เครื่องมือและแบบประเมินใน คลินิกผู้สูงอายุ รศ.นพ. ประเสริฐ อัสสันตชัย สาขาวิชาเวชศาสตร์ผู้สูงอายุ ภาควิชาเวชศาสตร์ป้องกันและสังคม คณะแพทยศาสตร์ศิริราชพยาบาล

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

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

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

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

Prevalence of chronic diseases among the Thai elderly Health System Research Institute 1998 age group 60-69 70-79 80-89 > 90 Knee arthralgia 22.9 26.1 20.8 Low back pain 16.5 17.9 17.7 10.4 Hypertension 14.9 15.0 14.6 6.2 Vision problem 10.2 14.4 16.7 Diabetes mellitus 10.0 7.0 3.1 2.1 Ischemic heart dis. 2.0 4.7 4.2 Stroke 1.7 2.2 3.8 Dementia 1.6 2.4 3.5

Chronic diseases influenced long term disability Chronic diseases influenced long term disability Health System Research Institute 1998 Odds ratio AR* Pop.AR** Accident -- 421 217.2 Stroke 16.89 788 190.7 Eye disease 1.93 152 182.9 Knee pain 1.81 76 179.9 Hypertension 1.50 112 166.0 * AR: attributable risk , ** Pop.AR : population attributable risk

Mortality rate of diseases among the Thai Elderly (per 105) Health Policy and Planning Institute 2000 60-74 yr. > 75 yr. rate YLL* Circulatory dis. 574 452567 1936 376946 Cancer 564 461888 897 89321 Diabetes mellitus 213 178984 348 56542 COPD 209 159142 920 162844 GI diseases 114 94674 301 57937 YLL : year of life lost – number of years lost due to premature death

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

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

Comprehensive geriatric assessment Physical assessment Mental assessment Social assessment Functional assessment

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 ?

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

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

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 - 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

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 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 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 - 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

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 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

สาเหตุที่เป็นเรื้อรัง Urinary Incontinence สาเหตุที่เกิดขึ้นฉับพลันและอาจหายขาดได้ สาเหตุที่เป็นเรื้อรัง

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

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

ภาวะทุโภชนาการในผู้สูงอายุ MEALS 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)

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

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) 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 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 http://www.si.mahidol.ac.th/project/geriatrics/Research/research2.htm

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 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

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 ??