Health issues - Elderly, chronically ill and people with physical disabilities
Common health problems
The RIVM registers chronic health problems to determine the number of chronically ill people (see box).
- Rheumatoid arthritis
- Chronic neck and back complaints
- COPD and asthma
- Diabetes mellitus
- Congenital heart defects
- Heart valve abnormalities
- Heart failure
- Coronary heart disease
- Rhythm disorders
- Parkinson's disease
- HIV infection and AIDS
- Diseases related to alcohol
- Mood and anxiety disorders
- Personality disorders
- Mental disability
More than one disease
About 11% of the Dutch population (1.9 million) have more than one chronic disease. This occurs especially in women and in the elderly.
Common combinations are: diabetes and coronary diseases, diabetes and problems with vision, coronary heart disease and COPD. These diseases are linked together. That is called comorbidity. When the diseases are not related, it is called multipathology or multimorbidity. An example of this is that someone with COPD also has Parkinson's disease and a hearing disorder. The concepts of comorbidity and multimorbidity are often used interchangeably.
The percentage of people with multimorbidity varies from 10% among chronically ill adolescents to more than 50% among chronically ill elderly people. The latter percentage will increase because more and more people reach an advanced age. This means that care for people with a chronic disease is becoming increasingly complex.
Not all diseases lead to limitations in functioning. It is therefore good to look not only at the diseases, but also at the limitations that result from them.
Then you see that with the increase of age the limitations increase as far as seeing, hearing and moving is concerned. Restrictions in women with increasing age categories. Especially in women, there are many limitations in old age. Most of the restrictions occur among singles, widows, widowers, the low-skilled and people living in care and nursing homes.
Vulnerability, geriatric patients and geriatric syndromes
Vulnerability in the elderly is a process in which physical, psychological and social deficits in the functioning accumulate. This increases the chance of (more) health problems. An additional problem or condition can then disrupt the delicate balance. The patient has little 'reserve', can have little to do with it. A minor disturbance, for example a bladder infection, can have major consequences: dehydration, confusion, poor eating, becoming less active, muscle weakness, and so on.
In 2015, 700,000 elderly people aged over 65 will be vulnerable. A quarter of the elderly living at home and three quarters of the residents of nursing homes are vulnerable. Patients in nursing homes are almost all vulnerable. In 2030 there will be about one million.
Not every elderly patient is a geriatric patient. A vital 75-year-old who falls off his bike and breaks his hip is not yet a geriatric patient. You speak of a geriatric patient, if there is:
- Higher age; usually older than 70 years;
- Multiple conditions that adversely affect each other;
- Physical, psychological and social problems;
- Vulnerability or a shaky balance.
Usually a syndrome is understood to mean a combination of symptoms that all have the same cause. This is different for the geriatric patient. Characteristic of geriatric syndromes is that they are caused by various factors (see box).
- Mobility problems and falls
- Continence problems
- Memory problems
- Delirium or acute confusion
- Gloom, loneliness and life-stage problems
- Unexplained decline in daily functioning
- 'Getting lost'
- Loss of muscle mass
Polypharmacy means that a patient uses five or more drugs. This is especially common in the elderly and chronically ill. Older patients without chronic conditions use an average of three different medicines per year. Patients with more than two chronic disorders use no less than eleven different medicines every year! About 45% of the elderly belong to the polyfarmacy group. And almost a quarter of the over-75s use seven or more medicines. 11% of all visitors in community pharmacies are polypharmacies.
More than half of the medicines that are prescribed to people aged over 65 are medicines for big-six disorders. The big six are the six most important chronic disorders, for which most care is provided: diabetes, cardiovascular diseases (including risk management), asthma / COPD, psychosocial disorders (mainly depression and dementia), rheumatic diseases and cancer. Drugs for these conditions are therefore common in the top ten most prescribed medicines.
Top ten most prescribed medicines in the basic package in 2015
(source: SFK Top 10 of package medicines 2015 (2016) https://www.sfk.nl)
|Medicine||Application||Number of users
|1.||Diclofenac||Anti-inflammatory and painkiller||1,3|
|4.||Omeprazole||Gastric acid inhibitor||1,2|
|5.||Metoprolol||O.a. angina pectoris, increased blood pressure||1,1|
|6.||Macrogol, combination preparations||Constipation, bowel emptying||1,1|
|7.||Indifferent dermatica||On the skin, for example eczema||1,0|
|9.||Colecalciferol||Prevention of osteoporosis||0,8|
|10.||Acetylsalicylic acid||Inhibition of platelet aggregation||0,8|
In polypharmacy, the chance of side effects and interactions is high, as a result of which the vulnerable health can deteriorate even further. This danger is all the greater in case of poor kidney function (see box). At least, for drugs that are secreted by the kidney and have a small therapeutic breadth.
Determine kidney function
Many drugs are excreted via the kidneys, as are some waste products. A waste substance excreted by the kidneys is creatinine, a waste product of (muscle) protein. In case of poor kidney function, a high, sometimes dangerous concentration of medicines or waste substances in the blood can occur. If the medicine is still necessary, the dosage of the agent must be adjusted.
Renal function decreases with age. With drugs with a small therapeutic width (digoxin, lithium carbonate), a toxic concentration can therefore quickly arise. Then it is important to know how kidney function is. This is also important if medicines are used that can affect kidney function, such as NSAIDs, ACE inhibitors and intravenous contrast fluid (used in hospital examinations). In all these cases, it is important to determine the glomerular filtration rate (GFR). A normal filtration rate for an adult is 80-120 ml / min.
The filtration rate of the kidneys is calculated with a formula. The outcome, the number, is an estimate of the filtration rate of the kidney: eGFR (estimated GFR). For the sake of convenience, we use the abbreviation GFR in this book, also when it concerns an estimate. The MDRD calculation is the most commonly used for this (http://www.labuitslag.nl). Data required for this are:
- Creatinine concentration in the blood.
The MDRD formula was originally prepared for white people. In black people, the result must be multiplied by 1.21. Another formula, the CKD-EPI, is somewhat more reliable. This is based on the same data. In black people, the result must be multiplied by 1.159.
Be careful with interpreting the result
The calculated GFR is always an estimate. In addition, the MDRD is not suitable for children, acute kidney failure and abnormal muscle mass (extremely underweight, amputations, long-term bedrocking, bodybuilders). Medicines such as cimetidine, trimetroprim and cotrimoxazole also inhibit creatinine excretion through the kidneys. The result of the MDRD is then unjustifiably too low: you think that the kidneys are working badly, while in reality this is not the case or not so bad.
In the general practice, the average GFR of a 70-plus is around 60 ml / min. In fragile older patients with multimorbidity and polypharmacy, the average GFR is lower, around 40 ml / min. That has consequences for practice:
- In some patients you have to calculate the GFR. You have to take blood for that.
- Certain medicines should not be prescribed at a GFR below 30 ml / min: biophosphonates, antidiabetics from the sulfonylurea group (only tolbutamide may be prescribed), nitrofurantoin and metformin. The pharmacist's assistant therefore checks whether the renal function value is known.
- The (starting) dose of certain medicines must be reduced: most ACE inhibitors, antibiotics, amoxicillin / clavulanic acid, quinolones, sulphonamides and tetracyclines, many anticonvulsants and low molecular weight heparins.
The pharmacists' organization KNMP recommends appropriate dosing for reduced levels of renal function for most medicines.
Until recently, creatinine concentration could only be determined from venous blood (via venipuncture). Since recently, this can also be done from capillary blood (via a finger prick).
Oral health in the elderly
In 2009, 53% of the over-75s had a complete dental prosthesis. In 2030 that will probably only be 8%. More dental care is therefore needed.
Nevertheless, less than 40% of the over-80s go to the dentist for monitoring. This is less than 60% for the 65- to 75-year-olds. They do not think it necessary or do not think so, they have problems with transport or find it too expensive, especially if treatment is necessary.
Of the elderly who are admitted to a nursing home, 80% have moderate to poor oral health (see box). Of course, that group is not a cross-section of the elderly. But this figure shows that oral health in a vulnerable group of elderly people with multimorbidity is often part of their health problems.
Mouth disorders in nursing home residents
|Disorder||How often with a nursing home resident|
|Carrot caries||40 - 60 %|
|Gingivitis||20 - 30 %|
|Periodontitis||45 - 75 %|
|Prosthetitis||60 % of elderly with a prosthesis|
|Mouth corner Ignition||16 % of older people with a full denture|
In addition, there are often chewing and swallowing problems, especially in people with muscle weakness (due to a stroke or muscle disease) and with a loose prosthesis or pain due to a fungal infection, canker sores or jaw joint problems. A dry mouth, partly due to drug use, is common.
Oral health for chronically ill people
Chronic diseases affect oral health. Directly, for example in diabetes. Indirectly, when the chronic illness makes it difficult to properly perform oral care (stroke, muscle weakness or Parkinson's disease). Problems can also be caused indirectly by drugs that cause dry mouth, for example, or reduce resistance (chemotherapy agents reduce overall resistance, corticosteroids in inhalers cause reduced resistance in the mouth).
A healthy mouth contributes to good general health and quality of life. In other words, mouth problems affect general health, lower quality of life and affect self-confidence and social contacts.
A vicious circle is created. When people are less able to perform their oral care due to movement problems (stroke, muscle disease, Parkinson's disease), mouth problems can arise which in turn affect their general health:
- Problems with chewing and swallowing
- Bad food, malnutrition
- Periodontitis, with a chance of endocarditis and a risk factor for cardiovascular disease.
Mental health and social problems
The most common mental disorder in the elderly is an anxiety disorder. In addition, mood disorders are common, especially depressions. Depression occurs in 2% of the over-55s and in 15% of the residents of a nursing home. Depression is also common in people with COPD, diabetes, Parkinson's disease and stroke.
Dementia mainly occurs in the elderly. Korsakov's syndrome (due to vitamin deficiency often due to excessive alcohol consumption) occurs from the age of about 45 years.
A delirium, acute confusion caused by a physical cause, mainly occurs in (frail) elderly people. A delirium often occurs during a hospital stay, whether or not after an operation. Examples of triggering factors are: operations (anesthesia, respiration), malnutrition, dehydration and infection. A delirium in itself indicates that the patient is vulnerable.
Common social problems in the elderly are: loneliness, dependence on informal care, neglect and abuse (https://www.ouderenfonds.nl). The Netherlands Knowledge Center for the Elderly Psychiatry http://www.nkop.nl/ offers information, including short films about various psychological and social problems in the elderly.
Alcohol consumption among people aged over 60 is higher on average than among younger adults. The percentage of smokers among the elderly is lower than among younger adults. There are relatively many ex-smokers in the elderly group. Almost 70% of the over-55s meet the Dutch Healthy Movement Norm (NNGB). This standard means that elderly people move moderately intensively for at least five times a week, for example walking or cycling. You can also say that almost a third of the elderly do not reach this standard. In the group of older people over the age of 75, a much larger share does not meet that standard. Three out of five over-65s are overweight. That is more than in people under 65 years of age. And obesity (BMI 30 or higher) is more common among over-65s than among younger adults. Malnutrition also occurs among older people. Older people who receive home care and elderly people who are admitted to nursing and care homes and hospitals are vulnerable in terms of the risk of malnutrition.
As far as food is concerned, more than half of people living independently over 70 years do not meet the guidelines for fruit, vegetable, moisture and vitamin D intake. In short, together not such a favorable lifestyle pattern (Drijvers 2014).
60% of the chronically ill are overweight. 20% of the chronically ill are seriously overweight. People with disabilities move on average less than people without disabilities, especially people with motor impairments move less.
In the care for the elderly and the chronically ill, as an assistant you often have to deal with their informal caregivers. Older people and the chronically ill who receive professional care also usually receive informal care. But more and more elderly people also provide informal care to their sick partner and / or elderly father or mother. That can be a big burden, so they get health problems themselves. Especially the care for a demented partner or parent is heavy. Overloading can lead to derailed care: conflicts, exploitation, neglect, bonding or locking up the partner, abuse.
The social network of some elderly people is very small or unable to provide informal care.
Quite often, the request for help comes to practice or pharmacy via informal care. Certainly when the ability to take control is decreasing. Or when the informal caregiver assesses the situation differently from the older person and the elder does not seek help.
More and fewer help questions
Practical assistants have in recent years increasingly asked questions to arrange things (aids, home care, guidance from the Social Support Act, extra home visit). This question can come from the older self, but also from family who are worried about the deteriorating health and self-care of the elderly. Loneliness, a small social network and a lack of informal care also mean that older people often ask for help at the general practice.
On the other hand, some of the elderly sometimes also refrain from assistance, (follow-up) examinations or treatments because of the health insurance's own risk. GP's help is not covered by the own risk, but visit to a specialist, for example.