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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

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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

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Page 1: 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

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

Page 2: 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 )

Page 3: 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

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

Page 4: 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

-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

Page 5: 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

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

Page 6: 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

Family History:

Page 7: 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

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

Page 8: 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• Introduction• Geriatric syndrome• Functional assessment• Summary

Page 9: 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

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 )

Page 10: 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

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

Page 11: 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

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 )

Page 12: 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

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,

Page 13: 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

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

Page 14: 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

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 )

Page 15: 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

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

Page 16: 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• Introduction• Geriatric syndrome• Functional assessment• Summary

Page 17: 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

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

Page 18: 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

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

Page 19: 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

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

Page 20: 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

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

Page 21: 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

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

Page 22: 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

Juan F. Gallegos-Orozco ,Chronic constipation in the Elderly Am J Gastroenterol 2012

Page 23: 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

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

Page 24: 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

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

Page 25: 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• Introduction• Geriatric syndrome• Functional assessment• Summary

Page 26: 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

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

Page 27: 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

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.

Page 28: 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

Aims of Geriatric care

• Maintain function: diagnosis and treatment• Maintain self care

Function= ability + motivation + opportunity

功能 = 能力 + 動機 + 機會

Page 29: 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

AbilityMotivation Motivation

Opportunity

Page 30: 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

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

Page 31: 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

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

Page 32: 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

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

Page 33: 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

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

Page 34: 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

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

Page 35: 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

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

Page 36: 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

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

Page 37: 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

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

Page 38: 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

Short Physical Performance Battery-1

SPPB

• Balance: modified Romberg– Side by side, – Semi-

tandem stand

– Tandem stand

• Walking speed• Chair rise test

Page 39: 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

Short Physical Performance Battery-2

SPPB

• Balance: modified Romberg– Side by side, – Semi-tandem

stand– Tandem

stand• Walking speed• Chair rise test

Page 40: 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

Hirth V: Case-based Geriatrics: a global approach. 2011

Page 41: 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

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

Page 42: 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

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

Page 43: 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

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

Page 44: 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

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

Page 45: 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

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

Page 46: 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

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

Page 47: 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• Introduction• Geriatric syndrome• Functional assessment• Summary

Page 48: 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

Conclusion Level 3:

DEEPIN

Level 2:CognitiveAffectiveMobilityNutritional

Level 1: MobilityNutrition