Forms of organization of gerontological rehabilitation. Organizational forms of geriatric care to the population
On an integrated approach to providing medical and social assistance To old people
A.S. Gracheva,
deputy Head of the department for organizing quality control of medical care to the population of Roszdravnadzor
Magazine "Russian Pharmacies"
Published on the website
The article is devoted to the current problem of organizing medical and social care for elderly and senile people, and contains examples of positive foreign and domestic experience in this area over the past 20 years. The features of the course of diseases in this category of patients and the principles of geriatric pharmacology are briefly outlined.
Quite drastic changes in the demographic structure of society in recent years, caused by the aging process of the population, arouse natural interest in the social and medical problems of older people.
The UN Principles for Older People “Making the lives of older people fulfilling” defines the role and place of older people in society, including ensuring independence, care, participation in social development, opportunities to realize their internal potential (UN General Assembly resolution 40/91).
Demographic aging of the population - an increase in the proportion of elderly and old people in the total population, which two decades ago was considered as a phenomenon relating exclusively to developed countries, now covers almost the entire world. According to literature data, in 2000 the number of this part of the population reached 590 million people, and by 2025 the number of elderly people on the planet will reach 1 billion people.
Due to the fact that the pace of aging has accelerated in Russia, there has been a need for an in-depth study of various factors associated with this phenomenon, especially since the aging of the country's population is accompanied by dramatic changes in the health status of citizens. The search for new ways of interdepartmental interaction and rational forms of organizing medical care for older people meets the principles of restructuring the health care system.
IN Russian Federation almost a fifth (18%) of the country’s total population, about 30 million people, are people retirement age, of which about 11% (3.2 million) are people over 80 years of age.
It is expected that by 2015, every third of the elderly will belong to the group of the oldest (75 years and older). The aging of the population is most pronounced in the European part of Russia (Northwestern, Central, Volga-Vyatka, Central Black Earth regions).
This trend will require further development of not only gerontology, but also geriatric services, in particular geriatric pharmacology. Gerontology and geriatrics is a field of medical and biological science that includes the study of aging processes, causes of occurrence, mechanisms of development and features of the course of diseases in older people. age groups Oh.
Considering the need to provide assistance to older people, both domestic and foreign authors and organizations began to pay significant attention to this problem. Abroad, soon after the Second World War, national associations of gerontologists and geriatricians were created, which formed the International Association of Gerontologists (IAG) in 1950.
At the UN World Assemblies on Aging (1982, 2002), a set of measures for social protection and assistance to the elderly was approved. Gerontological care began to be viewed as a medical and social problem. Large gerontological centers were established in a number of cities in Europe and North America.
In our country, the first city society of gerontologists was created in 1957 in Leningrad. Subsequently, the head research institute of gerontology of the Academy of Medical Sciences was organized in Kyiv and the All-Union Society of Gerontologists and Geriatricians was established. Work began on creating departments of geriatrics with the aim of training geriatricians, but at that time it was not possible to create a coherent system of geriatric care.
In the Russian Federation, geriatric services began to be systematically created only in the late 80s - early 90s. The intensification of this work was facilitated by the unification of domestic gerontologists and geriatricians into the Gerontological Society of the Russian Academy of Sciences (1994), which was subsequently accepted into the IAG.
Features of the course of diseases in elderly and senile people
The development of geriatrics (clinical gerontology) is aimed at studying the features of diagnosis, treatment and prevention of diseases in old age. The aging of the population makes urgent the problem of providing medical and social care to elderly and senile people, about 80% of whom suffer from multiple chronic pathologies.
The course of many diseases in elderly and senile patients has its own characteristics. Thus, in the structure of morbidity among older people, the main place is occupied by coronary heart disease, hypertension, diabetes mellitus, respiratory diseases, and diseases of the musculoskeletal system. At the same time, patients are rarely diagnosed with only one disease; much more often, a combination of three, four, and sometimes more diseases is detected, which creates additional difficulties in treatment and worsens the prognosis for recovery.
Many common diseases can occur in elderly patients latently, without clear clinical symptoms, while at the same time being accompanied by a tendency to develop serious complications.
So, infectious and inflammatory diseases in elderly patients, they are often not accompanied by an increase in body temperature, which is due to reduced reactivity of the body. One of the frequent concomitant manifestations of diseases in elderly and senile people is pain, the significance of which is often underestimated, not diagnosed in a timely manner and, as a result, not treated. Clinical symptoms of acute surgical diseases are sometimes erased, which leads to a delayed start of treatment. These difficulties are sometimes also associated with the fact that the elderly patient himself sometimes cannot clearly draw the line between health and illness, explaining the ailment that has arisen due to purely “age-related” reasons. The combination of several diseases in one and the same elderly person, aggravating his condition, often makes it impossible to conduct a full examination.
Principles of Geriatric Pharmacology
It is believed that on average, one patient over 60 years of age has four to five different diseases, which is naturally accompanied by an increase in the consumption of various medications by such a patient. However, in the body of older people, the pharmacodynamics and pharmacokinetics of drugs most often change; there is a significantly higher frequency of their side effects. Physician ignorance of these features can aggravate the course of the disease in elderly patients. Therefore, it is already a very urgent task for doctors of various specialties to master the basics of geriatric pharmacology.
The peculiarities of the action of drugs in the elderly also create difficulties in treating these patients. The doctor must have a clear understanding of the principles of drug dosing in geriatrics, the peculiarities of drug interactions, and ways to increase the resistance of the body of older people to the undesirable effects of medications. The question of prescribing a particular drug should be decided only after a comprehensive analysis of its effect on the body of an elderly patient. One of the rules of geriatric pharmacotherapy is strict individualization of doses. At the very beginning of treatment, drugs are prescribed in doses reduced by approximately 2 times compared to those for middle-aged patients. And only by gradually increasing the dose, individual drug tolerance is established. Once the therapeutic effect is achieved, the dose is reduced to a maintenance dose, which, as a rule, is also lower than the dose prescribed to middle-aged patients. The method of taking the medicine should be as simple and understandable as possible for the patient. If possible, liquid dosage forms should be avoided, since due to impaired vision and hand tremors, elderly patients have difficulty dosing them. In addition, the lack of strict control over the tightness of the vial can lead to changes in the concentration of the drug, its contamination or damage. Medical staff in the hospital Special attention should pay attention to monitoring the timely intake of prescribed medications, since elderly and elderly people often forget to take the medicine on time or, conversely, take it again without waiting for the prescribed time.
In elderly people, along with a decrease in the number of receptors in the nervous tissue, functional exhaustion and a decrease in its reactivity are simultaneously observed. This contributes to the development of difficult to predict, atypical, inadequate amounts of the administered drug, and even paradoxical reactions. As a result of structural age-related changes in the mucous membrane of the gastrointestinal tract, the absorption of drugs is impaired, which reduces healing effect. In addition, age-related changes in the liver and kidneys mean that drugs and their metabolic products are slowly eliminated from the body. This contributes to the accumulation of the drug and the development of various side effects. In this regard, it is necessary to first prescribe small doses of the drug, followed by an individual dose increase depending on tolerability.
According to medical statistics, the risk of side effects in patients over 60 years of age is 1.5 times higher than in younger people. And in patients aged 70–79 years, adverse reactions to drug administration develop 7 times more often than in patients aged 20–29 years. Elderly and senile people are 2-3 times more likely than young and middle-aged people to be hospitalized due to side effects of drugs. And the largest number of deaths associated with irrational pharmacotherapy occurs in the age group of 80-90 years.
It should be emphasized that medications prescribed to older people without taking into account the specifics of geriatric pharmacotherapy can cause much more harm than the disease itself for which they are used.
Due to the peculiarities of physiological and pathological processes in old age, the need for a specific approach to the management of patients in older age groups, at the beginning of the last century, attempts were made to isolate geriatrics and the corresponding specialty of a geriatrician into a separate clinical discipline. However, the specialty of a geriatrician was introduced only in 1994, and the place of this specialist in the primary health care system is not yet clearly defined, and therefore his functional responsibilities are not fully realized.
Possibilities postgraduate education in gerontology and geriatrics are also limited. Therefore, most of the problems associated with the diagnosis, treatment and rehabilitation of elderly patients still have to be solved by a general practitioner, who is required to have general clinical training and the ability to solve related, interdisciplinary issues. Meanwhile, as experience shows, when caring for an elderly patient, a general practitioner seeks help from doctors of narrow specialties. A kind of redistribution of medical responsibilities occurs, as a result of which the elderly patient, depending on the nature and number of diseases (or syndromes), becomes the object of attention of doctors of various specialties, each of whom, as a rule, treats “his own” pathology, losing the vision of the elderly patient as a whole with his particular geriatric problems.
Often, elderly and senile patients are prescribed diagnostic tests that are uninformative, burdensome for their age and condition, and sometimes expensive. At the same time, it turns out that the participation of related specialists in the diagnostic process and the conduct of special studies does not reduce the incidence of late diagnosis of diseases such as tuberculosis, sepsis, pulmonary embolism, urinary tract infections, and malignant tumors at a later age.
The need for an integral approach to an elderly patient based on extensive clinical training of a doctor can be most clearly illustrated by the example of managing a patient with diabetes mellitus. The nature of the course and specific complications of this disease, along with frequent concomitant pathology, require the doctor to have appropriate knowledge and skills not only in endocrinology (timely diagnosis and selection of adequate therapy), but also in such clinical areas as cardiology (arterial hypertension, diabetic cardiomyopathy, heart failure ), nephrology (diabetic nephropathy), urology (urinary tract infection, neurogenic bladder), neurology (polyneuropathy), ophthalmology (diabetic retinopathy, cataracts), orthopedics and surgery (diabetic foot).
The reality of the clinical interdisciplinarity of geriatrics is felt, in particular, in the management of elderly patients with various mental disorders, especially depression and “mild” dementias (initial manifestations), which are often not recognized.
The role of nursing staff in the prevention of aging is very limited, and in the hospital it is not visible at all. Family nurses implement knowledge of aging prevention more clearly, but, unfortunately, they are clearly not enough to allow nursing staff to begin solving this problem. From the point of view of the effectiveness of organizing outside care for elderly patients, the organizational and clinical potential of nursing staff is not used rationally enough.
Organization of medical and social assistance to the elderly
Health care for the elderly is a wide range of services and services, including the provision of care for acute and chronic conditions, nursing, outpatient care, short-term and long-term care, and community-based personal care.
The following systems of services for the elderly are distinguished: information and educational, preventive, medical care for outpatient and hospital patients, long-term care, home care, social hospitals, general support services.
Geriatric care for the population is a system of measures to provide long-term medical and social services with the aim of maintaining or restoring the ability to self-care, partially or completely lost due to chronic diseases, facilitating the reintegration of elderly patients into society, as well as ensuring independent existence.
Projected changes in the size and structure of the population of older and older people indicate that the need for long-term forms of care will increase. Older people are 5 times more likely to need long-term care services (LTC) than patients of other age groups.
Identify fundamental approaches to development various types help for the elderly:
– ensuring continuity of various services (inpatient, outpatient, home care);
– development of preventive and supportive services;
– development of integrative services at the local level;
– attracting public and private investment to provide a full range of services to the elderly;
– the desire to create cost-effective service systems, including disease prevention, compensation for impaired functions, and support for independent living at home.
Analysis of the available literature on the problems of gerontological PD allows us to identify three main types of services provided: medical, social and medical-social
Long-term care is defined as one or more services provided to maintain the functional abilities of a chronically ill person to achieve the highest possible level of physical, mental and social well-being. Such services are provided both at home and in a specialized institution.
One of the goals of DP is to enhance the patient's ability to self-care. Including health and social services, this type of care also provides rehabilitation and support services over the long term, as far as possible. DP focuses on the personality of the patient with functional impairment, who needs to strengthen support systems to satisfy various types daily activities - cooking, taking medications, housework, etc.
Abroad, there are three levels of DP: institutional, residential and at home. The first includes rehabilitation in specialized departments of general hospitals, hospice, and convalescent care. The second is represented by day hospitals (hospitals) for rehabilitation and medical/social day care. Home care includes medical care (hospice) as well as patient monitoring.
Problems holding back the growth of DP in many countries, according to experts, include, in particular, insufficient funding, which entails a decrease in the availability of this type of assistance. In Russia, issues of caring for elderly patients at home are becoming increasingly important due to various factors - the restructuring of the healthcare and social services system, the reorientation of primary medical and social care to the population towards outpatient care, and the growing number of elderly people.
The most important type of long-term care for the elderly is the provision of services at home or home care (hereinafter referred to as DH), which is an integral part of the system of services for the elderly in the community, including day care centers, mental health centers, hospices, etc.
These forms of gerontological care are widespread, for example in the USA. In 1945, a home care department was created at the Montefiore Hospital (New York State). His work was based on a team concept, which involved collaboration between doctors and social workers. In the 1950-60s. The number of PD programs for patients with functional impairments and mental illness increased. In 1958, PD standards were presented at a special conference. Since 1961, grants have been provided to projects for the development of services alternative to hospital care, 15% of such projects included PD. Through the movement to create community mental health centers, the concept of social work outside hospitals was formulated. In 1964-65 The new health care financing programs Medicaid and Medicare have shaped the concept of long-term care for the elderly and people with limited functional abilities. In the 1970s PD is provided with funding for these programs.
Main goals of the PD:
– improving the patient’s functional status until achieving complete independence and the ability to self-care;
– improving and maintaining the patient’s functional status to ensure the opportunity to live in a family or receive care at the place of residence;
– ensure the opportunity for an elderly person to remain at home as long as possible.
Home care, as an alternative to long-term institutional care, is becoming a valuable resource in senior living communities, providing for their needs, especially for those with functional impairments. Some of them receive psychological support from relatives or friends, but professional help and therapy are important elements in preventing hospitalization and, in many cases, institutionalization.
Organizing medical PD is the most effective and efficient way to use the available resources of the healthcare system. The advantages of this type of care over other types and forms of gerontological care include:
– recovery at home occurs in more early dates;
– the home environment is more comfortable, since patients feel greater responsibility for their care on the part of loved ones than in care homes;
– hospital patients more often resort to taking sleeping pills due to sleep disturbances in hospital wards;
– saving time due to the absence of the need to visit family members in hospitals;
– the cost of PD is lower than other types of treatment.
The positive influence of the family environment on the health of the elderly is well illustrated by the following data: the morbidity rate among such elderly people is almost 2 times less than among those living alone, the mortality rate is more than 3 times lower, and the average life expectancy is higher than among those living alone.
The patient of the PD service is an elderly person who has a disease or functional impairment that limits his ability to leave his home, except in cases of using a cane, walker, crutches, wheelchair, or special transport. Experts say seniors should not be sent to residential care as long as they remain able to stay at home. The group of potential patients includes patients with developing functional impairments, the elderly after hospitalization, the incapacitated and chronically ill, patients with mental disorders, terminally ill patients, people who abuse alcohol or psychotropic drugs.
Various impairments in the functional status of elderly and old people are the reason for the need to provide comprehensive home care. Depending on the individual needs of the elderly, all services provided by PD services can be divided into two large groups services:
1. Support of daily life activities.
2. Professional services.
Experts also highlight specialized PD programs, such as hospice programs.
To manage the disease in PD settings, three main areas can be distinguished:
1. determining the results of the care provided, including the patient and his satisfaction with payment for services;
2. maintaining quality of life as perceived by the patient and his family;
3. determination of the volume of financial costs.
Outcomes of disease management programs include:
– reduction in the number of exacerbations of diseases;
– reduction of health care resources used;
– patient satisfaction with the care received.
Quality of life criteria include:
– ability to do work;
– ability to maintain relationships;
– ability to carry out daily activities;
– ability to implement various social roles.
A number of authors, speaking about various indicators reflecting the results of care, share those that affect the functioning of the patient and the degree of his autonomy. These include: physiological (pain), functional, cognitive, affective, social relationships, social participation, degree of satisfaction with care and satisfaction with the environment.
There are also criteria for the quality of care:
– the ability to evaluate the assistance provided;
– duration (duration) of the services provided from the point of view of the existence of the organization;
– the duration of the provision of services in terms of the needs of patients in cases where they require such assistance;
– effectiveness of assistance;
– safety for the environment.
To date, the development of geriatric centers, inpatient and day care departments in multidisciplinary hospitals has not been properly developed. In addition, there is a need for new principles for the provision of long-term medical and social care in specialized geriatric departments.
The goals of gerontological care include:
1. Ensuring that older people, if appropriate, have access to all forms of medical care, including outpatient, inpatient and emergency medical care, subject to constant monitoring of its volume and quality, medicines and medical products. Creation in the Russian Federation of an extensive system of gerontological assistance to the population, consisting of specialized offices and institutions and having the appropriate personnel potential.
2. Formation of a palliative care system, including special institutions - hospices, palliative care departments in hospitals, palliative care rooms in outpatient clinics.
3. Improving the system of gerontopsychiatric care through the development of a network of gerontopsychiatric offices in the structure of general outpatient institutions, units in psychoneurological dispensaries, gerontological departments in psychiatric hospitals, psychosomatic gerontological departments in general hospitals, as well as social structures psychological assistance To old people.
4. Improving targeted rehabilitation and physical education work with older people, aimed at promoting health and preventing diseases.
5. Ensuring the availability for older people of hearing aids, prostheses, glasses, individual means of transportation and rehabilitation, and exercise equipment for physical therapy.
However, despite some progress in the development of out-of-hospital care for the elderly population in the country, the priority of outpatient services remains low. The development of the system of outpatient care for the elderly population was facilitated by the order of the Ministry of Health of Russia dated July 28, 1999 No. 297 “On improving the organization of medical care for elderly and senile citizens in the Russian Federation,” based on national and international experience in providing geriatric care. An appendix to the order is a regulation on the organization of the activities of the geriatric center. Since the mid-90s. In the last century, the personnel training system also began to develop and improve, and the development of educational standards in geriatrics began. Solving current problems of outpatient care for the elderly population can be facilitated by the use of both international and domestic experience.
The first large territorial service system for the elderly in our country was created in 1989 in Nizhny Novgorod, where a regional gerontological center was founded. In 1994, the City Geriatric Center was created in St. Petersburg. Subsequently, similar large centers were created in Samara, Ulyanovsk, Yaroslavl and a number of other cities in the country. The most important link in the work of these centers was outpatient care for elderly and senile people.
According to experts, in organizational terms, medical and social care for the elderly at home is one of the most difficult problems.
One of the reasons for the difficulties may be due to the fact that the provision of medical and social care to older people is entrusted to different departments - health authorities and social protection authorities without proper relationship between these departments, which affects the quality of services in medical and social care at home.
To assess the capabilities and effectiveness of medical and social rehabilitation, an integral indicator was developed - the index of medical and social adaptation (hereinafter - MSA) of elderly and old people. Determining the index made it possible to identify a decrease in MSA with age and the presence of various degrees of maladjustment in geriatric disabled people.
An example of a model of comprehensive care for the elderly at home is the model developed in the Department of Social Protection of the Population of the city of Dubna and presented in the “Methodological material for workers of medical and social services for home care for the elderly and disabled” (Dubna, 1996 .).
The model is based on the work of an interdisciplinary team, which includes the following specialists: a gerontologist, a nurse, a psychologist, a massage therapist, a social worker, a health visitor, a hairdresser, and a priest. In 1996, the model provided services to 369 elderly clients, the age structure was dominated by people 70-80 years old. An analysis of the financial status of the clients served showed that almost a third of them had an income below the subsistence level.
A department for home care for the elderly and disabled was created in the city's Department of Social Protection. The department consisted of three departments of medical and social care at home, a specialized department and a hospice at home. Each department of medical and social care at home included a director, social workers, nurses, sanitary workers, and a hairdresser.
The specialized department consisted of a manager, a nurse, junior nurses, social workers, volunteers, and a vehicle driver. The home hospice included a medical director, nurses, auxiliary nurses, social workers, and volunteers. The medical supervision of all three programs was carried out by a gerontologist, who coordinated his work with a psychologist and massage therapist, as well as with the staff of the social ward of the city hospital. General management was carried out by the head of the department.
The home hospice program provided medical and social services to elderly patients with a life expectancy of no more than 6 months. A total of 87 people were served, most of them lived in families (63 people), 24 patients were single. An analysis of the causes of mortality showed that circulatory diseases, neoplasms, as well as injuries and poisoning predominated. The hospice team interacted with the clinic and hospital. During the initial home visit, the social worker filled out a questionnaire to assess the needs of the hospice patient and his family, which included 15 questions that reflected various parameters of the patient’s status, including a scale of the types of assistance needed. The team also used questionnaires, the purpose of which was to identify the assessment of the nurse’s work, the patient’s assessment of pain, etc.
A similar model of hospice at home has been operating in Krasnodar since 1998. The hospice department of the social service center was created to provide social, social, medical, and socio-psychological assistance to terminally ill patients. The team structure includes a leader, his deputy - a geriatrician (gerontologist), the staff of five visiting teams, including a doctor, a nurse, a social worker and a junior nurse. This program has a full staff of 25 employees providing assistance to 30 clients. Each visiting team serves 3-5 patients per day. The branch serves more than 100 clients per year. Two-thirds of them are elderly and senile people (52% of them are elderly - 60-75 years old, 25% - over 75 years old). 86% of the elderly served had pensions below the subsistence level, every fourth was single or living alone. The duration of customer service was up to 3 months in almost half of the cases. Each client received from 2 to 5 medical and 2-3 social services daily. All hospice services at home were free for clients; the cost per day per patient was 38.2 rubles, while in the hospital they were 300 rubles. In the development of this model, a mobile emergency response team was created for patients living in remote areas of the city and for urgent medical and social services at home, as well as a volunteer service.
Comparing this home hospice model with the Dubna model, we can note the absence of a psychologist on its staff, whose role in hospice programs is important.
Analyzing their own experience of operating a model of comprehensive care at home for the elderly, specialists from the city of Dubna made the following conclusions: the home care model satisfied the needs for medical and social care of almost 400 elderly residents of the city; comparative analysis model of care at the clinic level and this model allows us to talk about better quality of care and a wider range of services provided new model; practical experience of the hospice program at home made it possible to open a hospice school in the city as an educational and methodological center for training medical and social workers, as well as training family members of patients in care skills.
conclusions
Currently, in Russia as a whole, about 1.5 million older citizens need constant medical and social assistance. Of particular relevance is the search, development and improvement of new forms of providing comprehensive care to elderly and senile people at home. In many countries around the world, home care services for the elderly and elderly have become a phenomenally growing industry. Thus, in the USA, from 1989 to 2004, the market for home assistance services grew from 9.4 billion to 30.3 billion dollars, i.e. more than 3 times. World experience shows that the efforts of state medical and social structures alone are not enough. In solving this urgent problem, it is necessary to unite the joint efforts of government agencies and interested public organizations.
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Geriatric rehabilitation is understood as a part of rehabilitation science that is aimed at preserving, maintaining, restoring the functioning of elderly and old people and strives to achieve their independence, improve the quality of life and emotional well-being. Like in perhaps no other field of medicine, in geriatrics, and even more so in geriatric rehabilitation, it is unacceptable to separate various aspects of the rehabilitation process - medical, psychological, social, etc. The concept has been introduced - a comprehensive geriatric assessment, which includes a multidisciplinary assessment of all aspects of an older person's life, including describing and explaining problems and how to solve them, identifying the need for various geriatric services, finding resources, funding plans for working with the elderly, focused on the disabled. It is now noted that it is necessary to "view the older person as a whole individual..., instead, health and social care professionals tend to assess individual dimensions of health and well-being. However, older people are exposed to a range of adverse factors, and their physical, psychological social and economic well-being and health are closely interrelated... which necessitates the need for a combined assessment of the different aspects of health and well-being." WHO recommends considering five main aspects of assessing the functional status of older people: activities of daily living. mental and physical health, social and economic status. For “it is functional status, not diagnosis, that determines whether an older person can live independently and with dignity.”
Another WHO document lists characteristics of illness in older people that are relevant to health and social care services:
· multiple pathological conditions,
nonspecific manifestation of the disease,
rapid deterioration of the condition if treatment is not provided,
high incidence of complications caused by the disease and treatment,
· need for rehabilitation.
Therefore, health and social care services need to integrate measures to complex diagnostics and evaluation of the treatment and rehabilitation system. The "demographic revolution" has created a problem of rising costs for government welfare programs that has affected virtually all parties, and for many of them has become an unbearable burden. That's why "... a major task of the 90s was the organization of care elderly people" and this type of care will affect a wider range of workers than child care, from senior managers to secretaries. In each country, a decision must be made who will be responsible for meeting the health care and social needs of older people: relatives own funds, the state using public funds, or both.
There are different types of care that are required by older people with disabilities, which have the following hierarchy:
· medical care: surgical procedures, medications or devices used under the supervision of qualified medical personnel, oral care, eye care, manual therapy, physical therapy, etc.;
· personal care: attention to physical needs and comfort (activities of daily living);
· housework: cooking, cleaning, maintaining order, etc.;
· social support: assistance in communicating with administrative employees, visitors, friendly communication;
· supervision: reducing risk by keeping an eye on vulnerable people.
The goal of geriatric rehabilitation is to enable patients to perform daily tasks and restore their position in the family and society. According to many researchers, a medical rehabilitation program should simultaneously include social, psychological and economic aspects. Timely rehabilitation can prevent the onset of the rapid aging process, stimulate lost functions, and return aging and older people to adequate work activity.
According to a number of scientists, an elderly person should live in his own home as long as possible, even in the presence of illnesses and infirmities. In connection with this situation, programs were proposed home care, Meals on Wheels service, day care centers, recreation programs, etc. The main goal is to adapt the elderly to life in society and outside the walls of hospitals. Success is guaranteed only by a rehabilitation program that combines treatment methods both in and outside the hospital.
Due to the fact that the desire to live is weakened or often completely exhausted in old people, unlike people of other age groups, it is necessary to revive their desire and will to live again, to convince the patient to be a collaborator in the matter of treatment and recovery. The geriatrician must be familiar with the home conditions of his patients, maintain relationships with voluntary organizations, and accurately define the role of his colleagues and assistants. Nurse must be dedicated to her geriatric patients and must also be trained in geriatric and rehabilitative care. The experience of recent decades has shown that the pessimism that existed in the past regarding the regenerative capabilities of the aging body has not been justified. Timely and systematically implemented rehabilitation measures in a large number of cases lead to functional recovery sufficient for self-care or requiring minimal outside assistance. Along with its humanistic significance, this circumstance also has economic consequences for the family and society (B. Davetakov, 1969).
Fundamentally important points for the organization of geriatric rehabilitation were reflected in the report of the WHO Scientific Group on the Planning and Organization of Geriatric Services 1151. In one of the sections of the report, categories of elderly people are identified that have the greatest risk of deterioration in health or economic and social status, the so-called risk groups. These include:
· persons aged 80-90 years and older;
· elderly people living alone (family of one);
· elderly women, especially single women and widows;
· elderly people living in isolation (singles or couples);
· childless elderly;
· elderly people suffering from serious illnesses or physical disabilities;
· elderly people forced to live on minimal government or social benefit or even for even more insignificant means.
Identification of risk groups for the elderly who are subject to rehabilitation is essential, because not all elderly and old people need rehabilitation measures of a medical, psychological, and social nature. Thus, there is evidence that only about 1% of people under 65 years of age are disabled. But with retirement, most people are deprived of the right to work, or at least to engage in their previous work. Approximately 50% of people aged 70 would like to work (even after 3 years of retirement). According to the same data, in a population of 100,000 people, 14,000 elderly (65 years and older) can be identified, of whom 1,200 are homebound, 300 are bedridden, and 300 are residents of nursing homes. This is why perhaps the founding document on geriatric rehabilitation calls for "an attempt to identify high-risk groups, i.e. those who will ultimately require rehabilitation, and the rehabilitation needs of these groups."
The report of the WHO Scientific Group clearly defines the goals of geriatric rehabilitation: reactivation, resocialization, reintegration.
Reactivations involves encouraging an elderly patient who is in a passive state, physically and socially inactive, to resume active Everyday life in your environment.
Resocialization means that an elderly person, after illness or even during it, resumes contact with family, neighbors, friends and other people and thereby emerges from a state of isolation.
Reintegration returns an old person back into society, who is no longer considered a “second-class” citizen and who takes full part in normal life, and in many cases is engaged in very useful activities.
It is emphasized that the rehabilitation process is lengthy and often begins at home. In this regard, the following recommendations are made to geriatric services:
1. When planning geriatric programs, emphasis should be placed on all aspects of prevention.
2. A comprehensive approach must be taken when addressing the complex health and social needs of older people.
3. Geriatric services should be family and community oriented.
4. The services created should be based on the principles of integration and coordination.
The document for the first time identified such progressive trends as the gradual replacement of individual care for an elderly patient by one doctor with care by a multidisciplinary team, each member of which is involved in one of the aspects of patient care. In addition, geriatric services are seen as interconnected components of wider collaborations between health and social care systems.
One of the most important goals of health care for elderly and elderly people is formulated as follows: to maintain their independence, comfort and satisfaction at home, and, if their independence decreases, to maintain them as long as possible by all possible means.
The following obstacles to successful rehabilitation at the inpatient level can be identified:
· insufficient training of doctors providing treatment in hospitals in the field of rehabilitation or poor knowledge of the requirements of society;
· lack of continuity in rehabilitation courses, since different stages of this course are under the jurisdiction of different departments (Ministry of Health, Ministry of Social Affairs, local departments);
· lack of strict planning of a rehabilitation program, for example, only physical and mental rehabilitation.
One cannot but agree with the author that the ultimate goal of geriatric rehabilitation is to maintain or restore the independence of the elderly in physical, psychological, social and, if possible, professional relations. Three levels of rehabilitation centers are proposed:
· local: pensioners' clubs, communal canteens, special meeting rooms for the elderly, day centers;
· territorial: nursing home or treatment center;
· regional: geriatric center.
According to the authors, rehabilitation should include processes of education and retraining of patients; required Active participation the patient himself. Another advantage of rehabilitation is that it does not require complex equipment and most activities can take place at home or in an outpatient setting. The effectiveness of multidisciplinary teams consisting of medical and non-medical personnel, which are able to maximize the patient’s functioning in the appropriate psychological, professional and social environment, is noted. A team of psychiatrists, orthopedists, neurologists and therapists is able to provide care and supervision for several months or even years.
A section of the recently published popular reference book “Old Age” is devoted to rehabilitation and geriatric prevention, in which the concept of rehabilitation was narrowed to physical exercise, physiotherapy, massage and hydrotherapy. However, rehabilitation is also a social process, treatment, psychotherapy, training and job selection, adapting living conditions to the needs of people with disabilities, “educating” the environment towards people with impaired functions.
It is extremely important that every old person has some kind of life goal, not counting the very prevention of old age or the desire to live longer. In the process of rehabilitation, it is necessary to develop the old person's interest in the fact that his life serves something or someone. The most important components of successful rehabilitation and geriatric prevention are counteracting social isolation and loneliness, awakening interests, revitalizing social contacts, encouraging independence, and choosing meaningful work.
To summarize, we can highlight the following main areas of geriatric rehabilitation:
· medical;
· gerontological care;
· social;
· educational;
· economic;
· professional.
Medical includes physical and psychological rehabilitation. In turn, physical consists of therapeutic exercises, occupational therapy, physiotherapy, etc.
Psychological is composed as medicinal methods, as well as various types of psychotherapy, which widely “permeate” all rehabilitation activities, including the family, medical and non-medical personnel, and the entire environment.
Gerontological care includes three areas: diagnosis, intervention, and results.
Social rehabilitation means resocialization, i.e. the return of the elderly to society, overcoming their isolation, the social activity of elderly and old people, the expansion of their social contacts. For this purpose, they use both formal sources of assistance (state social assistance systems) and informal sources - family members, friends, neighbors, co-workers, voluntary and charitable organizations. An important component of social rehabilitation is spiritual rehabilitation, the meaning of which is to provide spiritual support to the elderly.
Educational geriatric rehabilitation - information from old people about the processes occurring in the body of aging people, about self-help opportunities and sources of support. This is an impact on an elderly person in the direction of increasing his self-confidence based on the acquisition of new experiences and new roles. Of great importance is the media, which can increase the educational level of older people, inform about common problems associated with old age, and form a positive image of older people in society.
Economic geriatric rehabilitation means promoting the economic independence of elderly and old people, which has a significant impact on their psychological well-being. In many ways, this type of rehabilitation is associated with the existing social security, pension, health care and social protection systems, etc., in a particular country.
Vocational geriatric rehabilitation includes such aspects as maintaining the longest possible working capacity, organizing a system of retraining and training for elderly and old people on the basis of rehabilitation centers, providing jobs for older people, and involving pensioners as widely as possible in socially significant activities.
It must be emphasized that this division into types is very conditional, since (and this was mentioned above) the rehabilitation process is a dialectical unity, and the individual components are interdependent and complement each other. The ultimate goal of all these activities is to restore independence in physical, mental, social, including spiritual, and, if possible, in professional relations, achieving best quality life and well-being of elderly and old people.
Depending on the duration determined by the condition of the elderly patient, geriatric rehabilitation is carried out:
· in acute conditions,
in subacute conditions,
· long-term.
Already at the first stages of work, it became obvious that medical consultations at home alone are not enough for old people: the doctor leaves, and the patient is again left alone with his problems. Thus was born the idea of creating a patronage group for household assistance and care for the elderly who most need it. The first attempts to form a unit of health visitors were unsuccessful due to the lack of stable funding.
Home health care refers to the provision of services and necessary equipment to patients where they live to restore and maintain maximum levels of health, function and comfort.
Medical and social care at home is an alternative to hospitalization for older people. This type of care is cheaper than inpatient and outpatient treatment.
It is advisable to base rehabilitation measures in relation to aging and old people on the skillful stimulation of their existing mental and physical capabilities, primarily with the help of those forms of activity that were previously the most familiar and valued, on compliance with the rhythm of life developed in the past, prevention and timely treatment intercurrent diseases.
The steady trend of increasing the proportion of elderly and elderly in the population structure, patients with chronic diseases and long-term illnesses, disabled people, the characteristics of their lifestyle with the resulting socio-economic problems reflect important aspects in the organization of gerontological care.
The “Demographic Revolution” has contributed to an increase in the category of the population that is at greatest risk of deteriorating health, economic and social conditions, and will ultimately need social protection. These are the so-called risk groups, which may include:
· elderly people living alone;
· elderly women, single and widows;
· elderly people living in isolation;
· childless elderly;
· elderly people suffering from serious illnesses or physical disabilities;
· elderly people forced to live on minimal state or social benefits or even on even more insignificant means;
· persons aged 80–90 years and older.
Older people are more exposed to environmental influences, more sensitive to psychological influences, and often live in poor living conditions receive poor quality medical and social care. As people age, their needs for various types of services increase, while their ability to perform activities of daily living and independence decreases. The provision of care for the elderly creates the problem of rising costs for government social welfare programs and places an unsustainable burden on society.
Features of diseases in older people that are important for the provision of social and medical care are manifested in a variety of pathogenetic disorders, the specificity of the manifestation of the disease, rapid deterioration of the general condition in the absence of treatment, a high frequency of complications, and the need for supportive care over a long period of time. This highlights the need to integrate health and social services.
The existing state system of social protection for elderly and old people remains for the most part at the level of social services, limited to the provision of emergency social support of a one-time nature, providing places for permanent residence for those in need of constant care in
boarding houses, boarding houses, night or day stay departments, organization of funeral services.
The WHO Regional Committee for Europe, discussing the need for changes in the policies of social services and health authorities in connection with the aging population, notes that one of the most important areas of activity regarding the provision of care to the elderly is rehabilitation.
The deepening and specialization of social work, the opening of rehabilitation centers that provide support and socio-medical assistance to older people, confront social work specialists with the need to solve many issues of providing integrated care and rethinking the concept of health care in the social sphere.
Considering the human community as a complex self-developing biosocial system, it should be recognized that social pathology is a reflection of the biological and social form of disharmonious development of society. The anthropoecological approach to the problems of social pathology is based on the system-forming integrative principle of studying and understanding cause-and-effect relationships in the human body and its environment.
One of the most important ways to harmonize social development is rehabilitation, considered as a biosocial system. Persons belonging to various groups of the population, to a greater or lesser extent, need rehabilitation insofar as they have physical, mental, educational, professional, social and other deprivation.
Domestic and world science has accumulated quite extensive theoretical and practical material on rehabilitation. However, the updating of this material in relation to social work in gerontology, directly related to the life activity of an elderly person, his lifestyle and health factors of varying content, remains insufficient, primarily due to the lack of comprehensive research and connections of scientific developments in the study of various components, stages of rehabilitation process taking into account their biosocial unity.
Considering rehabilitation as an action to eliminate limitations in life, it is necessary to highlight the main parameters of the functioning of the elderly:
· daily activities;
· mental and physical state;
· social and economic status.
Rehabilitation of the elderly should take into account the needs that are necessary for a particular person, and should be based on the principle of providing care in the community as the most appropriate, effective and supportive approach to medical and social services, in contrast to inpatient forms of rehabilitation.
Social and medical care for the elderly is seen as interconnected components of various forms of cooperation between health care and social protection systems.
Rehabilitation of older people is a unified organizational and methodological process focused on the individual and his problems, where medical, psychological, social and other factors are components of an integral system. Dividing the rehabilitation space and assigning it to certain departments does not ensure the achievement of the final goal of rehabilitation and leads to a scattering of forces in both the health care system and social security.
Complex effects on the body, the use of proven techniques from various natural sciences and humanities with active teaching
by the patient himself can reduce the possibility of disability in the elderly and prolong active life in a familiar microsocial environment.
Achieving the goals of geriatric rehabilitation (reactivation, resocialization, reintegration and spiritual renewal) provides a comprehensive impact on the elderly person to resume active daily life in their environment, overcome the state of isolation caused by a long-term illness, and fully participate in normal life. Rehabilitation ensures the preservation or restoration of independence of the elderly in physical, psychological and social relations. Spiritual rehabilitation restores the ability to adequately determine life goals and rethink moral values, provides an opportunity (including with the help of the church) to prepare for the end of one’s life journey.
In gerontology, the rehabilitation process is directly related to the individual’s environment, and therefore an individual rehabilitation program will not be effective if the environment is not rehabilitated.
Rehabilitation is considered as a complex individual process, which includes:
· ongoing supportive treatment;
· maintaining the functioning of basic life support systems;
· bringing an elderly person out of mental depression;
· restoration of the ability to adequately work.
Rehabilitation activities are aimed at maintaining or restoring lost psychological and economic independence, improving emotional well-being and preventing the transition of health problems to disability.
Social gerontologists distinguish the science of gerontological nursing, which considers three aspects: diagnosis, intervention, results.
Diagnostics in the process of care is the receipt of clinical information about individual, family or community responses to actual or potential medical and social problems of older people.
Intervention consists of five important areas:
1) informing older people about developing internal processes during aging, about sources of social support, etc.;
2) promotion of physical activity (life style of the elderly): proper nutrition at a later age, overcoming a sedentary lifestyle;
3) alleviating the suffering of the elderly, improving their condition, adding functions;
4) impact on environment, including on sociopolitical processes, where possible to contain negative influence social, economic and political factors on the functioning and well-being of older people;
5) improving self-help abilities by transferring the necessary knowledge in the field of self-monitoring for early detection of the disease and the use of self-help techniques.
results gerontological care consists of successfully managing changes that occur in late life, emotional well-being, acquiring new skills and roles, new relationships and abilities, and life attitudes.
Modern rehabilitation prevents the danger of deterioration of health, slows down the process of rapid aging, supports and stimulates fading body functions. Rehabilitation changes the mental and physical state, revives the desire and will to live, helping the elderly achieve independence in society. Timely and rationally carried out rehabilitation measures can maintain the functioning of the body at a level sufficient to achieve independence in society.
In general, the structure and features of various organizations related to medical and medical-social services for the elderly are explained following diagram
1. It should, however, be remembered that the formation of such organizations is just beginning and the content and forms of their work will change rapidly, which is what has happened in recent years, primarily in the medical and social sphere of public services. Attention should be paid to the variety of forms of assistance to the elderly and the subordination of the organizations that provide them: medical, social, preventive, health-improving, etc.
When forming the structure of gerontological centers, it is taken into account that old age is a complex biological and social phenomenon that requires an integrated approach and manifests itself as:
- Limitation of performance,
- Limitation of physical mobility and social activity;
- Limitation of cultural and social connections, psychological isolation from society;
- Availability in most people of this age complex of chronic diseases.
The practical activities of aging prevention centers should therefore be based on a comprehensive view of aging as a complex biosocial process, and should be aimed at:
a) increasing the performance of all ages and especially the older generation;
b) improving the level of health of the elderly,
c) increasing the physical and mental activity of the older generation;
d) disease prevention,
e) slowing down the aging process,
f) increase in average and maximum life expectancy.
Traditional in Russia is the use by the state of means of passive protection of the population of a given age, which are fundamentally costly: payment Money(pensions), medical patronage at home, consumer services at home, etc. However, due to the changed real living conditions of society and the socio-psychological orientation of residents of civilized states towards active participation in the life of society, the opposite, active the principle is to increase the level of physical and social activity of representatives of the older generation, which allows them to maintain a sense of usefulness as a person until a very old age. This is only possible by shifting the emphasis to disease prevention and geroprophylaxis in general, state protection of programs relating to the health and social aspects of life of the older generation, while increasing the level of health and physical condition of the most broad masses population, with changes in mentality and goals and views on the value of their own health.
For middle-aged and elderly people who remain physically active, this can be optimally solved by opening specialized Centers that combine advisory and health-improving activities. For the oldest ages, it turned out to be promising, as foreign experience shows, to open special boarding houses that combine the convenience of social services with qualified medical supervision and services and the widest range of cultural events with access to social activity in a variety of areas, ensuring the relevance of older people in society in social, cultural and psychological terms.
Gerontological Centers must actually combine therapeutic, preventive and health-improving areas of work, which should be reflected in their structure, the means used and personnel. It seems quite clear that gerontological centers should not only be geriatric centers - only a place of treatment for old people. This approach leads to duplication of the entire structure of medical care (since there is no fundamental difference between diseases and age), to the creation of huge, similar to modern clinical hospitals, multidisciplinary medical complexes, the only difference being the age of the patients. The Gerontological Centers themselves should focus their work primarily on:
a) prevention of aging, incl. promotion of such methods and services, primarily for the middle, working and socially active age (30-60 years);
b) methods of prenosological diagnosis, prevention and health promotion;
c) rehabilitation, preventive and health measures after illnesses.
Thus, Gerontological Centers should be more likely to be preventive, valeological, rehabilitation, physical education, sports and cosmetology than traditionally narrow-profile medical ones. The differences from existing Health Centers are: emphasis on prevention, control and reversal of aging and related diseases; good training in the field of biology of aging, gerontology and bioactivation agents; the presence of our own powerful diagnostic methods (first of all, this is the determination of the parameters of Biological Age and a set of methods of clinical physiology and biochemistry); the presence of our own methods of prevention, containment and reversal of aging (actual rejuvenation), bioactivation agents, etc.; the possibility of a high level of specialized consulting; the presence of a number of additional services (cosmetology, physical education and mass forms of work, etc.); fundamentally comprehensive nature of services; execution, along with comprehensive programs, individual specialized standard programs related to age (anticlimacteric, antiosteoporosis, prevention of lens opacification, etc.); fundamental availability of recommended means, methods, apparatus and methodological literature (a means stall on the territory of the Center); powerful advertising and propaganda in the Center and outside are of great importance, since the basis of the effects of aging prevention lies only in the formed LIFESTYLE with the whole complex of methods, means, diets, etc. used. Thus, Gerontological Centers must have a powerful therapeutic and rehabilitation-biostimulating potential and cannot be reduced only to medical or only to physical education institutions.
The Centers themselves can be:
a) Stationary - it is optimal to deploy them on the basis of sanatoriums and dispensaries, which corresponds to the contingent, premises and other features of the work.
Maybe:
- formation of groups for healing, biostimulation and rejuvenation from the sanatorium contingent, which is optimal for starting the deployment of work and is low-cost;
- formation of your contingents and departure to the sanatorium;
- deployment of full-fledged separate stationary Centers on the basis of sanatoriums and dispensaries.
b) Consultative and diagnostic - on the basis of clinics and private medical centers - with an emphasis on the therapeutic side of the work of the centers, on the basis of self-supporting with clinics, with the involvement of local consultants, with an emphasis on specialized programs of geriatric and preventive gerontological care.
c) Rehabilitation and health centers are the most widespread type of Centers, with the formation of permanent client groups. On the basis of physical education and health centers and newly formed Gerontological Centers.
The created Gerontological Center must:
1) Function on the basis of the highest scientific achievements and serve as a clinical base for work and testing of new techniques.
2) Provide a complete, comprehensive, rapid diagnosis without pain and inconvenience, including determination of biological age with all parameters, conclusions and recommendations.
3) Provide detailed qualified recommendations (invited specialist consultants working in this field) on all aspects of diagnosis, treatment and recovery in the direction of life extension, prevention and reversal of aging and bioactivation, incl. for middle and young ages (treatment of syndrome chronic fatigue, stress, weight correction, figure correction, etc.).
4) Provide a single comprehensive effect on the body based on individualized courses based on world achievements and domestic original developments.
When carrying out geroprophylactic, biocorrective, therapeutic and biostimulating measures, primarily the following methodological approaches and techniques are used: individual detailed diagnostics; individual detailed consultations with medical specialists; special diets, regimes of body cleansing and therapeutic fasting; purified bioactivated water; special health regime (lifestyle correction); special psychological regime, consultations and active management by a specially trained psychologist, autopsychotechnics; correction (harmonization) of biorhythms, including the original domestic method of galvanoelectroacupuncture; massage and manual therapy, exercise therapy and exercise equipment, physiotherapy, hydrotherapy, laser therapy; special drugs- biostimulants, bioimmunocorrectors, psychostimulants, adaptogens, anti-stress drugs; special drugs that affect deep aging processes (geroprotectors, adaptogens, anti-stress drugs, phyto-vitamin-microelement complexes, etc.); a wide range of therapeutic, preventive and health-improving drugs and products of domestic and foreign production; basic lectures, video and printed information and training; other general and special medical and health procedures.
Gerontological advisory and preventive care at the city and regional levels is usually based on geriatric hospitals, with predominant medical inpatient services, and social protection services: veterans' homes and dispensaries, with an emphasis on care and rehabilitation activities, as well as broad cultural programs.
At the federal level, Gerontological Centers are actually represented by Clinical hospitals with a gerontological focus (inpatient hospital forms of care), which are bases for advanced training institutes for doctors, departments of geriatrics and research institutes of gerontology with powerful services for their own scientific research and various specialized forms of geriatric care. Preventive forms of work at this level are represented by the Research Institute of Rehabilitation and Balneology with specialization in various “diseases of the elderly,” as well as the Centers for Preventive Medicine, which pay increasing attention to the problems of the elderly. In addition, there are research institutes and universities that study the biology of aging, social and legal issues of helping the elderly, etc.
Concept of geriatrics
Lecture No. 1 (1 hour) Organization of geriatric services. Methods for examining elderly and senile people.
MDK 01.01 Diagnostics in geriatrics
The transformation of the general rotation of a point with the center of rotation coinciding with the origin can be obtained as a superposition of three plane rotations. This transformation is expressed mathematically by multiplying three matrices (1), (2), (3). Matrix multiplication is not a commutative operation, so it is necessary to specify some order in which the rotations are performed. The agreement on the order is made entirely arbitrarily, but once the order of execution is fixed, it must be strictly adhered to.
Geriatrics(from the Greek geron - old man and iatreia - treatment) a section of gerontology that studies the characteristics of diseases of old age, as well as methods of their treatment and prevention.
Organization of medical and social assistance to the elderly
Health care for the elderly is a wide range of services and services, including the provision of care for acute and chronic conditions, nursing, outpatient care, short-term and long-term care, and community-based personal care.
The following systems of services for the elderly are distinguished: information and educational, preventive, medical care for outpatient and hospital patients, long-term care, home care, social hospitals, general support services.
Geriatric care for the population is a system of measures to provide long-term medical and social services with the aim of maintaining or restoring the ability to self-care, partially or completely lost due to chronic diseases, facilitating the reintegration of elderly patients into society, as well as ensuring independent existence.
Projected changes in the size and structure of the population of older and older people indicate that the need for long-term forms of care will increase. Older people are 5 times more likely to need long-term care services (LTC) than patients of other age groups.
One of the goals of DP is to enhance the patient's ability to self-care. Including health and social services, this type of care also provides rehabilitation and support services over the long term, as far as possible. DP focuses on the individual patient with functional impairments who needs to strengthen support systems to meet various types of daily activities - cooking, taking medications, housework, etc.
There are three stages of DP: The first includes rehabilitation in specialized departments of general hospitals, hospice, and convalescent care. The second is represented by day hospitals (hospitals) for rehabilitation and medical/social day care. The third - home care is represented by medical care (hospice), as well as monitoring the condition of patients.