Update in Geriatrics Care in Aging Society

พ.ท. ผศ. พญ. พฒนศร ศรสวรรณกองตรวจโรคผปวยนอก และเวชศาสตรครอบครว รพ.พระมงกฎเกลา13 กมภาพนธ 2562

To integrate healthy promotion in older adults in clinical practice

To manage common chronic diseases in older adults

To recognize geriatric syndrome in older adults

1. Health promotion2. Chronic disease 3. Geriatric syndrome4. Take home messages

Healthy aging

ภาวะสงวยอยางมสขภาพด

Process of developing & maintaining functionalablility

Enables well-being in older age

Friedman SM, et al. J Am Geriatr Soc 2019.

Chronic conditions

Physical

Cognition mental

Injury

Social

Healthy aging. WHO 2015

Activities of daily living (ADLs) Most common functional assessment tools

Report: independence, assist, dependence

Levels Definition Tools Example

1. Basic ADL (BADLs)

Basic self maintenance needs

-Barthel index-Katz index

Toilet, TransferBathing,Continent,Dressing,EatingGrooming,Stairs,Mobility

DressingEatingAmbulationToiletHygeine

2. Instrumental ADL (IADLs)

Maintain independentliving

-Lawton IADLs-Chula ADLindex

Shopping, Housekeeping, Accounting, Food preparation, Transport, Medication

Hirth V, et al. Case-based Geriatrics 2011.

Evidence- Mod-severe not driving: limit 1 bADL, 2 IADLs- MMSE: not predictive- MoCA: < 18 failing on road assessment- Visuospatial: clock drawing test

Trail B: 3 rule> 3 mins> 3 errors

Frank CC, et al. CGS Journal of CME 2018.

Comprehensive Geriatric Assessment (CGA)

AssessmentMultidimensionalMultidisciplinary

Evaluate: 5 domains1. Biological

2. Psychological

3. Functional

4. Social

5. EnvironmentalElsawy B. Am Fam Physician 2011. Luk JKH, et al. HKMJ 2000.

Concept start in 1930Dr. Marjory WarrenEvaluate & rehabilitate Get out of bed &

discharged to home

Contents Hx PEBrain Cognition Memory Mini-Cog

Eyes vision Poor vision Close each eye

Sleep Insomnia -

Ears Hearing Decrease Finger rub

Oral Hygeine Pain, bleed Teetch, gum

Malnutrition Weight BMI, demispan

Heart CVD risks DM, HT CVD, CV risk

Depression 2Q -

GU Incontinence Urinary -

Knee OA knee Pain CSTEW (>2/5)

Leg Fall Fall, fear Single leg, TUGT

ADLs Function BADLs: dress,eat

IADLs: house, finance

-

• Women: Mindex = BW (kg)/demi-span (m) • Malnutrition: < 56

• Men: Demiquet = BW (kg)/demi-span (m)2

• Malnutrition: < 76

Timed-up-and-go Test

พฒนศร ศรสวรรณ. วารสารระบบบรการปฐมภมและเวชศาสตรครอบครว 2561.www.pcfmjournal.com/

Malnutrition

Mini-Cog

• ดอกไม• รถไฟ• แมน า

0-1 positive

2-3

positive

negative

แอปพลเคชน สงอาย 5 G

คณะแพทยศาสตร มหาวทยาลยขอนแกน สถาบนเวชศาสตรสมเดจพระสงฆราชญาณสงวรเพอผสงอาย กรมการแพทย

สมาคมโรคตดเชอแหงประเทศไทย 2561

100%

H1N1 42%, H3N2 51%, B 35%

30-50% local reaction: IP 50-80%

IP 75%, CAP 45%

1 mo

0,1,6 mo

PCV-- >2mo--PPV

Immunization

Target BP for the elderly

Alhawassi TM, et al. J Clin Hypertens 2015.

Thai guidelinesDiagnosis: 140/90 mmHg

TargetAge 60-79 yrs = <140-150/90 mmHgAge > 80 yrs = < 150/90 mmHg

แนวทางการรกษาโรคความดนโลหตสงในเวชปฏบตทวไป 2558.

• Age >75 yrs: 9,000 patients • Random:

• SBP 120 or 140 mmHg• Intensive arm

• CVD outcome: lower 34%• All-cause mortality: lower

33%• Side effects: hypotension

Systolic Blood pressure Intervention Trial (SPRINT)

Wright JT Jr., et al. N Engl J Med 2015.Williamson JD, et al. JAMA 2016.

Cushman WC, et al. J Am Geriatr Soc 2018.

Cushman WC, et al. J Am Geriatr Soc 2018.

Recommendation: target BP in older adults

Wright JT Jr., et al. N Engl J Med 2015.

LeFevre M, et al. Am Fam Physician 2018.

Supiano MA, et al. J am Geriatr Soc 2017.

Systematic review: quality Screening tool: unvalidated SPRINT trail

Crawford C. Am Fam Physicians 2017.

Accurate BP measurement Home BP measurement Lifestyle modification

Qaseem A, et al. Ann Intern Med 2017.

<150

• General

<140

• Stroke

• Transient ischemic attack

<140: high CVD risks

• Diabetes

• Vascular disease

• CKD with GFR < 45

• Metabolic syndrome

Risk factor in asymptomatic patient to prevent CVD events

Not treat disease to relieve sufferingHarm: hypotension, syncope, electrolyte

imbalance, acut kidney injury

Treat HT: older adults

LeFevre M, et al. Am Fam Physician 2018.

2018 ESC/ESH Guidelines

Williams B, et al. European Heart Journal 2018.

Williams B, et al. European Heart

Journal 2018.

แนวทางเวชปฏบตการใชยารกษาภาวะไขมนผดปกต เพอปองกนโรคหวใจและหลอดเลอด พ.ศ. ๒๕๕๙

Primary prevention

Williams B, et al. European Heart

Journal 2018.

TC & Mortality

Cumulative survival1.0

0.8

0.6

0.4

0.2 0 1 2 3 4 5 6

Too low TC Increase mortality

in the elderly

Age > 75 yrs (av. 81 yrs)N = 700

Not use drug

Tuikkara P, et al. Scandinavian Journal

of Primary Health Care 2010.

Antiplatelet therapy: HT

Williams B, et al. European Heart Journal 2018.

แนวทางเวชปฏบตส าหรบโรคเบาหวาน 2560

แนวเวชปฏบตส าหรบโรคเบาหวาน 2560

ADA 2019: Older adults

American Diabetes Association 2019.

CPG Thai 2017 AGS 2014 ADA 2019

Healthy < 7 7-7.5(few comorbid)

< 7.5(few chronic illness)

Complex 7-7.5(function:

independent/comorbidity)

8-9(poor health)

< 8(multiple chronic illness or 2+iADL

or mild/mod cognitiveimpairment)

7-8(function: dependent)

Very complex < 8.5(Frailty/dementia)

< 8.5(end-stage chronic illness or

2+ADL or mod/severe cognitive impairment)

Note EOL: Avoidsymptomatic hyperglycemia

- General: 7.5-8- Harm: < 6.5 (FPG <120 mg/dL)

แนวเวชปฏบตส าหรบโรคเบาหวาน 2560 J Am Geriatr Soc 2014. American Diabetes Association 2019.

FPG(mg/dL)90-130

90-150

100-180

Goals: glycemia, BP, lipid

American Diabetes Association 2019.

American Diabetes Association 2019.

กลมอาการผสงอาย Intellectual impairment:

delirium, dementia, depression

Inanition: malnutrition

Instability: fall

Immobility: impaired physical mobility

Incontinence: urinary incontinence

Iatrogenesis: adverse drug reaction

Geriatric syndromes

Sharon K, et al. J Am Geriatr Soc 2007.

Sarcopenia New geriatric syndromeAging-related Progressive & generalized lossMuscle massFunction

Disability, quality of life, falls, hospitalize, mortality

Limpawattana A, et al. Osteoporosis and Sacopenia 2015.

Muscle strength & life course

Cruz-Jentoft AJ, et al. Age and Ageing 2019.

Factors: worsen sarcopenia

Cruz-Jentoft AJ, et al. Age and Ageing 2019.

Low muscle mass

Low strength

Sarcopenia

Low physical performance

Cruz-jentoft A, et al. Age Ageing. 2010.

Sarcopenia

Cruz-Jentoft AJ, et al. Age and Ageing 2019.

European Working Group on Sarcopenia in Older People (EWGSOP)

Limpawattana A, et al. Osteoporosis and Sacopenia 2015.

Asian Working Group of Sarcopenia

Cruz-Jentoft AJ, et al. Age and Ageing 2019.

Chair stand test: > 15s for 5 rises

Timed-up-and-go test (TUG):> 20s

European Working Group on Sarcopenia in

Older People

Factors: worsen sarcopenia

Cruz-Jentoft AJ, et al. Age and Ageing 2019.

คมอเยยมบานผสงอาย. ราชวทยาลยเวชศาสตรครอบครวแหงประเทศไทย

www.thaifammed.org

ธงโภชนาการผสงอาย

Medication-related anorexia & weight loss

Anorexia

• Digoxin

• Theophylline

• Antibiotic

• Levodopa

Sedation

• Anticholinergic

• Benzodiazepine

• Opiate

Impaired taste buds

• Metronidazole

• Metformin

• ACEI

• Ca blocker

• Ferrous

Huffman GR. Am Fam Physician 2002.

Side effects: older adults in primary care

Merel SE, et al. J Am Geriatr Soc 2017.Parham K, et al. J Am Geriatr Soc 2016.

Warle-van Herwaarden M, et al. Br J Clin Pharmacol 2015.

Upper gastrointestinal event: risk groups

Proton pump inhibitors (PPIs): Percentage

M. Warle-van Herwaarden et al. Br J Clin Pharmacol 2015.

Acid-inhibiton: related adverse event

Kinoshita Y. J Neurogastroenterol Motil 2018.

Acid-inhibiton: unrelated adverse event

Kinoshita Y. J Neurogastroenterol Motil 2018.

Balancing advantages & disadvantages PPI

Kinoshita Y. J Neurogastroenterol Motil 2018.

Farrell B, et al. Can Fam Physician 2017.

MedicationsNon-adherence: 31.3%Drug-drug interactions: 59.1%

Epperly T, et al. Am Fam Physician 2017Gill SS, et al. Arch Intern Med 2005.

Grimmer T, et al. J Am Geriatr Soc 2018.

Medications: cognitive impairment

All medications

• adherance

Hypertension

• Target

• Orthostatic hypotension

Diabetes

• Target

• Hypoglycemia

Cognitive adverse effects

• Anticholinergic

• Benzodiazepine

• Antipsychotic

Cognitive-enhancing

• Monitor adverse events

Lee L, et al. Can Fam Physician 2018.

Thompson W, et al. J Am Geriatr Soc 2019.

Deprescribing tools: Frail older persons

STOPPFrail

Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy

Without indication or poor compliance

25 medications• Musculoskel: calcium, antiresorptive,

NSAIDs• Hormone: estrogen, corticosteroids• Infection: prophylactic antibiotics• Supplement: multivitamin, nutritional

supplement

• CVD: lipid-lowering, alpha-blockers (HT), oral diabetes, ACE-inh, ARB

• Neuro: neuroleptics, memantin, muscarinic antagonists

• GI: PPIs, H2-blocker, antispasmodic• GU: 5-alpha-reductase inh, alpha-1-

selective blockers• Resp: theophylline, leukotriene antagonist Lavan AH, et al. Age Ageing 2017.

Health promotionHealthy aging, geriatric assessment, immunization

Chronic diseases Function, life expectancy, preferenceAppropriate target goals

Geriatric syndromeSarcopenia, optimized medication

Take home messages