Prevalence of chronic diseases among the Thai elderly Health System Research Institute 1998 age group > 90 Knee arthralgia Low back pain Hypertension Vision problem Diabetes mellitus Ischemic heart dis Stroke Dementia
Chronic diseases influenced long term disability Health System Research Institute 1998 Odds ratioAR * Pop.AR ** Accident Stroke Eye disease Knee pain Hypertension * AR: attributable risk, ** Pop.AR : population attributable risk
Mortality rate of diseases among the Thai Elderly (per 10 5 ) Health Policy and Planning Institute yr.> 75 yr. rateYLL * rateYLL * Circulatory dis Cancer Diabetes mellitus COPD GI diseases YLL : year of life lost – number of years lost due to premature death
Action Plan in Preventive Geriatrics Comprehensive geriatric assessment Appropriate intervention and monitoring (according to the findings in assessment)
Comprehensive geriatric assessment Physical assessment Physical assessment Mental assessment Mental assessment Social assessment Social assessment Functional assessment Functional assessment
Comprehensive geriatric assessment Physical assessment 1)History of fall, incontinence 2)Pain assessment 3)Drug history: polypharmacy! 4)Nutritional history 5)Life-style: smoke, drink, exercise, aids & appliances 6)Vaccinations : influenza, tetanus, pneumococcal ?
Innovation in “Get-up-and-go-test Timed 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 Categorical scale & scoring < 10 sec. = freely mobile < 20 sec. = mostly independent sec. = variable mobility > 29 sec. = impaired mobility
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 disease, Vascular dementia, NPH DDx : Alzheimer’s disease, Vascular dementia, NPH
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
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, progressive supranuclear palsy, thiamin deficiency, hypothyroidism, drug intoxication
Spastic Gait Hemiplegia - Stiff, flexed hip, extended knee, plantar-flexed foot - Stiff, flexed hip, extended knee, plantar-flexed foot - Affected arm: flexed elbow across abdomen, impaired arm swing, toe scraping or dragging across the floor - Affected arm: flexed elbow across abdomen, impaired arm swing, toe scraping or dragging across the floor - Visual neglect or hemianopia - Visual neglect or hemianopia Paralegia (scissoring gait) - Cervical spondylitic myolopathy, Subacute combined degeneration of spinal cord, chronic cord compression, lacunar infarcts - Cervical spondylitic myolopathy, Subacute combined degeneration of spinal cord, chronic cord compression, lacunar infarcts
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
Podalgic Gait Foot disorders: corns, calluses, in-growing toe nails, bunion, atrophy of plantar pads Foot disorders: corns, calluses, in-growing toe nails, bunion, atrophy of plantar pads Loose or tight-fitting footwear Loose or tight-fitting footwear
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
Urinary incontinence - Urine secretion 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
Mechanism of Micturition T 11 T 12 L 1 L 2 S2S2 S3S3 S4S4 A B C D E Bladd er Pelvic floor A Parasympathetic cholinergic …. … Bladder contraction B Sympathetic …. ……. …….. … Bladder relaxation C Sympathetic ………….. …….. Bladder relaxation D Sympathetic ……….. ……… Bladder neck and urethral contraction E Somatic (Pudendal nerve) …... …. Contraction of pelvic floor musculature Spinal cord Hypogastri c Plexus
Causes of Acute & Reversible Forms of Urinary Incontinence D Delirium R Restricted mobility, Retention I Infection*, Inflammation*, Impaction (fecal) P Polyuria**, Pharmaceuticals * Urinary Tract Infection, Atrophic vaginitis, urethritis. ** Hyperglycemia, Congestive heart failure.
Persistent Incontinence 1. Stress Leakage of urine (small amounts) with increases in intraabdominal pressure 2. Urge Leakage 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
Causes of Persistent Incontinence 1. Stress Pelvic floor, Bladder outlet or Urethral sphincter weakness 2. Urge Overactive bladder, Detrusor hyperreflexia due to Cystitis, Urethritis, Tumor, Stone, Diverticuli,Stroke, Dementia, Parkinsonism, Suprasacral spinal cord injury 3. Overflow Obstruction by Prostate, Stricture, Cystocele DM, spinal cord injury Detrusor-sphincter dyssynergy 4. Functional severe dementia, depression, impaired mobility, environmental barriers
ภาวะทุโภชนาการใน ผู้สูงอายุ MEALS ON WHEELS M: medications M: medications E: emotional (depression) E: emotional (depression) A: alcoholism, anorexia, abuse of the elders A: alcoholism, anorexia, abuse of the elders L: late-life paranoia L: late-life paranoia S: swallowing problems (dysphagia) S: swallowing problems (dysphagia) O: oral problems O: oral problems N: no money (poverty) N: no money (poverty)
W: wandering and other dementia- related problems W: wandering and other dementia- related problems H: hyperthyroidism, pheochromocytoma H: hyperthyroidism, pheochromocytoma E: enteric problems (malabsorption) E: enteric problems (malabsorption) E: eating problems E: eating problems L: low salt, low cholesterol diet L: low salt, low cholesterol diet S: shopping and meal preparation problems S: shopping and meal preparation problems 3 common causes: malignancy depression GI problems
Mini Nutrition Assessment (MNA)
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 !!
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
Screening for depression In practice: ask 2 questions 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
Thai Geriatric Depression Scale Train the Brain Forum ct/geriatrics/Research/research2.h tm
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 !!
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 !!
Comprehensive geriatric assessment - Examination 1)Blood pressure hypertension (2 positions)postural hypotension (2 positions)postural hypotension 2)Body weight under-nutrition 3)Special sense disability, fall (VA, hearing) (VA, hearing) 4)Breast examination breast cancer 5)Get-up-and-go test fall, immobility