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Lt. Col. Asst. Prof. Patsri Srisuwan
Comprehensive care for the elderly Lt. Col. Asst. Prof. Patsri Srisuwan
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Objectives To realize common aging process and presentation
To apply comprehensive geriatric assessment in in the real practice To develop holistic geriatric care
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Outline Principle of care Comprehensive geriatric assessment
Holistic geriatric care Take home messages
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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.
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Aging families Stage 7-8 in family life cycle Adapt to
Physiological change Dependence status Anticipate loss Spouse, friends and society
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RAMPS R: reduce body reserve A: atypical presentation
M: multiple pathology P: polypharmacy S: social adversity
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Geriatric syndromes กลุ่มอาการผู้สูงอายุ (big I’s) instability
immobility incontinence intellectual impairment Iatrogenesis Inanition
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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.
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ขั้นตอนการตรวจสุขภาพ
พัฒน์ศรี ศรีสุวรรณ. คลินิก 2559.
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แนวทางการตรวจสุขภาพที่จำเป็นและเหมาะสมสำหรับประชาชน 2559
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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
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Geriatric Assessment Vital signs: BP, HR Ht, BW Cognition Eye: Vision
Hearing Malnutrition Depression Incontinence Mobility
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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.
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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
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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.
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Blood pressure Hypertension with out end organ damage
White coat hypertension Pseudohypertension Osler maneuver Messerli FH, et al. N Engl J Med 1985.
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Cognition Three-item recall after 1 min Mini-Cog
Clock drawing test: Borson S, et al. Int J Geriatr Psychiatry 2000;15:
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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:
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Malnutrition Women Men Mindex = BW (kg)/demi-span (m)
< 55.95 Men Demiquet = BW (kg)/demi-span (m)2 < 75.6
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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.
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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
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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.
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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.
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Precipitating factors
Fall accidental spontaneous Extrinsic factors Intrinsic factors Precipitating factors
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Extrinsic risk factors
Environment Unsafe Activities Inappropriate
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Intrinsic risk factors
Central processing: cognition Sensory input: vision, vestibular, proprioception Cardiovascular diseases: arrhythmia Orthostatic hypotension: 10-30% Medication: HT, anticholinergic Musculoskeletal: arthalgia, feet
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Precipitating factors
Infection: UTI Metabolic: hypo/hyper glycemia Electrolyte: hypo Na, K Hypoxia: CHF
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Management Injuries Risk Osteoporosis Prevention
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Fall prevention Exercise Medication: avoid Environment Vision
Strengthening & balance training Medication: avoid Anticholinergic drugs Sedative drugs Environment Safety Vision Correct vision
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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.
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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.
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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
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Prevention of dementia
Patsri Srisuwan. Prevention of dementia through modifiable risk factors 2015.
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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
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