長期照護個案 功能性評估與診斷 陳晶瑩醫師 臺大醫院家庭醫學部 2014/09/13

1. 長期照護個案 功能性評估與診斷 陳晶瑩醫師 臺大醫院家庭醫學部 2014/09/13

2. Outline • Case presentation (個案報告) • Introduction( 引言) • Geriatric syndrome(老年症候群） • Functional assessment（功能評估） • Summary (總結)

3. Present Illness 88y/o man, underlying HT, Af (高血壓, 心房顫動) Excellent function, totally independent • Acute onset of L’t side weakness(左側無力) • Admitted on 2013/11/8 • MRI: right ICA occlusion with borderzone infarction(梗塞) • transfer to PMR（復健科）, discharged on 2014/1/5 • could walk with walker under supervision, BI: 55 2013/11/08 • At home, seldom walk • regular OPD rehab (slowly climb 5 stairs ) • use chopsticks to eat • intact communication 2014/1-2

4. Present Illness • Progressive poor appetite, oral intake ↓, function ↓ • dysphagia（吞嚥困難）, choking, nausea/vomiting • BW loss 20kg in 6 months • OPD visit on 2014/6/11 2014/2-6 • Admission • Fever, leukocytosis 白血球增加 Tazocin • NG feeding • Chest/Abdomen CT: left lower lung abscess(肺膿瘍, spleen, liver microabscess（肝脾小膿瘍 • improved lung abscess under Tazocin(6 wks) • discharge on 7/26 • could eat porridge、pudding, improved transfer , walk with walker 6/12

5. Present Illness • OPD f/u: • try oral intake, still intermittent choking(嗆咳) • ever fever with CRP↑  oral Cefixime • progressive ADL↓, became maximal assistance in all transfer • sometimes confusion with irregular circadian rhythm (日夜顛倒) 2014/7-8 • Admitted to rehab ward for reconditioning （功能回復) • - On admission: BI: 10 • under rehab. : improved transfer, walker under moderate assistance for 5m • diarrhea (腹瀉)with stool WBC:2-5  Metronidazole 8/20 • fever, sticky sputum(痰液黏稠), WBC↑ on 8/21 •  Tazocin, transfer to acute ward on 8/24 8/16

6. Family History:

7. Problem List(問題列表) • Pneumonia(肺炎), pseudomonas related • Dysphagia(吞嚥困難)/ malnutrition(營養不良) • Delirium(譫妄) • Dementia (失智)? (MMSE:22/30專科畢, borderline) • Depression(憂鬱) ( GDS 7/15, improving • Urinary and fecal incontinence(尿及大便失禁) ( improving after improving )delirium • Polypharmacy(多重用藥): adjusted • Functional decline, multi-factor related possible due to stroke, delirium, r/o dementia, depression, malnutrition, deconditioning

8. Outline • Case presentation • Introduction • Geriatric syndrome • Functional assessment • Summary

9. Characteristics of illness of elderly(老年疾病特質) • Multiple illness(多重疾病) • Obscured illness(潛隱疾病) • Underreporting of illness(未報告疾病) • Attitude of ageism(歸因於老化) • Atypical presentation(非典型表現) • Iatrogenic medical problems(醫源性疾病) • Altered spectrum of health conditions(疾病範疇不同)

10. Spectrum of care Family medicine Geriatrics Acute disease Chronic disease Cognitive Affective Mobility Nutritional Preventive medicine Health seeking behavior • Acute disease • Chronic disease • Preventive medicine • Health seeking behavior

11. History taking-1 • The patient’s chief complain • The family member’s observation/concerns • Present illness • Common pathways: baseline and current status • Consciousness(意識) • Appetite(胃口) • Mobility(活動力) • Continence(失禁)

12. Nonspecific symptoms that may represent specific illness • Confusion • Apathy • Self-neglect • Anorexia(胃口不好) • Falling • Incontinence • Dyspnea(喘) • Fatigue(疲倦) • An abrupt change in functional status is a vital sign of potential illness Ham RJ et al: Primary Care Geriatrics 5th 2007,

13. History taking-2 • Past major systemic disease • Functional change( 功能變化( after recent or recurrent hospitalization or Emergency Department visits or major events • Iatrogenesis(醫源性介入): time , indication and contraindication of removal • Current medication: CDC AIDS

14. Chen’s polypharmacy evaulation • C: compliance(順從性) • D: drug list(藥物列表) • C: controlled status(疾病控制狀態) • A: adverse effect/ interaction: (副作用) drug to drug/diagnosis • I: indications for drugs(藥物使用適應症) • D: drugs for diagnosis(疾病相關治療) • S: simplify medication: drugs, dose, frequency(藥物簡化)

15. History taking-3 • Geriatric syndrome: DEEPIN • ADL/IADL impairment: What, When, Why • ADL: DEATH • IADL: SHAFT • Family history: Where is the resources(資源)? • Family members: age, occupation, residence relationship • Who is living together • Care aid: communication , education

16. Outline • Case presentation • Introduction • Geriatric syndrome • Functional assessment • Summary

17. Traditional Medical SyndromeSpecific Morbid Process Multiple phenomenologies Moon facies Buffalo Hump Truncal obesity Proximal muscle weakness Cortisol Excess Easy bruisability Skin thinning Osteoporosis JAGS 2003;51(4):574-6

18. Geriatric SyndromeMultiple morbid process Specific phenomenology Dementia Dehydration Severity of illness Sensory impairment Delirium syndrome Medication effects Sleep disturbance Older age JAGS 2003;51(4):574-6

19. Geriatric syndromes • To define complex clinical conditions that are common in older persons • Do not fit into discrete disease or syndrome categories • Geriatric syndrome is defined as an accumulation of impairments in multiple systems that produces a phenotypic decline in function or independence Cruz-Jentoft et al. Curr Opin Clin Nutr Metab Care 2010;13:1-7 JAGS 2006;54(5): 831-42

20. Geriatric syndromes • multifactorial etiology, • shared risk factors with other geriatric syndromes, • association with functional decline, • association with increased mortality JAGS 2006;54(5): 831-42

21. Functional review • D: Delirium, dementia, depression, • E: Eyes (vision impairment) • E: Ears (hearing impairment) • P: Physical performance, “phalls”(falls), polypharmacy, pain, pressure sore • I: Incontinence/constipation, iatrogenesis,insomnia • N:Nutrition Geriatrics 2001;56(8):36-40, modified

22. Juan F. Gallegos-Orozco ,Chronic constipation in the Elderly Am J Gastroenterol 2012

23. Geriatric giants: the big “I”s • Intellectual failure • Incontinence • Immobility • Instability • Iatrogenic disease • Inability to look after oneself Nichol CG, Wilson KJ: Elderly Care Medicine 2012

24. Resident assessment protocols (RAP)Triggered by MDS (minimum data set) • Delirium • Cognitive loss/dementia • Visual function • Communication • ADL function/ rehabilitation • Urinary incontinence and indwelling catheter • Psychosocial wellbeing • Mood state • Behavior symptoms • Activities • Falls • Nutritional status • Feeding tubes • Dehydration/fluid maintenance • Dental care • Pressure ulcers • Psychotropic drug use • Physical strain Gallo JJ: Handbook of Geriatric Assessment 2006

25. Outline • Case presentation • Introduction • Geriatric syndrome • Functional assessment • Summary

26. Reasons to screen for functional status • A symptom of acute or worsening chronic illness • Determining appropriate level of care and transition of care • Managing acute illness and determining prognosis and treatment options • Deciding on the intensity and effectiveness of treatment

27. Brief history of geriatric assessment Late 1930s: Marjory Warren Who initiate the concept of specialized geriatric assessment units while in charge of a large London infirmary Lack of diagnostic assessment and rehabilitation kept them disabled. Every elderly patient receive comprehensive assessment and an attempt at rehabilitation before being admitted to a long-term care hospital or nursing home.

28. Aims of Geriatric care Maintain function: diagnosis and treatment Maintain self care Function= ability + motivation + opportunity 功能=能力+動機+機會

29. Motivation Ability Motivation Opportunity

30. Functional Self-reported tools Performance-based instrument Gait speed: 1m/sec, 0.6-1/sec, 0.6m/sec Get-up-and-go test SPPB ( Short physical performance battery) Shoulder and hand function • Basic ADL • IADL • Advanced ADL • The vulnerable Elder 13 Survey

31. 日常生活活動功能評估 Activity of Daily Living (ADL) • Dressing • Eating • Ambulatory (transfer) • Toileting • Hygiene • Continence • Bathing • Dressing • Toilet • Transfer • Continence • Eating

32. 工具式日常生活活動功能評估 Instrumental ADL (IADL) • Shopping • Housekeeping • Accounting • Food preparation • Transportation,Telephone • Medication • Laundry

33. The Vulnerable Elder 13 Survey (VES-13) • Age 75-84 (1); >85 (3) • Self-reported health • Fair or poor (1); Good, very good ,or excellent (0) • Physical disability(1 for each, max 2) • Stooping, couching, or kneeling(1) • Walking ¼ mile • Lifting 10 lb • Heavy housework • Reaching above shoulder level • Writing or grasping small objectives • Functional disability ( 4 for each) • Shopping • Light housework • Finance • Walking across rooms • bathing

34. Assessment of Mobility in the Primary Care Setting: screening questions Self-reported difficulty Report no difficulty preclinical limitations can be elicited by asking, “Because of underlying health or physical reasons, have you modified the way you climb 10 steps? Walk¼ mile? Either by changing the method or frequency of these activities?” • “For health or physical reasons, do you have difficulty climbing up 10 steps? Walking¼ mile?” • 爬10級樓梯或走400公尺是否有困難? • 是否因健康或體能因素改變上述行動方式或頻率? Check risk factors! JAMA. 2013;310(11):1168-1177

35. Risk factors for mobility limitation Most common Less common depressive symptoms cognitive impairment, being female recently hospitalized, using alcohol or tobacco, having feelings of helplessness. • older age, • low physical activity, • obesity, • strength or balance impairments, • chronic diseases, such as diabetes or arthritis Gait changed disease:parkinsonism cerebellar stroke JAMA. 2013;310(11):1168-1177

36. Mobility/Balance • Gait: • ask about falls and fear of falls • Observe transfer • Timed up and go test ( positive screen: > 15”) < 10”:freely movable <20”: mostly independent 20-29”:variable mobility >29”: impaired mobility • Balance: modified Romberg • Side by side, • Semi-tandem stand • Tandem stand • Chair rise test • Shoulder function • Behind head • Behind waist • Hand function • Grasp • pinch Hirth V: Case-based Geriatrics: a global approach. 2011

37. Timed up and go test Ask the patient to Factors to note Sitting balance Imbalance with immediate standing Pace and stability of walking Excessive truncal sway and path deviation Ability to turn without staggering Observe and time the patient • Standing up from a chair • Stand still momentarily • Walk 10 feet (3 meter) • Turn around and walk back to chair

38. Short Physical Performance Battery-1 SPPB • Balance: modified Romberg • Side by side, • Semi-tandem stand • Tandem stand • Walking speed • Chair rise test

39. Short Physical Performance Battery-2 SPPB • Balance: modified Romberg • Side by side, • Semi-tandem stand • Tandem stand • Walking speed • Chair rise test

40. Hirth V: Case-based Geriatrics: a global approach. 2011

41. Mobility disability • the gap between an individual’s • physical ability(eg, muscle strength or balance) • environmental challenges such as walking outdoors on uneven surfaces. • range from • preclinical (ie, the limitation only exists in highly challenging environments) to • severe (as occurs among bedbound individuals) JAMA. 2013;310(11):1168-1177

42. Mobility and assessment Assessment of mobility mobility • a person’s ability to transfer from bed or chair, • Walk ¼ mile • climb stairs independently • the distance a person can trave laway from home with or without assistance. Physical ability to walk or move A person’s environment Life space Ability to adopt JAMA. 2013;310(11):1168-1177

43. Risk factor or screening positive • Obtain additional history regarding changes in mobility • Identify physical, social, and environmental components that lead to mobility limitations and • refer to appropriate clinician • Review for medications that may affect strength, balance, gait, mental status, or have other central nervous system effects • Perform physical examination including gait speed Acute medical condition that leads to impaired mobility detected? JAMA. 2013;310(11):1168-1177

44. Drug-related disability Over treatment Under treatment Pain Arthitis Compression fracture Osteoporosis PAOD Dyspnea: CAD Anemia Depression • Mobility: EPS, muscle relaxants, • Dizziness: postural hypotension, BZD • hyponatremia: diuretics, SSRI • Sleepy/sedative: hypnotics, TCA

45. Common causes of immobility in older adults • Musculoskeletal disorder(骨關節疾病) • Arthritis, osteoporosis, fractures, podiatric • Neurological disorder(神經性疾病) • Stroke, Parkinson disease, hydrocephalus, dementia • Cardiovascular disease(心血管疾病) • CHF, CAD, PAOD • Pulmonary disease: COPD(肺部疾病) • Sensory factors(感官疾病) • Environmental causes(環境因素) • Forced immobility, inadequate aid, pain • Others(其他) • Deconditioning, malnutrition, depression, drugs (失用,營養不良,憂鬱,藥物) Kane RL et al: Essential of Clinical Geriatrics. 2013

46. Rehabilitation Principle Physical therapy Relieve pain Evaluate ROM Improve strength, endurance, motor skills and coordination Improve gait and stability The need of assistive device • Strength: resistance exercise • Balance: balance exercise • Environmental barrier • Social barrier to mobility Kane RL et al: Essential of Clinical Geriatrics. 2013 JAMA. 2013;310(11):1168-1177

47. Outline • Case presentation • Introduction • Geriatric syndrome • Functional assessment • Summary

48. Conclusion Level 3: DEEPIN Level 2: Cognitive Affective Mobility Nutritional Level 1: Mobility Nutrition