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01
1.
当院における全人的医療の試み 原町ささき内科 院長 佐々木陽彦
2.
初めに • 地域機関病院で消化器、糖尿病、循環器など、 あらゆる臓器を担当した。 • 大学病院で老年医学、がん、呼吸器疾患など の、研究・診療・学生教育を行った。 •
在宅療養診療所で高齢者の終末期を担当した。 • 大学病院勤務で国のレベルで医療(特に高齢 者医療)を俯瞰できた。 • これまでの経験を踏まえ、私自身が診療所を 開設するに至った背景、今後の方針を記す。
3.
高齢者は一臓器にのみならず、多臓器が絡みあう複雑な病態を呈している。 心臓 (虚血性心疾患、 心不全、など) 糖尿病・ 高脂血症 骨粗しょう症・ 圧迫骨折・ 転倒 肺 (COPD、呼吸不全、 など) 精神・神経 (うつ、脳梗塞、 認知症、など) 消化器 (GERD、ピロリ菌、 潰瘍、便秘、など) 老年 症候群 循環器外来 呼吸器外来 (呼吸器専門医) 糖尿病外来 総合内科専門医 骨粗しょう症外来 消化器外来 高齢者は臓器別にみることは限界であり、多臓器の方面から考える必要がある。 当院には各外来があり、多臓器の方面から考えることが可能である。
4.
ここでは、一例として、COPD(慢性閉塞性肺疾患)を取り上げる。 COPDは喫煙などの有害物質による経年的な気道閉塞を伴う、息切れ、咳を伴う高齢者疾病である。 このようにCOPD1つを取り上げても、1つ1つの併存症のコントロールが病状の進展抑制に重要 である。逆に併存症の管理をよくするためにも、原病(COPD)の管理が重要である。 肺局所の炎症 併存症の炎症 COPD増悪・予後不良 虚血性 心疾患 心不全 骨粗鬆症
糖尿病 うつ病 GERD 併存症のコントロール悪化 全身性炎症の進展・悪化 IL-1b、IL-6、IL-8、TNF-a、hsCRP COPD発症
5.
COPDの自然史を示したものである。 現状では、経年的な病状進行の抑制方法がない。 しかしながら、原病、並びに併存症のコントロール、がんのスクリーニングを適切に行うことで、 経年的な病状進行のスピードを低下させることは可能であり、1日でも長く健やかに過ごせるこ とも事実である。これはCOPDに限らず、あらゆる疾患に当てはまることである。 発症 肺がんの発症・進行 心血管疾患 骨粗鬆症・筋力低下 糖尿病 抑うつ 消化管障害 (潰瘍、GERDなど) 併存症の悪化 1秒率の低下 症状の程度 呼吸困難・運動能力低下・繰り返す増悪 Ⅰ期 Ⅱ期 Ⅲ期
Ⅳ期 急性増悪 喫煙習慣 急性増悪 急性増悪急性増悪 急性増悪
6.
高齢者の全人的な苦痛を示したものである。 今まで取り上げてきた身体的な苦痛ばかりでなく、様々な苦痛がある。 高齢者においては、これら苦痛に対して積極的に支援することが求められる。当院は身体的苦 痛の緩和はもとより、これら苦痛にも思いを馳せて地域のかかりつけ医としてお役に立てれば と考えている。 身体的苦痛 痛み 他の身体症状 ADLの低下 社会的苦痛 家庭の問題 仕事の問題 ADLの低下 スピリチュアルな苦痛 老いの恐怖 人生の意味への問い 罪の意識 精神的苦痛 不安 不眠 抑うつ 全人的苦痛 (トータルペイン)
7.
終わりに • 当院はあらゆる内科疾患を見ていく。 • 当院は特に、高齢者が多臓器の疾患を抱え ている現状を見据え、病気ではなく「ひと」を 診ていく。 •
当院は治る病気は治癒に向かわせる一方、 進行性病気もその段階におけるベストの治療 を考え、同時に併存症、身体的問題以外の 諸問題にも目を向ける。
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