lunes, 22 de diciembre de 2008

Prevenir caidas y fracturas de cadera en el anciano: no todo son pastillas


En un reciente artículo publicado en la revista de la Sociedad Española de Medicina Rural y Generalista se ha publicado un interesante artículo sobre una técnica bastante ignorada pero utilizada por algunos médicos de familia: el mapa del hogar.

Aunque los médicos, en especial los médicos que trabajan en hospitales, suelen ver a los pacientes en un entorno controlado (en una planta de un hospital) donde todo está diseñado para asegurar la seguridad del paciente lo cierto es que los pacientes, y en especial los pacientes ancianos dependientes, pasan la mayor parte de su vida en otro entorno: en su propio hogar.

El principal factor de riesgo para que un anciano tenga una fractura de cadera no es, como suele pensarse, la osteoporosis, sino algo mucho más sencillo: las caidas.

Las personas ancianas pierden capacidades físicas y mentales, tienen menos equilibrio, menos fuerza en las piernas, menos capacidad de reacción, su visión está disminuida... todos son factores que van a jugar en su contra y van a favorecer las caidas.

Por tanto las caidas son uno de los grandes problemas que hay que prevenir en las personas mayores, para así prevenir fracturas de cadera, de hombro o incluso hemorragias cerebrales (especialmente frecuentes en pacientes que toman medicación anticoagulante).

Existe una técnica sencilla para ayudar a prevenir las caidas que consiste en hacer un pequeño plano de la vivienda donde vive el anciano. Así se pueden identificar barreras arquitectónicas que dificulten sus movimientos (y le resten autonomía), como por ejemplo escalones, ausencia de ascensor o ascensores donde no cabe una silla de ruedas, bañeras donde el anciano no puede entrar para ducharse (es mejor el plato de ducha, con suelo antideslizante).

Es también importante asegurarse de que la iluminación de la vivienda es la adecuada (recordemos que los ancianos tienen peor visión y esto puede provocar caidas), que no existen alfombras que puedan hacer tropezar, o cables por el suelo, o suelos resbaladizos u otros elementos peligrosos.

Con medidas relativamente sencillas y que están en nuestra mano podemos prevenir muchas caidas y mucho sufrimiento para nuestros mayores.

Por supuesto, esta misma técnica es de aplicación cuando tenemos niños pequeños en casa. En este caso habrá que revisar en especial la existencia de enchufes expuestos, líquidos de limpieza, tóxicos o medicamentos accesibles, ventanales o terrazas que puedan provocar caidas, cuchillos accesibles y otros peligros.

Mediante un análisis minucioso y sistemático que identifique esos factores de riesgo que están en nuestro entorno, a los que a veces no damos importancia pero que tan cruciales son para nuestros ancianos o nuestros niños podemos prevenir muchos accidentes de forma sencilla y eficaz.

domingo, 21 de diciembre de 2008

La importancia del mapa del hogar


En la revista SEMERGEN se ha publicado recientemente uno de los escasos artículos sobre la técnica de mapa del hogar.

Esta técnica nos permite analizar de manera sistemática el hogar de nuestros pacientes. Este análisis es especialmente útil en pacientes ancianos o discapacitados que realizan la mayor parte de su vida dentro de los hogares.

Es bien conocido que después de la edad, el principal factor de riesgo de fractura de cadera no es la osteoporosis, sino "la caida". Y el mapa del hogar nos sirve para identificar los "puntos negros".

Los autores, médicos de familia de Granada, han aplicado esta técnica para el análisis de los pacientes de su Centro de Salud asignados al programa asistencial de "Atención Domiciliaria al Anciano dependiente", un total de 85 pacientes.

Entre las cosas que se incluyen en el mapa del hogar están:

- Cómo utilizan la vivienda, quién ocupa cada habitación, dónde se encuentra habitual o permanentemente el paciente identificado, dónde come, cuál es el lugar de reunión de la familia y en qué lugar ve la televisión.
- Información acerca de la circulación, dentro del hogar, del paciente identificado y de la cuidadora principal.
- Preguntamos también si están satisfechos con la habitación que ocupan, si tienen suficiente independencia y suficiente intimidad.
- Es también oportuno preguntar sobre qué tipo de cambios deberían hacerse en la casa para vivir mejor o para estar más cómodo.

Se analizan por ejemplo, de forma sistemática:

- número de personas que viven en el hogar y en qué habitaciones.
- higiene del hogar (con una escala categórica)
- tipo de iluminación en cada estancia, si es natural o artificial, adecuada o deficitaria
- puntos de calefacción y tipo (butano, calefactor eléctrico o central)
- barreras arquitectónicas (con especial atención al cuarto de baño, donde el paciente puede encontrar importantes barreras), incluido si hay o no ascensor donde quepa una silla de ruedas.
- factores de riesgo del hogar: como elementos que pueden provocar caidas (suelos deslizantes, alfombras móviles, cables) u otros elementos peligrosos para personas con problemas cognitivos (mecheros, cuchillos, puertas con cerrojos, balcones con riesgo de caida).
- flujo de circulación del paciente, es decir zonas por la que suele circular en su vida diaria dentro del hogar

Sobre los resultados estadísticos del estudio cabe destacar que:

- La mayoría de los pacientes ancianos viven solos o solo con otra persona (un 50%).
- En 15 de las 85 viviendas la higiene era mala o deficiente.
- La iluminación era insuficiente en 19 de las 85 viviendas.
- El 85% de las viviendas tenían al menos una barrera arquitectónica. Tan solo el 27% de las barreras arquitectónicas identificadas (104) pudieron resolverse (en especial convertir la bañera en plato de ducha gracias a financiación pública).
- En el 33% de las viviendas se encontraron factores de riesgo, los más frecuentes fueron cables sueltos en el suelo, mala iluminación y alfombras deslizantes. Se pudo elimitar el 85% de los 42 factores de riesgo detectados.

¿Qué conclusiones podemos sacar desde el punto del residentes de medicina de familia en este estudio?.

Al contrario de la sensación que se tiene al trabajar en un hospital los pacientes pasan la mayor parte de su vida en su propio entorno (su vivienda) y no en una planta de medicina interna.

Por esta razón es fundamental tener en cuenta en la valoración de nuestros pacientes, y en especial en el paciente anciano o frágil, cómo se relacionan con su entorno físico más inmediato. El estudio de este entorno físico debe ser realizado de forma rigurosa y lo más sistemática posible, es decir de forma profesional. El uso de los mapas del hogar es una forma accesible y sencilla de llevar a cabo este análisis.

La posibilidad de hacer visitas al domicilio del paciente es un privilegio que tenemos los residentes de medicina de familia frente a otras especialidades. Debemos aprovecharlo, disfrutarlo y convertirlo en nuestra "técnica de trabajo diferencial".

Mediante medidas sencillas, pero muchas veces olvidadas como por ejemplo retirar alfombras o mejorar la iluminación, podemos conseguir verdaderos impactos en la salud de nuestro pacientes y por ejemplo prevenir fracturas de cadera con mucha mayor efectividad que mediante el tratamiento farmacológico de la "osteoporosis".

lunes, 15 de diciembre de 2008

Gastroesophageal reflux disease - information for primary care physicians

Gastroesophageal reflux disease (GERD) is a very common health problem, and family doctors have been exposed to a vast array of literature recently on the topic, as well as a massive promotion of anti-reflux drugs by the Pharmaceutical Industry. As such, it is difficult not to be a little bit complacent about the issue when almost everything seems to have already been told about it.
This article is a review article from the New England Journal of Medicine published on 16 October 2008: N Engl J Med 359;16

GERD, in the light of the latest scientific evidence, is an overlooked and is far from being a straightforward affair; it currently faces a number of controversies surrounding its diagnosis and management. In other words, GERD is way much more than endoscopy and proton pump inhibitors, and a lot remains to be known and understood about this disease.
One of them is the not so perfect correlation between clinical symptoms and endoscopic findings, as only around 40% of individuals with Barrett’s esophagus and a third of indivuals with esophagitis reported having symptoms. Additionally, two-thirds of individuals with symptoms had no endoscopic signs of esophagistis.
The implications of this is that we may be overestimating the added value of endoscopy, while overlooking the need to investigate other cause of dyspeptic symptoms, namely cardiac, as well as referring patients for other examinations which may be turn out to be more appropriate, like esophageal manometry or ambulatory pH monitoring.
It is also important not to forget the often overlooked extraesophageal syndromes, which are well pointed out in table 1.

In terms of therapeutics, the value of Proton Pump Inhibitors (PPI) is unquestionable, as well as their superiority over H2-blockers and placebo. The differing response of esophagitis and heartburn to PPI is less known, since the studies show that they are more effective in treating the symptoms of esophagitis rather than heartburn. The author attributes these differences to the heterogeneity of study populations in the studies, and to the fact that the outcome measures in most trials of PPI were a complete resolution of symptoms rather than substantial improvement. Don’t forget as well, like I said above, that heartburn is pretty much an unspecific symptom, with another potential aetiology other than gastrointestinal, and which thus does not respond to PPI.

It is also worthy reviewing the side effect profile of PPI, since it is one of the most prescribed class of drugs in primary care, and fiercely promoted by the drug industry.
The most common side effects are headache, diarrhoea, constipation, and abdominal pain. Furthermore, its long term use is associated with potentially serious consequences in the long run, such as an increased risk of hip fracture due to interference in the calcium metabolism, infectious gastroenteritis, and Clostridium difficile colitis.

It is also curious to note that fundoplication surgery seems also to be more effective in treating esophagitis rather than heartburn. Moreover, the rate of recurrent esophagitis hasn’t differed much in studies assigning a treatment arm for PPI and another for fundoplication. It is worthy to take note that besides the inherent morbidity associated with any surgery, a procedure such as Nissen fundoplication increases the risk of severe dysphagia, flatulence, inability to belch, diarrhoea, bloating, abdominal pain and constipation. Not to mention the significant rate of need of undergoing a new operation and to continue on PPI therapy after the surgery.
Surgery, should therefore, be considered very carefully, since it has not been proven to be much better than standard medical therapy, and carries a long list of morbidity and complications. The interesting bit is that around 2 in 3 patients will continue to require long-term PPI, and the risk of developing Barrett’s oesophagus or oesophageal adenocarcinoma is the same in populations of patients who have just received either medical or undergone surgery.
Since surgery has been losing popularity, this may mean that more patients with dyspeptic complaints may end up receiving medical care from primary care physicians than by surgeons from now on than it the past. Additionally, the author does not state which types of patients will tend to benefit more from surgery rather than with medical therapy alone, so I would reckon that primary care physicians should privilege medical therapy, and discuss the need for surgery in complicated, PPI refractory cases, with general surgeons in the local hospital.

The author has also approached the current controversy surrounding the indication for endoscopy in patients with chronic symptoms of GERD, so as to screen for Barrett’s oesophagus, which as we all know, increases tremendously the likelihood of having oesophageal adenocarcinoma. The Canadian guidelines do not recommend screening endoscopy, a view shared by the American Gastroenterological Association, which also does not recommend against endoscopy. The American College of Gastroenterology takes a more liberal stance, and supports endoscopy in cases of patients with “symptoms suggesting complicated disease”, namely dysphagia, odynophagia, bleeding, weight loss, anemia, those at risk for Barrett’s esophagus, and when the patient and the physician feel it is appropriate. These indications of the American College of Gastroenterology.
With such discrepancies in the air, particularly from organizations from the same country (United States), it might be a good idea looking first at your national or local guidelines, if available, particularly if you are working in either Spain or Portugal.

The author of this article concludes by giving his own take on this controversy, which seems to be in line with the recommendations of the American College of Gastroenterology. Dr Kahrilas states that in his practice he usually just requests an endoscopy to patients with GERD referring symptoms of odynophagia, gastrointestinal blood loss, anemia or dysphagia, since he considers that patients with GERD have a low absolute risk of developing oesophageal adenocarcinoma, and that there is insufficient evidence in terms of improved survival or a decreased rate of death.

This article is important for primary care physicians, because it is such a “staple” issue of our practice, and we seem to be pressing the same button over and over again, as we get the feeling that everything has already been said about GERD. Maybe not.
Don’t forget also that proton pump inhibitors are one of the most prescribed class of drugs, and that they carry side effects which junior doctors are often not familiar with.
Peter Kahrilas raises many other interesting issues in this article which are of utmost relevance to primary care. These issues include the awareness that it is important to have a sound clinical judgement in order to tackle the gap between symptoms and clinical findings, whereby patients may have symptoms but not any endoscopic injuries, and the situation where patients have no complaints but have endoscopic injuries.
Additionally, it is important to acknowledge that there isn’t a consensual evidence based opinion regarding the need to screen patients with GERD for the presence of Barrett’s esophagus, in order to reduce the risk of esophageal adenocarcinoma. As such, it might be appropriate to discuss this issue with the patient so as to reach a mutual decision.

lunes, 8 de diciembre de 2008

Gastroesophageal reflux disease - patient information

Kahrilas, P. Gastroesophageal reflux disease N Engl J Med 2008; 359:1700-7


It is estimated that between 14 and 20% of the population of the United States is affected by gastroesophageal reflux disease (GERD).
It is important that you become aware of this disease because it is a frequent situation often requiring medication, that your family doctor is perfectly qualified to manage, and it increases the likelihood of developing esophageal cancer. This happens as the stomach, which produces the acid that is essential to digest food, spills out acid backwards to the esophagus more often than it should. The acid, in contact with the inner wall of the esophagus, and in substantial amounts, can damage the wall of the esophagus and thus cause symptoms.
Like I said, even though it is often necessary to take medication for GERD, I would like to focus instead on dietary and lifestyle measures, because, for several reasons, patients are often not adequately informed of simple measures they can do on their own to help them improve their symptoms. Foods that are acidic or promote the exit of acid to the esophagus, are likely to worsen your symptoms, so they should be avoided. Many of these food products may inclusively be difficult to eliminate or cut down from your diet, as we are so used to having them everyday, and they’re too ingrained in western diets, specially in a society which for professional reasons has to eat out most of the time. These products, include, for instance, carbonated beverages, coffee, tea, fatty/fried foods, chocolate, citrus fruits, and so on (I would refer you to table 2 in the article). Furthermore, do not forget also of lifestyle measures. Some may be easier to implement, like avoiding eating 3h before bedtime or elevating the head of the bed, while others may be extremely difficult to difficult to implement, like quitting smoking, losing weight or drinking less.
Another relevant issue I would like to raise is the eventual need for surgery, should lifestyle measures and medication turn out unsatisfactory. The surgery, which bears the pompous name Nissen fundoplication, basically entails making sort of a “collar” around the lowest part of the esophagus (which is usually the part most affected by the effects of the acid, as it is the segment of the esophagus closest to the stomach), using a portion of the stomach. It may be advisable that you discuss the pros and cons of undergoing the surgery with your family doctor before he refers you to the surgeon. For instance, besides the inherent risks of undergoing a surgery, the operation does not guarantee you that you will not require another operation nor will require you to continue taking the drugs indefinitely. Add to that the risk of developing swallowing difficulties, abdominal pain, diarrhoea, constipation, etc, and you will realize that the surgery may end up doing more harm than good.