1. Lt. Col. Asst. Prof. Patsri Srisuwan
Comprehensive care
for the elderly
Lt. Col. Asst. Prof. Patsri Srisuwan

2. Objectives To realize common aging process and presentation
To apply comprehensive geriatric assessment in in the real practice
To develop holistic geriatric care

3. Outline Principle of care Comprehensive geriatric assessment
Holistic geriatric care
Take home messages

4. Aging Constellation of deteriorative changes Loss of homeostasis
Structure
Function
Loss of homeostasis
Increase in the probability of death
Troen BR, et al. Case-based geriatrics 2011;7-20.

5. Aging families Stage 7-8 in family life cycle Adapt to
Physiological change
Dependence status
Anticipate loss
Spouse, friends and society

6. RAMPS R: reduce body reserve A: atypical presentation
M: multiple pathology
P: polypharmacy
S: social adversity

7. Geriatric syndromes กลุ่มอาการผู้สูงอายุ (big I’s) instability
immobility
incontinence
intellectual impairment
Iatrogenesis
Inanition

8. Age-related laboratory variations
Increased change
FBS T3
TSH
Vasopressin
No significant change
BUN Ca
Cortisol
Free thyroxine
GH, LFT
Hb/Hct, MCV
Plt, WBC
Decreased change
Aldosterone
Androgens
Angiotensin II
FSH LH
PTH
Ferri FF. Practical guides to the care of the geriatric patient 2009.;1-16.

10. ขั้นตอนการตรวจสุขภาพ
พัฒน์ศรี ศรีสุวรรณ. คลินิก 2559.

11. แนวทางการตรวจสุขภาพที่จำเป็นและเหมาะสมสำหรับประชาชน 2559

13. Independent Assistance Dependent
ADLs
Basic
Formal
Katz Barthel
Informal (DEATH)
Dressing
Eating
Ambulation
Toileting
Hygiene
Instrument
Lawton
Informal (SHAFT)
Shopping
House keeping
Accounting
Food preparation
Transportation
Independent
Assistance
Dependent

14. Geriatric Assessment Vital signs: BP, HR Ht, BW Cognition Eye: Vision
Hearing
Malnutrition
Depression
Incontinence
Mobility

15. Lanier JB, et al. Am Fam Physician 2011.
Blood pressure
Measure
Both side:
10% SBP difference > 10 mmHg
pulse rate: atrail fibrillation
Variability (Day: 50%)
White-coat effect
Postprandial hypotension (2 hrs)
Lanier JB, et al. Am Fam Physician 2011.

16. Orthostatic hypotension
Measure
BP: standing/sitting or supine, 1& 3 mins
BP changes: SBP < 20 mmHg, DBP <10 mmHg
HR changes
Compensatory tachycardia
>30/min: first sign

17. Orthostatic hypotension
Compensatory tachycardia
Yes
Drug
Anticho, antiHT/angina
Dehyrdate
Diuresis, anorexia
Defunctional heart
Low EF, AS
Deconditioning
Bed rest, low BMI No
B-blocker
Autonomic dysfunction
DM, hypothy, PD
MacDonald J, et al. CGS Journal of CME 2016.

18. Blood pressure Hypertension with out end organ damage
White coat hypertension
Pseudohypertension
Osler maneuver
Messerli FH, et al.
N Engl J Med 1985.

20. Cognition Three-item recall after 1 min Mini-Cog
Clock drawing test:
Borson S, et al. Int J Geriatr Psychiatry 2000;15:

21. Mini-Cog Three-item recall 0/3 1-2 /3 3/3 DEMENTED NONDEMENTED
Normal
Abnormal
DEMENTED
NONDEMENTED
Borson S, et al. Int J Geriatr Psychiatry 2000;15:

22. Malnutrition Women Men Mindex = BW (kg)/demi-span (m)
< 55.95
Men
Demiquet = BW (kg)/demi-span (m)2
< 75.6

23. Strategies พัฒน์ศรี ศรีสุวรรณ. คลินิก 2559. Aspects Examples S
Screening
Comprehensive geriatric assessment I
Immunization
Recommended vaccines C
Chemoprophylaxis
Aspirin for high risk of CVD A
Advice/counseling
(SNAP+MIDS)
S: smoking
N: nutrition
A: alchohol use
P: physical activity
M: medication
I: injury
D: dental
S: safe sex
พัฒน์ศรี ศรีสุวรรณ. คลินิก 2559.

25. Multidisciplinary team
Holistic care for the elderly
Community
Multidisciplinary team
Health care systems
Resources
Supports
Family & caregivers
Bio, psycho, social, spiritual aspects
Care to patient
Caregiver burden
Financial strain
Person
Functional status
Quality of life
Health promotion & prevention
Rakel R, et al. Principles of Family Medicine 2007: 1-14

26. Epidemiology Prevalence 30-40% Recurrent Hip Fx: mortality 20-30%
60-70%
Hip Fx: mortality
20-30%
Rubentein LZ, et al. Clin Geriatr Med 2002.
Moncada L. Am Fam Physician 2011.

27. Panel on prevention of falls in older persons AGS & BGS.
History
Injuries
Detail
Pre symptom
Event
Previous falls
Panel on prevention of falls in older persons AGS & BGS.
J Am Geriatr Soc 2011.

28. Precipitating factors
Fall
accidental
spontaneous
Extrinsic factors
Intrinsic factors
Precipitating factors

29. Extrinsic risk factors
Environment
Unsafe
Activities
Inappropriate

30. Intrinsic risk factors
Central processing: cognition
Sensory input: vision, vestibular, proprioception
Cardiovascular diseases: arrhythmia
Orthostatic hypotension: 10-30%
Medication: HT, anticholinergic
Musculoskeletal: arthalgia, feet

31. Precipitating factors
Infection: UTI
Metabolic: hypo/hyper glycemia
Electrolyte: hypo Na, K
Hypoxia: CHF

32. Management
Injuries
Risk
Osteoporosis
Prevention

33. Fall prevention Exercise Medication: avoid Environment Vision
Strengthening & balance training
Medication: avoid
Anticholinergic drugs
Sedative drugs
Environment
Safety
Vision
Correct vision

34. Anticholinergic drugs
Category
Example
antihistamines
Chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine
H2 histamine blockers
Cimetidine, ranitidine
tricyclic antidepressants
Amitryptyrine, imipramine
antipsychotics
Chlorpromazine, clozapine, olanzapine
antiparkinsonians
Benztropine, trihexyphenydyl
muscle relaxants
Orphenadrine
antiemetics
Dimenhydrinate
gastrointestinal/urinary/antispasmodic
Atropine, hyoscyamine, oxybutynin, tolterrodine
Seritan A. Current Psychiatry 2008.

35. Indications for Geriatric home assessment
Falls
Immobility
Bereavement
Suspected abuse
Caregiver burnout
Terminally ill patients
Chronically ill patients
Poor therapeutic response
Multiple medical problems
Refusal of office visits or treatment
Rabin DL et al. Community options for elderly patients 1995.

36. INHOMESSS for the elderly
Assessment
Immobility
BADLs(Barthel index), IADLs(Lawton), fall
Nutrition
BMI,MNA, food frequency & amount questionnaires (FAQ)
Home environment
Home for the elderly
Other people
Family genogram, Zarit Burden Interview
Medication
Drug, vitamin, herb, Beer criteria
Examination
Comprehensive Geriatric Assessment
Safety
Home safety (fall)
Spiritual health
FICA (faith, importance, community, address)
Services
Health care access, resources

37. Prevention of dementia
Patsri Srisuwan. Prevention of dementia through modifiable risk factors 2015.

39. References
McDaniel SH, Campell TL, Hepworth J, Lorenz A. Family-Oriented Primary Care. 2nd ed. New York: Springer, 2005:28-42.
Jogerst GJ, Wilbur JK. Care of the Elderly. In Rakel RE, editor. Text book of Family Medicine.7th ed. Philadelphia: Saunders Elsevier; 2007:
Srisuwan P. Primary Prevention of Dementia: Focus on Modifiable Risk Factors. J Med Assoc Thai 2013;96(2):251-8.
Collins LG. Caregiver Care. Am Fam Physician 2011;83(11):
Pereles L. Home visits: An access to care issue for the 21st century. Can Fam Physician 2000;46:
Fun WS. Management update on functional decline in older adults 2012: Physical function. Journal of The Singapore Family Physician 2012;38(1):8- 17.
Active Ageing A Policy Framework. World Health Organization: Noncommunicable Disease Prevention and Health Promotion Department Ageing and Life Course (online).2002