The PACE Symposium is a continuing medical education (CME) programme organized by TEVA Pharmaceuticals in partnership with MIMS (held 04 November 2017 at The Westin Singapore).
By 2030, we expect that the number of Singaporeans aged over 65 years will double to more than 900,000 individuals – meaning 1 in every 5 Singaporeans will be above the age of 65 years by 2030. With advancing age, the elderly face issues such as frailty and increased risk of acute morbidity and chronic illnesses. While mortality will mostly still be attributed to cardiovascular diseases and cancers, morbidity from chronic conditions that require continuing primary care attention will increase. Associated with this increase in morbidity, the elderly also require special care, leading to increased healthcare utilization in various forms, from hospital care, to nursing home care, hospice care, rehabilitative services and psychological support. Additionally, care for the elderly in the primary care setting should be holistic and participative.
There is little consensus on the specific definition of multi-morbidity, but it commonly refers to the coexistence of two or more chronic conditions in an individual. The most common conditions encountered in these patients include hypertension, hyperlipidemia, diabetes, arthritis, stroke, obesity, thyroid dysfunction, obstructive pulmonary disease, heart failure and impaired vision and/or hearing. The prevalence of multi-morbidity among the elderly in Singapore is estimated at around 50%, and is correlated with reduced functional status, poorer quality of life and lower independence. It is also associated with increased healthcare costs (eg, physician visits, hospitalizations, prescription medications, etc). Furthermore, each additional chronic condition increases healthcare and social care costs substantially. Management of patients with multi-morbidity should be holistic, participative, and individualized to the specific disease entities involved as well as patient and caregiver characteristics and preferences.
Life-threatening upper gastrointestinal diseases such as peptic ulcers and gastric cancers were common in the elderly. With the decline in H pylori infection and rising affluence, threats from acid-related diseases now relate to use of aspirin in heart disease and to an apparent increase in reflux associated symptomatology. Proton pump inhibitors (PPIs) with their profound suppression of acid secretion, achieve better peptic ulcer and oesophagitis healing rates. However, with widespread use of PPIs, there is emerging evidence of a risk for Clostridium difficile infection, malabsorption, and NSAID associated enteropathy. Prolonged PPI use is associated with alterations in gut microbiota, and small intestinal bowel overgrowth. Some evidence suggests that therapeutic modulation of the gut microbiota may offer some protection against these complications. Despite their greater prevalence of acid reflux associated diseases, many countries in the West have in place in their healthcare systems stricter controls on the use of PPIs. There is even a move towards developing deprescribing guidelines. With the impending arrival of a new class of acid suppressants, the potassium-competitive acid blockers (P-CABs), the stakes will become even higher.
Asthma and chronic obstructive pulmonary disease (COPD) are common chronic respiratory disease that greatly contribute to morbidity and mortality. In older patients, the distinction between these two conditions is often difficult to make, even more so when these two conditions co-exist in an individual. Recently, the Global Initiative for Chronic Obstructive Lung Disease guidelines for diagnosing, managing, and preventing COPD recognized asthma-COPD overlap syndrome (ACOS) as a separate entity. ACOS is a significant health problem worldwide; patients with ACOS have worse pulmonary symptoms and quality of life, and experience more frequent exacerbations than those with either asthma or COPD alone. Consequently, these impact healthcare resource utilization and costs. This session will clarify the clinical manifestations, diagnostic tools and effective treatment approaches to help patients manage their symptoms. We will also look into the critical role of the primary care physician, particularly in long-term monitoring and helping patients maximize lung function and manage exacerbations.
Inhalation has been used as a route for the delivery of drugs for many airway diseases, including asthma, chronic obstructive pulmonary disease and acute respiratory infections. However, over the years, inhalation devices have continuously evolved and the use of more sophisticated technology has increased the range of potential therapies that can be absorbed through inhalation. Inhaler technique is a common issue that limits drug effectiveness. This issue is magnified in frail elderly patients, where declining strength, cognition and function can have a profoundly negative effect on inhaler technique. The primary care physician plays a vital role in helping elderly patients and their carers learn proper inhaler technique which is central to reducing exacerbations, preventing hospitalization and improving health-related quality of life.