6 Prevalence of chronic diseases among the Thai elderly Health System Research Institute 1998 age group60-6970-7980-89> 90Knee arthralgia22.926.120.8Low back pain16.517.917.710.4Hypertension14.915.014.66.2Vision problem10.214.416.7Diabetes mellitus10.07.03.12.1Ischemic heart dis.2.04.74.2Stroke18.104.22.168Dementia22.214.171.124
7 Chronic diseases influenced long term disability Chronic diseases influenced long term disability Health System Research Institute 1998Odds ratioAR*Pop.AR**Accident--421217.2Stroke16.89788190.7Eye disease1.93152182.9Knee pain1.8176179.9Hypertension1.50112166.0* AR: attributable risk , ** Pop.AR : population attributable risk
8 Mortality rate of diseases among the Thai Elderly (per 105) Health Policy and Planning Institute 200060-74 yr.> 75 yr.rateYLL*Circulatory dis.5744525671936376946Cancer56446188889789321Diabetes mellitus21317898434856542COPD209159142920162844GI diseases1149467430157937YLL : year of life lost – number of years lost due to premature death
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 testCategorical scale & scoring< 10 sec. = freely mobile< 20 sec. = mostly independent20-29 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 stepMagnetic gait, slipping clutch syndromeDDx : Alzheimer’s disease, Vascular dementia, NPH
16 Abnormal Gait in Old Age Sensory Ataxic GaitWide-based, foot stamping walk with high stepping due to loss of proprioceptive input, constantly observe the foot positionRomberg’s sign positiveDDx : 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 drunkAbnormal tandem gait, en bloc turningPoor coordination: proprioceptive, labyrinthine, visualDDx: vestibular damage, stroke, chronic alcoholism, progressive supranuclear 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 hemianopiaParalegia (scissoring gait)- Cervical spondylitic myolopathy, Subacute combined degeneration of spinal cord, chronic cord compression, lacunar infarcts
19 Steppage gait Festinating Gait Lifting the feet hight off the ground due to foot drop (pretibial, peroneal muscle weakness)DDx: peripheral neuropathy, prolonged pressure, DM, alcoholism, B12 deficiencyFestinating GaitSymmetric rapid shuffling of feet, stooped posture, flexed hip and kneeCentre of gravity shifted forwardDDx: Parkinsonism, vascular dementia,hydrocephalus
20 Podalgic GaitFoot disorders: corns, calluses, in-growing toe nails, bunion, atrophy of plantar padsLoose 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 liftsDifficulty climbing stair, getting up from low-seated chairDDx: hypo/hyperthyroidism, polymyositis, osteomalacia, proximal myopathy
22 Urinary incontinence - Urine secretion - 100 ml / hour - Fullness ml- Normal bladder capacity ml- Discomfort ml- Desperate or desire to micturate ml- Bladder pressure < 15 cm of water- Postvoid residual volume < 100 ml
25 Causes of Acute & Reversible Forms of Urinary Incontinence D DeliriumR Restricted mobility, RetentionI Infection*, Inflammation*, Impaction (fecal)P Polyuria**, Pharmaceuticals* Urinary Tract Infection, Atrophic vaginitis, urethritis.** Hyperglycemia, Congestive heart failure.
26 Persistent Incontinence 1. Stress Leakage of urine (small amounts) with increases in intraabdominal pressure2. Urge Leakage of urine (larger volume) due to inability to delay voiding after sensation of fullness3. Overflow Leakage of urine (small amounts) from urinary retention4. 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. Stress Pelvic floor, Bladder outlet or Urethral sphincter weakness2. Urge Overactive bladder, Detrusor hyperreflexia due to Cystitis, Urethritis, Tumor, Stone, Diverticuli,Stroke, Dementia, Parkinsonism, Suprasacral spinal cord injury3. Overflow Obstruction by Prostate, Stricture, CystoceleDM, spinal cord injuryDetrusor-sphincter dyssynergy4. Functional severe dementia, depression, impaired mobility, environmental barriers
28 การประเมินภาวะโภชนาการในผู้สูงอายุ ขาดอาหารBMI < 18.5การเปลี่ยนแปลงของน้ำหนักตัวอาหารเกินBMI > 22.9เส้นรอบพุง abdominal circumference90 cm. ในชาย 80 cm. ในหญิง
29 ภาวะทุโภชนาการในผู้สูงอายุ MEALS ON WHEELS M: medicationsE: emotional (depression)A: alcoholism, anorexia, abuse of the eldersL: late-life paranoiaS: swallowing problems (dysphagia)O: oral problemsN: no money (poverty)
30 W: wandering and other dementia-related problems H: hyperthyroidism, pheochromocytomaE: enteric problems (malabsorption)E: eating problemsL: low salt, low cholesterol dietS: shopping and meal preparation problems3 common causes: malignancy depression GI problems
32 Comprehensive geriatric assessment Mental assessmentAbbreviated mental test (AMT)Standard mental testsThai Mental State Examination (TMSE)Chula Mental Test (CMT)Mini Mental State Examination-Thai 2002Pay attention to recent loss of mind and family member !!
33 Abbreviated Mental Test. Age. Time (to the nearest hour) 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 1Scoring: 0-3 severe, moderate, normal
34 Screening for depression In practice: ask 2 questionsOver 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
36 Comprehensive geriatric assessment Social assessment - relationship in familyCaregiver : aware of elder abuse in dementiaPhysical abuseCaring abuse : nutrition, drug compliance, pressure ulcer, incontinence, instrumentationFinancial : family support, welfareEnvironment : housing, neighbor, elderly club, communityPay attention to living alone, poor !!
37 Comprehensive geriatric assessment Functioal assessmentBasic activity of daily living (basic ADL): transfer, mobility, toilet use, grooming, urine, stool, bathing, dressing, eating, stairingInstrumental activity of daily living (iADL): washing & cleaning, cooking, shopping, financial, transport & communication, drug usePay attention to recent loss of ADL !!