome confusionnel 8,99 %. Après intervention, 372 patients ont été admis (moyenne d’âge : 84,9 ± 6,1 ans).Incidence du syndrome confusionnel 2,4 %, (RR:0,73; p = 0,001). L’adhésion du personnel soignant aux recommandations a été de 96 %. Résumé Propos. – Le syndrome confusionnel aigu est la complication la plus fréquemment observée chez le sujet âgé fragile hospitalisé. Le pronostic est péjoratif en termes de mortalité, de morbidité, de perte d’autonomie. Le syndrome confusionnel survient chez des patients à risque, soumis à un ou plusieurs facteurs de stress déclenchants. Une étude randomisée a démontré la capacité d’une stratégie préventive non médicamenteuse multidimensionnelle à réduire l’incidence hospitalière du syndrome confusionnel de 40 %. L’objectif de ce travail est d’évaluer l’efficacité d’une telle démarche préventive, adaptée à la pratique quotidienne d’un service de médecine interne gériatrique. Méthode. – L’étude est menée dans un service de médecine interne gériatrique de 26 lits d’un centre hospitalo-universitaire français. Le critère d’évaluation principal est la comparaison de l’incidence du syndrome confusionnel avant (patients de 75 ans et plus, non confus, admis du 1er juillet au 31 décembre 2004) et après la mise en oeuvre d’une stratégie préventive (patients de 75 ans et plus, non confus, admis du 1er juillet au 31 décembre 2005). Le critère secondaire est l’adhésion du personnel soignant au protocole de prévention. Résultats. – Avant intervention, 367 patients ont été admis (moyenne d’âge : 84,6 ± 6,2 ans). L’incidence du syndrome confusionnel a été de 8,99 %. Dans le sous-groupe des 123 patients déments, l’incidence du syndrome confusionnel a été de 15,4 %. Après intervention, 372 patients ont été admis (moyenne d’âge : 84,9 ± 6,1 ans). Sur l’ensemble du groupe, l’incidence du syndrome confusionnel a été de 2,4 %, soit une réduction du risque relatif de 73 % (p = 0,001). Dans le sous-groupe des 133 patients déments, l’incidence a été de 5,3 %, soit une réduction du risque relatif de 66 %. L’adhésion du personnel soignant aux recommandations a été de 96 %. Conclusions. – Cette étude démontre qu’il est possible d’adapter la recherche clinique à la pratique quotidienne pour prévenir le syndrome confusionnel du malade âgé fragile, hospitalisé en service de médecine interne gériatrique. Cette démarche préventive simple pourrait être appliquée à tous les services recevant des malades âgés à risque, dans le cadre d’une démarche qualité.

19 Prévention du syndrome confusionnel dans un service de médecine interne gériatrique A. Gentric, et al. Revue de médecine interne 2007;28:589–593 [1] Inouye SK. Delirium in older patients. N Engl J Med 2006;354:1157–65.

20 Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Lundström M, et al. Aging Clin Exp Res. 2007;19: 199 patients, ≥ 70 ans, randomisation: prise en charge postopératoire en gériatrie vs en orthopédie. Intervention: évaluation gériatrique, prévention, diagnostic et traitement du syndrome confusionnel. ↓ nombre de patients confus (56/102, 54.9% vs 73/97, 75.3%, p=0.003) dans groupe intervention vs groupe contrôle ↓ nombre de journées de confusion (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) ↓ nombre de complications: escarres, infections urinaires, troubles du sommeil, problèmes nutritionnels, chutes ↓ durée moyenne d’hospitalisation (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028). Aging Clin Exp Res Jun;19(3): Links Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Lundström M, Olofsson B, Stenvall M, Karlsson S, Nyberg L, Englund U, Borssén B, Svensson O, Gustafson Y. Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, SE Umeå, Sweden. BACKGROUND AND AIMS: Delirium is a common postoperative complication in elderly patients which has a serious impact on outcome in terms of morbidity and costs. We examined whether a postoperative multi-factorial intervention program can reduce delirium and improve outcome in patients with femoral neck fractures. METHODS: One hundred and ninety-nine patients, aged 70 years and over (mean age+/-SD, 82+/-6, 74% women), were randomly assigned to postoperative care in a specialized geriatric ward or a conventional orthopedic ward. The intervention consisted of staff education focusing on the assessment, prevention and treatment of delirium and associated complications. The staff worked as a team, applying comprehensive geriatric assessment, management and rehabilitation. Patients were assessed using the Mini Mental State Examination and the Organic Brain Syndrome Scale, and delirium was diagnosed according to DSM-IV criteria. RESULTS: The number of days of postoperative delirium among intervention patients was fewer (5.0+/-7.1 days vs 10.2+/-13.3 days, p=0.009) compared with controls. A lower proportion of intervention patients were delirious postoperatively than controls (56/102, 54.9% vs 73/97, 75.3%, p=0.003). Eighteen percent in the intervention ward and 52% of controls were delirious after the seventh postoperative day (p<0.001). Intervention patients suffered from fewer complications, such as decubitus ulcers, urinary tract infections, nutritional complications, sleeping problems and falls, than controls. Total postoperative hospitalization was shorter in the intervention ward (28.0+/-17.9 days vs 38.0+/-40.6 days, p=0.028). CONCLUSIONS: Patients with postoperative delirium can be successfully treated, resulting in fewer days of delirium, fewer other complications, and shorter length of hospitalization

21 Conclusion: l’évaluation gériatrique multidimensionnelle standardisée
Est utile chez les personnes âgées fragiles ou dépendantes Aide à la décision thérapeutique Aide à la définition du plan de soins Aide à la recherche clinique chez le sujet âgé Elle peut réduire les complications post-opératoires Doit être pratiquée en équipe interdisciplinaire par des professionnels formés Elle doit conduire à des recommandations Elle nécessite un suivi de ces recommandations