Transcript 投影片 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
Outline
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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
2013/11/08
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
- At home, seldom walk
- regular OPD rehab (slowly climb 5 stairs )
- use chopsticks to eat
- intact communication
Present Illness
2014/2-6
6/12
-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
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
Present Illness
2014/7-8
8/16
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)
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
Family History:
Problem List(問題列表)
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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
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Case presentation
Introduction
Geriatric syndrome
Functional assessment
Summary
Characteristics of illness of elderly
(老年疾病特質)
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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
Geriatrics
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• Acute disease
• Chronic disease
Acute disease
Chronic disease
Preventive medicine
Health seeking
behavior
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Cognitive
Affective
Mobility
Nutritional
• Preventive medicine
• Health seeking
behavior
History taking-1
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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
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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
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Case presentation
Introduction
Geriatric syndrome
Functional assessment
Summary
Traditional Medical Syndrome
Specific Morbid Process
Multiple phenomenologies
Moon facies
Buffalo Hump
Truncal obesity
Cortisol Excess
Proximal muscle weakness
Easy bruisability
Skin thinning
JAGS 2003;51(4):574-6
Osteoporosis
Geriatric Syndrome
Multiple morbid process
Specific phenomenology
Dementia
Dehydration
Severity of illness
Sensory impairment
Delirium syndrome
Medication effects
Sleep disturbance
Older age
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
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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
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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)
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Delirium
Cognitive loss/dementia
Visual function
Communication
ADL function/
rehabilitation
Urinary incontinence and
indwelling catheter
Psychosocial wellbeing
Mood state
Behavior symptoms
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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
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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
Motivation
Ability
Opportunity
Motivation
Functional
Self-reported tools
• Basic ADL
• IADL
• Advanced ADL
– The vulnerable Elder 13
Survey
Performance-based instrument
• Gait speed: 1m/sec, 0.61/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
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Bathing
Dressing
Toilet
Transfer
Continence
Eating
工具式日常生活活動功能評估
Instrumental ADL (IADL)
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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?
Check risk factors!
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?”
JAMA. 2013;310(11):1168-1177
Risk factors for mobility limitation
Most common
Less common
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older age,
low physical activity,
obesity,
strength or balance
impairments,
• chronic diseases, such as
diabetes or arthritis
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):11681177
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,
– Semitandem
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
mobility
• a person’s ability to transfer
from bed or chair,
• Walk ¼ mile
• climb stairs independently
Physical ability to
walk or move
A person’s
environment
Life space
• the distance a person can
trave laway from home with or
without assistance.
Ability to adopt
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 speed
JAMA. 2013;310(11):1168-1177
Acute medical condition that
leads to impaired mobility detected?
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
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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
JAMA. 2013;310(11):1168-1177
Physical therapy
• Relieve pain
• Evaluate ROM
• Improve strength,
endurance, motor skills and
coordination
• Improve gait and stability
• The need of assistive device
Kane RL et al:
Essential of Clinical Geriatrics. 2013
Outline
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Case presentation
Introduction
Geriatric syndrome
Functional assessment
Summary
Conclusion
Level 3:
DEEPIN
Level 2:
Cognitive
Affective
Mobility
Nutritional
Level 1:
Mobility
Nutrition