ดาวน์โหลดงานนำเสนอ
งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ
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เครื่องมือและแบบประเมินใน คลินิกผู้สูงอายุ
รศ.นพ. ประเสริฐ อัสสันตชัย สาขาวิชาเวชศาสตร์ผู้สูงอายุ ภาควิชาเวชศาสตร์ป้องกันและสังคม คณะแพทยศาสตร์ศิริราชพยาบาล
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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
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Philosophy in Preventive Geriatrics
Primary prevention (Health promotion) Secondary prevention Tertiary prevention
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Action Plan in Preventive Geriatrics
Comprehensive geriatric assessment Appropriate intervention and monitoring (according to the findings in assessment)
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Comprehensive geriatric assessment
Physical assessment Mental assessment Social assessment Functional assessment
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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 ?
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Geriatric Giants - atypical presentation
Instability (Fall) Immobility Intellectual impairment Incontinence Inanition Iatrogenesis
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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
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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 Normal pressure hydrocephalus
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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
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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, thiamin deficiency chronic alcoholism, progressive supranuclear palsy, hypothyroidism, drug intoxication
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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
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Steppage gait Lifting the feet hight off the ground due to foot drop (pretibial, peroneal muscle weakness) DDx: (peroneal nerve injury) Lumbar disc herniation(L4, L5, S1), Sciatic nerve trauma, spondylolisthesis, spinal stenosis, spinal cord injury, bone fractures (leg, vertebrae), stroke, tumor, DM, prolonged pressure
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Festinating Gait Symmetric rapid shuffling of feet,
stooped posture, flexed hip and knee Centre of gravity shifted forward DDx: Parkinsonism, vascular dementia, hydrocephalus
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Podalgic Gait Foot disorders: corns, calluses, in-growing toe nails, bunion, atrophy of plantar pads Loose or tight-fitting footwear
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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
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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
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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
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สาเหตุที่เป็นเรื้อรัง
Urinary Incontinence สาเหตุที่เกิดขึ้นฉับพลันและอาจหายขาดได้ สาเหตุที่เป็นเรื้อรัง
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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.
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Persistent Incontinence
Stress Leakage of urine (small amounts) with increases in intraabdominal pressure Urge Leakage of urine (larger volume) due to inability to delay voiding after sensation of fullness Overflow Leakage of urine (small amounts) from urinary retention Functional Leakage of urine (larger volume) with inability to toilet due to impaired cognition, physical function, psychological, environmental barriers
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Causes of Persistent Incontinence
Stress Pelvic floor, Bladder outlet or Urethral sphincter weakness 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
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การประเมินภาวะโภชนาการในผู้สูงอายุ
ขาดอาหาร BMI < 18.5 การเปลี่ยนแปลงของน้ำหนักตัว อาหารเกิน BMI > 22.9 เส้นรอบพุง abdominal circumference 90 cm. ในชาย 80 cm. ในหญิง
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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)
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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
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Mini Nutrition Assessment
(MNA)
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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 !!
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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, moderate, normal
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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
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Thai Geriatric Depression Scale Train the Brain Forum
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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 !!
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Comprehensive geriatric assessment
Functional 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 !!
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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
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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 ??
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