Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 312

As major international studies have shown, adverse events are not associated with age alone but rather with comorbidity, complexity, and frailty. Comorbidity is commonplace among the elderly: 98% of people over the age of 65 in one primary care population had multiple chronic medical conditions.⁴³ For patients, this leads to complex care needs, interacting medical conditions, and polypharmacy – all of which make them more vulnerable to poorer outcomes in general, such as increased mortality and length of hospital stays. In this group, acute illness is usually associated with exacerbations of multiple coexisting chronic diseases, which interplay to produce complex physiological, cognitive, and functional consequences. Of course, there is a great deal of inter‐individual heterogeneity in the way in which these complexities manifest themselves. It follows that acute illness leading to hospitalization in such individuals is rarely as straightforward as it might be in a younger, fitter patient, and hence more healthcare‐associated harm can occur. A review of dementia patients in acute hospitals revealed significant adverse events including falls, functional decline, delirium, increased length of stay, and even mortality.⁴⁴ There were many contributory factors including inadequate assessment and treatment, unnecessary interventions, and limited resources.

Frailty can be, but is not always, associated with the latter stages of chronic illnesses. Definitions vary, but frailty is understood to be a clinical syndrome in its own right, associated with loss of reserve in multiple organs and a clinical phenotype of generalized weakness, weight loss, exhaustion, and immobility.⁴⁵ This loss of reserve leads to the frail individual being less able to withstand illness and hospitalization than those without the condition.

The interaction between older people with multiple comorbidities, complexity, and frailty with the healthcare system is often complicated by the fact that illness presents in different, often more non‐specific ways in this population and may manifest as one of the geriatric syndromes described earlier.

In addition, cognitive impairment and sensory impairment may make it difficult for these patients to communicate with healthcare staff, which means they are less able to be involved in their own care than younger people, thus increasing their vulnerability to errors.