Upload
teness
View
152
Download
0
Embed Size (px)
DESCRIPTION
長期照護個案 功能性評估與診斷 陳晶瑩醫師 臺大醫院家庭醫學部 2014/09/13. Outline. Case presentation ( 個案報告 ) Introduction( 引言 ) Geriatric syndrome( 老年症候群) Functional assessment (功能評估) Summary ( 總結 ). Present Illness. 88y/o man, underlying HT, Af ( 高血壓 , 心房顫動 ) Excellent function, totally independent. - PowerPoint PPT Presentation
Citation preview
長期照護個案功能性評估與診斷
陳晶瑩醫師臺大醫院家庭醫學部
2014/09/13
Outline
• Case presentation ( 個案報告 )• Introduction( 引言 )• Geriatric syndrome( 老年症候群)• Functional assessment (功能評估)• Summary ( 總結 )
Present Illness88y/o man, underlying HT, Af ( 高血壓 , 心房顫動 )Excellent function, totally independent
2013/11/08
- At home, seldom walk- regular OPD rehab (slowly climb 5 stairs )- use chopsticks to eat - intact communication
2014/1-2
Acute onset of L’t side weakness( 左側無力 )- Admitted on 2013/11/8- MRI: right ICA occlusion with borderzone infarction( 梗塞 )- transfer to PMR (復健科) , discharged on 2014/1/5- could walk with walker under supervision, BI: 55
-Progressive poor appetite, oral intake ↓, function ↓- dysphagia (吞嚥困難) , choking, nausea/vomiting- BW loss 20kg in 6 months- OPD visit on 2014/6/11
2014/2-6
Admission -Fever, leukocytosis 白血球增加 Tazocin- NG feeding- Chest/Abdomen CT: left lower lung abscess( 肺膿瘍 , spleen, liver microabscess (肝脾小膿瘍- improved lung abscess under Tazocin(6 wks)- discharge on 7/26- could eat porridge 、 pudding, improved transfer , walk with walker
6/12
Present Illness
OPD f/u:- try oral intake, still intermittent choking( 嗆咳 )- ever fever with CRP↑ oral Cefixime- progressive ADL↓, became maximal assistance in all transfer- sometimes confusion with irregular circadian rhythm ( 日夜顛倒 )
2014/7-8
Admitted to rehab ward for reconditioning (功能回復 )- On admission: BI: 10- under rehab. : improved transfer, walker under moderate assistance for 5m- diarrhea ( 腹瀉 )with stool WBC:2-5 Metronidazole 8/20- fever, sticky sputum( 痰液黏稠 ), WBC↑ on 8/21 Tazocin, transfer to acute ward on 8/24
8/16
Present Illness
Family History:
Problem List( 問題列表 )• Pneumonia( 肺炎 ), pseudomonas related• Dysphagia( 吞嚥困難 )/ malnutrition( 營養不良 )• Delirium( 譫妄 )• Dementia ( 失智 )? (MMSE: 22/30 專科畢 , borderline)• Depression( 憂鬱 ) ( GDS 7/15, improving• Urinary and fecal incontinence( 尿及大便失禁 )
( improving after improving )delirium • Polypharmacy( 多重用藥 ): adjusted• Functional decline, multi-factor related possible due to stroke, delirium, r/o dementia,
depression, malnutrition, deconditioning
Outline
• Case presentation• Introduction• Geriatric syndrome• Functional assessment• Summary
Characteristics of illness of elderly( 老年疾病特質 )
• Multiple illness( 多重疾病 )• Obscured illness( 潛隱疾病 )• Underreporting of illness( 未報告疾病 )• Attitude of ageism( 歸因於老化 )• Atypical presentation( 非典型表現 )• Iatrogenic medical problems( 醫源性疾病 )• Altered spectrum of health conditions( 疾病
範疇不同 )
Spectrum of care
Family medicine• Acute disease• Chronic disease• Preventive medicine• Health seeking
behavior
Geriatrics• Acute disease• Chronic disease– Cognitive– Affective– Mobility– Nutritional
• Preventive medicine• Health seeking
behavior
History taking-1
• The patient’s chief complain• The family member’s observation/concerns• Present illness• Common pathways: baseline and current
status– Consciousness( 意識 )– Appetite( 胃口 )– Mobility( 活動力 )– Continence( 失禁 )
Nonspecific symptoms that may represent specific illness
• Confusion• Apathy• Self-neglect• Anorexia(胃口不好 )• Falling• Incontinence• Dyspnea( 喘 )• Fatigue(疲倦 )
• An abrupt change in functional status is a vital sign of potential illness
Ham RJ et al: Primary Care Geriatrics 5th 2007,
History taking-2
• Past major systemic disease• Functional change( 功能變化 ( after recent or
recurrent hospitalization or Emergency Department visits or major events
• Iatrogenesis( 醫源性介入 ): time , indication and contraindication of removal
• Current medication: CDC AIDS
Chen’s polypharmacy evaulation• C: compliance( 順從性 )• D: drug list( 藥物列表 )• C: controlled status( 疾病控制狀態 )
• A: adverse effect/ interaction: ( 副作用 ) drug to drug/diagnosis• I: indications for drugs( 藥物使用適應症 )• D: drugs for diagnosis( 疾病相關治療 )• S: simplify medication: drugs, dose, frequency
( 藥物簡化 )
History taking-3
• Geriatric syndrome: DEEPIN• ADL/IADL impairment: What, When, Why• ADL: DEATH• IADL: SHAFT
• Family history: Where is the resources( 資源 )?– Family members: age, occupation, residence
relationship– Who is living together– Care aid: communication , education
Outline
• Case presentation• Introduction• Geriatric syndrome• Functional assessment• Summary
Traditional Medical Syndrome
Specific Morbid Process Multiple phenomenologies
Cortisol Excess
Moon facies
Buffalo Hump
Truncal obesity
Proximal muscle weakness
Easy bruisability
Skin thinning
OsteoporosisJAGS 2003;51(4):574-6
Geriatric SyndromeMultiple morbid process Specific phenomenology
Dementia
Dehydration
Severity of illness
Sensory impairment
Medication effects
Sleep disturbance
Older age
Delirium syndrome
JAGS 2003;51(4):574-6
Geriatric syndromes• To define complex clinical conditions that are
common in older persons• Do not fit into discrete disease or syndrome
categories• Geriatric syndrome is defined as an
accumulation of impairments in multiple systems that produces a phenotypic decline in function or independence
Cruz-Jentoft et al. Curr Opin Clin Nutr Metab Care 2010;13:1-7
JAGS 2006;54(5): 831-42
Geriatric syndromes
• multifactorial etiology, • shared risk factors with other geriatric
syndromes,• association with functional decline, • association with increased mortality
JAGS 2006;54(5): 831-42
Functional review
• D: Delirium, dementia, depression, • E: Eyes (vision impairment)• E: Ears (hearing impairment)• P: Physical performance, “phalls”(falls),
polypharmacy, pain, pressure sore• I: Incontinence/constipation,
iatrogenesis,insomnia• N:Nutrition
Geriatrics 2001;56(8):36-40, modified
Juan F. Gallegos-Orozco ,Chronic constipation in the Elderly Am J Gastroenterol 2012
Geriatric giants: the big “I”s
• Intellectual failure• Incontinence• Immobility• Instability• Iatrogenic disease• Inability to look after oneself
Nichol CG, Wilson KJ: Elderly Care Medicine 2012
Resident assessment protocols (RAP)Triggered by MDS (minimum data set)• Delirium• Cognitive loss/dementia• Visual function• Communication• ADL function/
rehabilitation• Urinary incontinence and
indwelling catheter• Psychosocial wellbeing• Mood state• Behavior symptoms
• Activities• Falls• Nutritional status• Feeding tubes• Dehydration/fluid
maintenance• Dental care• Pressure ulcers• Psychotropic drug use• Physical strain
Gallo JJ: Handbook of Geriatric Assessment 2006
Outline
• Case presentation• Introduction• Geriatric syndrome• Functional assessment• Summary
Reasons to screen for functional status
• A symptom of acute or worsening chronic illness
• Determining appropriate level of care and transition of care
• Managing acute illness and determining prognosis and treatment options
• Deciding on the intensity and effectiveness of treatment
Brief history of geriatric assessment
• Late 1930s: Marjory Warren• Who initiate the concept of specialized geriatric
assessment units while in charge of a large London infirmary
• Lack of diagnostic assessment and rehabilitation kept them disabled.
• Every elderly patient receive comprehensive assessment and an attempt at rehabilitation before being admitted to a long-term care hospital or nursing home.
Aims of Geriatric care
• Maintain function: diagnosis and treatment• Maintain self care
Function= ability + motivation + opportunity
功能 = 能力 + 動機 + 機會
AbilityMotivation Motivation
Opportunity
Functional
Self-reported tools• Basic ADL• IADL• Advanced ADL
– The vulnerable Elder 13 Survey
Performance-based instrument
• Gait speed: 1m/sec, 0.6-1/sec, 0.6m/sec
• Get-up-and-go test• SPPB ( Short physical
performance battery)• Shoulder and hand function
日常生活活動功能評估 Activity of Daily Living (ADL)
• Dressing • Eating• Ambulatory (transfer)• Toileting• Hygiene• Continence
• Bathing• Dressing• Toilet• Transfer• Continence• Eating
工具式日常生活活動功能評估 Instrumental ADL (IADL)
• Shopping• Housekeeping• Accounting• Food preparation• Transportation, Telephone• Medication• Laundry
The Vulnerable Elder 13 Survey (VES-13)
• Age 75-84 (1); >85 (3)• Self-reported health
– Fair or poor (1); Good, very good ,or excellent (0)
• Physical disability(1 for each, max 2)– Stooping, couching, or
kneeling(1)– Walking ¼ mile– Lifting 10 lb– Heavy housework– Reaching above shoulder
level– Writing or grasping small
objectives
• Functional disability ( 4 for each)– Shopping– Light housework– Finance– Walking across rooms– bathing
Assessment of Mobility in the Primary Care Setting: screening questions
Self-reported difficulty • “For health or physical
reasons, do you have difficulty climbing up 10 steps? Walking ¼ mile?”
• 爬 10 級樓梯或走 400 公尺是否有困難 ?
• 是否因健康或體能因素改變上述行動方式或頻率 ?
Report no difficulty • preclinical limitations can
be elicited by asking, • “Because of underlying
health or physical reasons, have you modified the way you climb 10 steps? Walk ¼ mile?
• Either by changing the method or frequency of these activities?” Check risk factors!
JAMA. 2013;310(11):1168-1177
Risk factors for mobility limitation
Most common
• older age,• low physical activity, • obesity,• strength or balance
impairments,• chronic diseases, such as
diabetes or arthritis
Less common
• depressive symptoms• cognitive impairment,• being female • recently hospitalized, • using alcohol or tobacco,• having feelings of
helplessness.Gait changed disease: parkinsonism cerebellar stroke JAMA. 2013;310(11):1168-
1177
Mobility/Balance• Gait:
– ask about falls and fear of falls
– Observe transfer– Timed up and go test
( positive screen: > 15”) < 10”:freely movable <20”: mostly independent 20-29”:variable mobility >29”: impaired mobility
• Balance: modified Romberg– Side by side, – Semi-tandem stand– Tandem stand
• Chair rise test• Shoulder function
– Behind head– Behind waist
• Hand function– Grasp– pinch
Hirth V: Case-based Geriatrics: a global approach. 2011
Timed up and go test
Ask the patient to• Standing up from a chair• Stand still momentarily• Walk 10 feet (3 meter)• Turn around and walk back
to chair
Factors to note• Sitting balance• Imbalance with immediate
standing• Pace and stability of walking• Excessive truncal sway and
path deviation• Ability to turn without
staggering• Observe and time the
patient
Short Physical Performance Battery-1
SPPB
• Balance: modified Romberg– Side by side, – Semi-
tandem stand
– Tandem stand
• Walking speed• Chair rise test
Short Physical Performance Battery-2
SPPB
• Balance: modified Romberg– Side by side, – Semi-tandem
stand– Tandem
stand• Walking speed• Chair rise test
Hirth V: Case-based Geriatrics: a global approach. 2011
Mobility disability
• the gap between an individual’s– physical ability(eg, muscle strength or balance) – environmental challenges such as walking
outdoors on uneven surfaces.
• range from– preclinical (ie, the limitation only exists in highly
challenging environments) to – severe (as occurs among bedbound individuals)
JAMA. 2013;310(11):1168-1177
Mobility and assessment
Assessment of mobility• a person’s ability to transfer
from bed or chair,• Walk ¼ mile• climb stairs independently
• the distance a person can trave laway from home with or without assistance.
mobility
Physical ability to walk or move
A person’s environment
Ability to adopt
Life space
JAMA. 2013;310(11):1168-1177
Risk factor or screening positive• Obtain additional history regarding changes in
mobility• Identify physical, social, and environmental
components that lead to mobility limitations and• refer to appropriate clinician• Review for medications that may affect strength,
balance, gait, mental status, or have other central nervous system effects
• Perform physical examination including gait speedAcute medical condition thatleads to impaired mobility detected?
JAMA. 2013;310(11):1168-1177
Drug-related disability
Over treatment• Mobility: EPS, muscle
relaxants, • Dizziness: postural
hypotension, BZD• hyponatremia: diuretics,
SSRI• Sleepy/sedative: hypnotics,
TCA
Under treatment• Pain
– Arthitis– Compression fracture
• Osteoporosis• PAOD• Dyspnea: CAD• Anemia• Depression
Common causes of immobility in older adults
• Musculoskeletal disorder( 骨關節疾病 )– Arthritis, osteoporosis, fractures, podiatric
• Neurological disorder( 神經性疾病 )– Stroke, Parkinson disease, hydrocephalus, dementia
• Cardiovascular disease( 心血管疾病 )– CHF, CAD, PAOD
• Pulmonary disease: COPD( 肺部疾病 )• Sensory factors( 感官疾病 )• Environmental causes( 環境因素 )
– Forced immobility, inadequate aid, pain• Others( 其他 )
– Deconditioning, malnutrition, depression, drugs ( 失用 , 營養不良 , 憂鬱 , 藥物 )
Kane RL et al: Essential of Clinical Geriatrics. 2013
Rehabilitation
Principle• Strength: resistance
exercise• Balance: balance exercise• Environmental barrier• Social barrier to mobility
Physical therapy• Relieve pain• Evaluate ROM• Improve strength,
endurance, motor skills and coordination
• Improve gait and stability• The need of assistive device
JAMA. 2013;310(11):1168-1177 Kane RL et al: Essential of Clinical Geriatrics. 2013
Outline
• Case presentation• Introduction• Geriatric syndrome• Functional assessment• Summary
Conclusion Level 3:
DEEPIN
Level 2:CognitiveAffectiveMobilityNutritional
Level 1: MobilityNutrition