pailin paisin , md, fm social medicine department, pichit hospital december 14 th , 2011
DESCRIPTION
การดูแลสุขภาพผู้สูงอายุ Elderly health Care. Pailin Paisin , MD, FM Social Medicine Department, Pichit Hospital December 14 th , 2011. โรคที่พบบ่อยในผู้สูงอายุ. โรคที่พบบ่อยในผู้สูงอายุ. Hypertension Degenerative joint disease Hearing problem Lung disease Heart disease. - PowerPoint PPT PresentationTRANSCRIPT
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Pailin Paisin, MD, FMSocial Medicine
Department, Pichit Hospital
December 14th , 2011
การดแลสขภาพผสงอาย
Elderly health Care
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โรคทพบบอยในผสงอาย
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โรคทพบบอยในผสงอาย Hypertension Degenerative joint disease Hearing problem Lung disease Heart disease
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Cause of death
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Cause of death Cardiovascular disease Malignancy Cerebrovascular disease
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ลกษณะเฉพาะของปญหาผสงอาย ปญหาสขภาพหลายปญหา อาการมกจะคลมเครอ ไมชดเจน อาการหลายๆอยางประกอบกนเปนกลมอาการ “Geriatric syndrome”
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Geriatric syndrome : Is Immobility Instability Incontinence Intellectual
impairment Infection Impairment of
vision and hearing
Irritable colon Isolation
(depression) Inanition
(malnutrition) Iatrogenesis Insomnia Immune
deficiency Impotence
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Geriatric Assessment 3M HAND VISA
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Geriatric Assessment Medication Mentation Mobility Hearing ADLs Nutrition Depression
Vision Incontinence/
Insomnia Social support Advance
directives
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Medication
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Medication Multiple medical problems
Polypharmacy ? > 5 Prescribed vs non-prescribed Alternatives and supplements การบรหารยา Side effects Drug interaction Caution : renal excretion
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Medication NSAIDs Hypnotics Anticholinergic Steroid
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Compliance
Cognitive Hearing
Vision
Side effectPsychosocial
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Medication เรมทขนาดยาตำาๆ คอยปรบยาเพมชาๆ ประเมน : adherence, effectiveness,
adverse effects
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HT, DM, DLP เรมควบคมความดนโลหตไมไดมา 6
เดอน
Case 1
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Mentation Cognitive Delirium vs Dementia
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Mentation Delirium : การเปลยนแปลงของการรสต
แบบacuteหรอsubacute (acute or subacute alteration in mental status)
ความชก: 15% on admission Predispose factors : ประสาทสมผสผดปกตหรอถก
ปดกนประสาทสมผส(impaired sensory function/sensory deprivation), อดนอน(sleep deprivation), เคลอนไหวไมไดหรอถกจำากดการเคลอนไหว(immobilization), เปลยนสถานทหรอเปลยนสงแวดลอม(transfer to unfamiliar environment)Essentials of Clinical Geriatrics : Robert L.
Kane et al.
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Mentation :Delirium1. Disturbance of consciousness + reduced ability
to focus, sustain, or shift attention2. A change in cognition (Ex. Memory deficit,
disorientation, language disturbance) / development of perceptual disturbance
3. Development during a brief period (usually hours to days) and tendency for fluctuation during the course of the day
4. Evidence caused by1. General medical condition2. Substance intoxication, side effect, withdrawal
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Mentation : Delirium1. Disturbance of consciousness2. change in cognition / perceptual
disturbance3. Onset : brief period and fluctuation 4. Evidence
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Mentation สมองเสอม (Dementia) ?
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DSM-IV Criteria for Dementia The development of multiple cognitive
deficits that include Memory impairment and at least one of
the following Aphasia ( การไมสามารถบอกชอสงของได ความสามารถ
ในการใชภาษาลดลง) Apraxia ( การไมสามารถกระทำาสงตางๆ เมอถกบอกใหทำา) Agnosia ( การไมสามารถระบสงของตางๆ ได แมวา
ประสาทสมผสยงดอย) Disturbance in executive functioning (การ
วางแผน การรวบรวมความคด การคดเชงนามธรรมตางๆ)
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DSM-IV Criteria for Dementia Be sufficiently severe to cause impairment in
occupational or social functioning Represent a decline from a previous higher level of
functioning Diagnosis should not be made if the cognitive deficits
occur exclusively during the course of a delirium. However, a dementia and a delirium may both be
diagnosed if the dementia is present at times when the delirium is not present.
Dementia may be etiologically related to a general medical condition, to the persisting effects of substance abuse (including toxin exposure), or a combination of these factors.
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Mentation : สมองเสอม(Dementia) Memory impairment + ¼ (aphasia,
agnosia, apraxia, disturbance in executive function)
Impairment in occupational or social functioning
Duration : at least 6 months
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Delirium vs Dementia
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Feature Delirium Dementia
Onset Acute Insidious
Course Fluctuating, with lucid interval, worse at night
Generally stable over course of day
Duration Hours to weeks Months to years
Awareness Reduced Clear
Alertness Abnormally low or high
Usually normal
Attention Hypoalert/hyperalert, fluctuate
Usually normal
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Feature Delirium Dementia
Orientation Usually impaired : time
Often impaired
Memory impaired
Immediate & recent Recent & remote
Thinking Disorganized Impoverished
Perception Illusions & hallucination (visual)
Usually normal
Speech Incoherent, hesitant, slow or rapid
Difficulty in finding words
Sleep-wake cycle
Always disrupted Often fragmented sleep
Physical illness or drug toxicity
Present Often absent (Alzheimer dz.)
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Dementia : DDx D Drug intoxication : TCAs,
anticholinergics E Emotional disorder : depression M Metabolic & endocrine : hypothyroid,
anemia E Eye & ear disorder N Nutritional disorder : B12, folate T Tumor : 1˚& 2˚, NPH I Infection : HIV, syphilis A Alcohol/Atherosclerosis : vascular
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Mentation แบบทดสอบสมรรถภาพสมอง MMSE – low
sensitivity Clock drawing test – high sensitivity
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Mentation Mini cognitive test :
registration & recall +/- clock drawing
จำาของ 3 อยาง กลบมาถามซำา (Registration & recall) 0/3
1-2/3 Clock drawing MCI : mild cognitive impairment
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HT, DM, DLP เรมควบคมความดนโลหตไมไดมา 6
เดอน
Case 1
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จำาของ 3 อยาง 1/3
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MMSE ป. 2 Orientation to time : 3/5Orientation to place: 4/5Registration: 3/3
Attention/Calculation : 1/1Recall : 3/3
Naming : 2/2Repetition : 0/1
Verbal command : 1/1Written command : 1/1
Writing: 0/1Visuoconstruction : 0
Total score : 18/30Clock drawing test :
ทำาไมไดGeriatric Depression
Scale (GDS) 3/15
เลาเรองในอดตเรองเดมซำาๆ ประมาณ 4-5 ครง
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Dementia : DDx D Drug intoxication : TCAs,
anticholinergics E Emotional disorder : depression M Metabolic & endocrine : hypothyroid,
anemia E Eye & ear disorder N Nutritional disorder : B12, folate T Tumor : 1˚& 2˚, NPH I Infection : HIV, syphilis A Alcohol/Atherosclerosis : vascular
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Case 1 ขณะทมเยยมบานจะลากลบ ผปวยรองไห เสยใจทจะกลบแลว
Pseudodementia
“Depression”
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Case 1
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Geriatric Assessment Medication Mentation Mobility Hearing ADLs Nutrition Depression
Vision Incontinence/
Insomnia Social support Advance
directives
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Mobility Gait Gait aid Fall Gait change : Muscle mass, strength, flexibility
Impaired hearing & visionVelocity, step & stride
length
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Mobility Fall : extrinsic factors
สภาพทตองใชความเรว ( ลงทางลาดชน ลงบนได)
พนไมเรยบ ททไมคนเคย ทมด ทมเสยงดงหรอคนเยอะ
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FALL
Accidents Syncope
Drop attack
Dizziness/Vertigo
Orthostatic hypotension
Drug-related causes
Acute illness
CVS
Neuro
Urinary
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Fall Orthostatic hypotension : causes
Hypovolemia/ low cardiac output Autonomic dysfunction Impaired venous return Prolonged bed rest Drug –induced hypotension Postprandial hypotension
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Fall Drug-related causes
Antihypertensives Antidepressants : TCAs Antiparkinonian Diuretics Sedatives Antipsychotics Hypoglycemia Alcohol
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Fall Specific disease Acute illness of any kind CVS : arrythmia, VHD(aortic stenosis),
carotid sinus hypersensitivity Neurological : TIA, stroke(acute), seizure,
Parkinson dz., spinal cord/nerve root compression(C or L spondylosis), cereballar dz., normal pressure hydrocephalus(gait disorder), CNS lesion(eg. Tumor, subdural hematoma)
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Fall Urinary
Overactive bladder Urge incontinence Nocturia
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Mobility Test : Get up and go test Distance 3 m., time > 20 s. Risk of fall Goal : prevention of fall
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Case 2 หญงไทยค อาย 76 ป เดมมโรงงานทำาไอศครมท
นครศรธรรมราช Parkinson disease, hypertension, spinal
stenosis with radiculopathy, depression ญาตใหประวต ลม 20 ครง ใน 2 เดอน
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Geriatric Assessment Medication Mentation Mobility Hearing ADLs Nutrition Depression
Vision Incontinence/
Insomnia Social support Advance
directives
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Hearing Communication Sensory impairment depression Lip reader
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ADLs Basic ADLs : DEATH
Dressing & groomnig Eating Ambulating Toileting Hygiene
Instrumental ADLs Function Quality of life
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Geriatric Assessment Medication Mentation Mobility Hearing ADLs Nutrition Depression
Vision Incontinence/
Insomnia Social support Advance
directives
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Nutrition Nutritional status Malnutrition : Risk factors
ยาททำาใหเบออาหาร, โรคเรอรง, ภาวะซมเศรา, ปญหาสขภาพฟน, รบรสและกลนไดไมด, สถานะทางเศรษกจไมด, อาการออนแรง, แยกตวโดดเดยว
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Nutrition B12, Folate deficiency, anemia
pseudodementia
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Depression Pseudodementia Geriatric Depression Scale :
GDS >= 10 postpone MMSE
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Depression Pseudodementia Try treatment and follow up (repeat GDS
and MMSE)
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Vision Cataract Presbyopia
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VisionHearin
g
Sensory Impairment
Medication compliance
Depression
Fall
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Incontinence/Insomnia Physiologic : มแนวโนมจะมปญหาการกลนปสสาวะ
และปสสาวะบอยกลางคน
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Type of Incontinence urge incontinence (leakage with sudden
urgency) stress incontinence (leakage with
maneuvers that increase intraabdominal pressure)
mixed incontinence (urge and stress leakage)
incomplete bladder emptying (an elevated postvoid residual volume, often associated with weak stream, hesitancy, frequency and nocturia)
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Incontinence อายมากขน พบบอยขน ความรนแรงมากขน Morbidity
- perineal candida infection - cellulitis and pressure ulcers (constant skin moisture
and irritation) - ตดเชอทางเดนปสสาวะ sepsis (urinary retention andindwelling catheters) - ลม กระดกหก (slipping on urine) - การนอนถกขดจงหวะ อดนอน (nocturia or UI care in institutionalized persons)
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Incontinence Psychological morbidity
-poor self esteem-แยกตวจากสงคม-ภาวะซมเศรา-ปญหาเพศสมพนธ
ความอบอาย
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Incontinence Psychological morbidity
Frail elderly- caregiver burden
- decisions to place individuals in nursing homes
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Incontinence Not associated with increased mortality Causes : multifactorial Characteristic, situation, frequency,
aggravating factors, medication, substance, effect on patient and family
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Case 2 ชาย อาย 67 ป CVA with Lt. hemiparesis 5 yr., HT, BPH Fall Abnormal tone Lt. leg and arm cramp Urinary urgency FALL
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Case 2 Amlodipine, Atenolol, Doxasocin,
Norgesic, Celecoxib, Omeprazole, Gabapentin
Amlodipine mild edema Nocturia Abnormal tone Off Amlodipine, Gabapentin Start Carbamazepine Result : No fall, no cramp
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Insomnia Physiologic change in sleep patterns : งบ
กลางวน เขานอนหวคำา หลบยาก หลบไมลก ตนบอย
Physiologic vs problem Change in brief period การนอนเพง
เปลยนแปลงไปเมอไมนานมาน Effect on function มผลตอการใชชวคประจำาวน
หรอการทำางาน Type : initial, mid, terminal insomnia
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Insomnia Evaluate
Characteristic Physical symptoms, OSA Behavioral factors (daytime nap > 30 mmin.,
early bedtime, increased time spent in bed not sleeping),
Medication (hypnotic withdrawal, caffeine, alcohol (sleep fragmentation), antidepressant, diuretics, steroids)
Essentials of Clinical Geriatrics : Robert L. Kane et al.
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Geriatric Assessment Medication Mentation Mobility Hearing ADLs Nutrition Depression
Vision Incontinence/
Insomnia Social support Advance
directives
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Social support Caregiver – most important Family
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Advance directives Living will Power of attorney
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