เครื่องมือและแบบประเมินใน คลินิกผู้สูงอายุ

1. เครื่องมือและแบบประเมินในคลินิกผู้สูงอายุเครื่องมือและแบบประเมินในคลินิกผู้สูงอายุ รศ.นพ. ประเสริฐ อัสสันตชัย สาขาวิชาเวชศาสตร์ผู้สูงอายุ ภาควิชาเวชศาสตร์ป้องกันและสังคม คณะแพทยศาสตร์ศิริราชพยาบาล

2. ขาดองค์ความรู้ ต้องการการอบรม 36คน (38%) • ขาดบุคลากร แพทย์ เภสัชกร เจ้าหน้าที่อบรมแล้วย้ายไป 34คน (36%) • ไม่มีคลินิกผู้สูงอายุ 30 คน (32%) • รูปแบบคลินิกผู้สูงอายุควรเป็นอย่างไร 21คน (22%) • ผู้บริหารไม่สนับสนุน นโยบายไม่ชัดเจนผู้รับผิดชอบไม่ชัดเจน19คน(20%) • การทำงานแบบสหสาขาวิชาชีพไม่เป็นรูปธรรม 14 คน (15%) • ขาดคู่มือ เอกสาร 12 คน (13%) • ขาดงบประมาณ 8 คน (9%) • สถานที่คับแคบ 6 คน (6%) • อื่นๆ ขาดความมั่นใจ ขาดอุปกรณ์ในการบริการ ช่องทางพิเศษ NPO - BS

3. Special Characteristics in Geriatrics RAMPS • Reduced body reserve • Atypical presentation • Multiple pathology • Polypharmacy • Social adversity

4. Geriatric Giants -atypical presentation • Instability (Fall) • Immobility • Intellectual impairment • Incontinence • Inanition • Iatrogenesis

5. Common chronic diseases in older patients • Musculoskeletal disorders • Osteoarthritis, crystal-induced arthropathy • Osteoporosis • Atherosclerosis-related disorders • Hypertension, Diabetes mellitus, Dyslipidemia • Circulatory disorders : stroke, coronary heart disease • Neurodegenerative disorders • Dementia • Delirium • Depression

6. Prevalence of chronic diseases among the Thai elderlyHealth System Research Institute 1998

7. Chronic diseases influenced long term disabilityHealth System Research Institute 1998 * AR: attributable risk , ** Pop.AR : population attributable risk

8. Mortality rate of diseases among the Thai Elderly (per 105)Health Policy and Planning Institute 2000 YLL : year of life lost – number of years lost due to premature death

9. Philosophy in Preventive Geriatrics • Primary prevention (Health promotion) • Secondary prevention • Tertiary prevention

10. Action Plan in Preventive Geriatrics • Comprehensive geriatric assessment • Appropriate intervention and monitoring (according to the findings in assessment)

11. Comprehensive geriatric assessment • Physical assessment • Mental assessment • Social assessment • Functional assessment

12. Comprehensive geriatric assessment Physical assessment • History of fall, incontinence • Pain assessment • Drug history: polypharmacy! • Nutritional history • Life-style: smoke, drink, exercise, aids & appliances • Vaccinations : influenza, tetanus, pneumococcal ?

14. Innovation in “Get-up-and-go-test • Timed get-up-and-go test : sit, stand from arm-chair, walk 3 meters, turn, walk back to chair and sit down : one trial run before timed test • Categorical scale & scoring • < 10 sec. = freely mobile • < 20 sec. = mostly independent • 20-29 sec. = variable mobility • > 29 sec. = impaired mobility

15. Abnormal Gait in Old Age Frontal lobe gait (frontal ataxia or apraxia) • Difficult gait initiation and sway, wide-based, flexed posture, small shuffling, hesitant step • Magnetic gait, slipping clutch syndrome • DDx : Alzheimer’s disease, Vascular dementia, NPH

16. Abnormal Gait in Old Age Sensory Ataxic Gait • Wide-based, foot stamping walk with high stepping due to loss of proprioceptive input, constantly observe the foot position • Romberg’s sign positive • DDx : Thiamin deficiency, Subacute combined degeneration of spinal cord, spinal cord compression, diabetic neuropathy

17. Cerebellar Ataxic Gait • Wide-based, small irregular unsteady, staggering, sudden lurching to either side, forward or backward like being drunk • Abnormal tandem gait, en bloc turning • Poor coordination: proprioceptive, labyrinthine, visual • DDx: vestibular damage, stroke, chronic alcoholism, progressivesupranuclear palsy, thiamin deficiency, hypothyroidism, drug intoxication

18. Spastic Gait • Hemiplegia - Stiff, flexed hip, extended knee, plantar-flexed foot - Affected arm: flexed elbow across abdomen, impaired arm swing, toe scraping or dragging across the floor - Visual neglect or hemianopia • Paralegia (scissoring gait) - Cervical spondylitic myolopathy, Subacute combined degeneration of spinal cord, chronic cord compression, lacunar infarcts

19. Steppage gait • Lifting the feet hight off the ground due to foot drop (pretibial, peroneal muscle weakness) • DDx: peripheral neuropathy, prolonged pressure, DM, alcoholism, B12 deficiency Festinating Gait • Symmetric rapid shuffling of feet, stooped posture, flexed hip and knee • Centre of gravity shifted forward • DDx: Parkinsonism, vascular dementia, hydrocephalus

20. Podalgic Gait • Foot disorders: corns, calluses, in-growing toe nails, bunion, atrophy of plantar pads • Loose or tight-fitting footwear

21. Wadding Gait • Duck or penguin’s walk • Limb girdle muscle weakness, lateral trunk movement away from the foot as it lifts • Difficulty climbing stair, getting up from low-seated chair • DDx: hypo/hyperthyroidism, polymyositis, osteomalacia, proximal myopathy

22. Urinary incontinence - Urine secretion - 100 ml / hour - Fullness - 300 ml - Normal bladder capacity - 300-600 ml - Discomfort - 600 ml - Desperate or desire to micturate - 750 ml - Bladder pressure < 15 cm of water - Postvoid residual volume < 100 ml

23. Mechanism of Micturition Spinal cord Hypogastric Plexus C T 11 T 12 L 1 L 2 B Bladder D A S 2 S 3 S 4 E Pelvic floor AParasympathetic cholinergic ….… Bladder contraction BSympathetic ….…….……..… Bladder relaxation CSympathetic …………..…….. Bladder relaxation DSympathetic ………..……… Bladder neck and urethral contraction ESomatic (Pudendal nerve) …...…. Contraction of pelvic floor musculature

24. Urinary Incontinence • สาเหตุที่เกิดขึ้นฉับพลันและอาจหายขาดได้ • สาเหตุที่เป็นเรื้อรัง

25. Causes of Acute & Reversible Forms of Urinary Incontinence DDelirium RRestricted mobility, Retention I Infection*, Inflammation*, Impaction (fecal) PPolyuria**, Pharmaceuticals * Urinary Tract Infection, Atrophic vaginitis, urethritis. ** Hyperglycemia, Congestive heart failure.

26. Persistent Incontinence 1.StressLeakage of urine (small amounts) with increases in intraabdominal pressure 2.UrgeLeakage of urine (larger volume) due to inability to delay voiding after sensation of fullness 3.Overflow Leakage of urine (small amounts) from urinary retention 4.Functional Leakage of urine (larger volume) with inability to toilet due to impaired cognition, physical function, psychological, environmental barriers

27. Causes of Persistent Incontinence 1.StressPelvic floor, Bladder outlet or Urethral sphincter weakness 2.UrgeOveractive bladder, Detrusor hyperreflexia due to Cystitis, Urethritis, Tumor, Stone, Diverticuli,Stroke, Dementia, Parkinsonism, Suprasacral spinal cord injury 3.OverflowObstruction by Prostate, Stricture, Cystocele DM, spinal cord injury Detrusor-sphincter dyssynergy 4.Functional severe dementia, depression, impaired mobility, environmental barriers

28. การประเมินภาวะโภชนาการในผู้สูงอายุการประเมินภาวะโภชนาการในผู้สูงอายุ • ขาดอาหาร • BMI < 18.5 • การเปลี่ยนแปลงของน้ำหนักตัว • อาหารเกิน • BMI > 22.9 • เส้นรอบพุง abdominal circumference 90 cm. ในชาย 80 cm. ในหญิง

29. ภาวะทุโภชนาการในผู้สูงอายุMEALS ON WHEELS • M: medications • E: emotional (depression) • A: alcoholism, anorexia, abuse of the elders • L: late-life paranoia • S: swallowing problems (dysphagia) • O: oral problems • N: no money (poverty)

30. W: wandering and other dementia-related problems • H: hyperthyroidism, pheochromocytoma • E: enteric problems (malabsorption) • E: eating problems • L: low salt, low cholesterol diet • S: shopping and meal preparation problems 3 common causes: malignancy depression GI problems

31. Mini Nutrition Assessment (MNA)

32. Comprehensive geriatric assessment Mental assessment • Abbreviated mental test (AMT) • Standard mental tests • Thai Mental State Examination (TMSE) • Chula Mental Test (CMT) • Mini Mental State Examination-Thai 2002 Pay attention to recent loss of mind and family member !!

33. Abbreviated Mental Test.Age.Time (to the nearest hour).Address for recall at end of test should be repeated.Year.Name of institution.Recognition of two persons (doctor, nurse, etc.).Date of Birth (day and month sufficient).Year of marry, important event.Name of present monarch.Count backwards 20 to 1 Scoring: 0-3 severe, 4-7 moderate, 8-10 normal

34. Screening for depression • In practice: ask 2 questions • Over the past 2 weeks, have you felt down, depressed, or hopeless? • Over the past 2 weeks, have you felt little interest or pleasure in doing things? If “yes” for both questions, proceed to Thai Geriatric Depression Scale

35. Thai Geriatric Depression Scale Train the Brain Forum • http://www.si.mahidol.ac.th/project/geriatrics/Research/research2.htm

36. Comprehensive geriatric assessment Social assessment - relationship in family • Caregiver : aware of elder abuse in dementia • Physical abuse • Caring abuse : nutrition, drug compliance, pressure ulcer, incontinence, instrumentation • Financial : family support, welfare • Environment : housing, neighbor, elderly club, community Pay attention to living alone, poor !!

37. Comprehensive geriatric assessment Functioal assessment • Basic activity of daily living (basic ADL) : transfer, mobility, toilet use, grooming, urine, stool, bathing, dressing, eating, stairing • Instrumental activity of daily living (iADL) : washing & cleaning, cooking, shopping, financial, transport & communication, drug use Pay attention to recent loss of ADL !!

38. Comprehensive geriatric assessment- Examination • Blood pressure   hypertension (2 positions) postural hypotension • Body weight   under-nutrition • Special sense   disability, fall (VA, hearing) • Breast examination   breast cancer • Get-up-and-go test   fall, immobility

39. Comprehensive geriatric assessment- Laboratory • Pap smear   CA cervix • Fecal occult blood   CA colon • Fasting blood glucose   DM • Cholesterol   dyslipidemia • TSH   hypothyroidism • Osteoporosis screen   fracture NB:PSA ??