compre care elderly

Comprehensive care for the elderlyLt. Col. Asst. Prof. Patsri Srisuwan

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

1. Principle of care2. Comprehensive geriatric assessment3. Holistic geriatric care4. Take home messages

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

¨Stage 7-8 in family life cycle¨Adapt to ¤Physiological change ¤Dependence status ¤Anticipate loss nSpouse, friends and society

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

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

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

Prepare Address Involve Recognize Plan patient family emotion•  Time first •  Elderly•  Place •  Early in •  Elderly •  Family•  Communi •  Autonomy patient’s •  Family •  Separate care cation problems •  Role & perspec tiveMcDaniel SH, et al. Family-Oriented Primary Care 2005:242-60.

ข2นั ตอนการตรวจสุขภาพพฒั นศ์ รี ศรีสุวรรณ. คลินิก 2559.

แนวทางการตรวจสุขภาพที9จาํ เป็นและเหมาะสมสาํ หรบั ประชาชน 2559



ADLsIndependentAssBiassitcance InstrumentFoDrmealpenI(dnDfEeoArnmTHta)l Formal Informal (SHAFT) Katz Dressing Lawton Shopping Barthel Eating House keeping Ambulation Toileting Accounting Hygiene Food preparation Transportation

• Vital signs: BP, HR• Ht, BW• Cognition• Eye: Vision• Hearing• Malnutrition• Depression• Incontinence• Mobility

Blood pressure¨ Measure ¤Both side: n10% 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.

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

Orthostatic hypotension Compensatory tachycardia Yes NoDrug Dehyrdate Defunctional Deconditioning Drug Autonomic heart dysfunction Anticho, Diuresis, Low EF, AS Bed rest, low B-blocker DM, hypothy,antiHT/angina anorexia BMI PD MacDonald J, et al. CGS Journal of CME 2016.

Blood pressure¨Hypertension with out end organ damage 1. White coat hypertension 2. Pseudohypertension nOsler maneuver Messerli FH, et al. N Engl J Med 1985.

Type SBP (mmHg) DBP (mmHg)Office > 140 > 90Home > 135 > 85ElderlyAge (years)60-79 140-150 90>80 150 902013 ESH/ESC guidelines Thai Clinical Practice Guideline for HT 2015.

Cognition¨Three-item recall after 1 min¨ Mini-Cog ¤Three-item recall after 1 min ¤Clock drawing test: 11.10 Borson S, et al. Int J Geriatr Psychiatry 2000;15:1021-27

NONDEMENTEDAbnormal Normal NONDEMENTEDBorson S, et al. Int J Geriatr Psychiatry 2000;15:1021-27

Malnutrition¨Women ¤Mindex = BW (kg)/demi-span (m) n< 55.95¨Men ¤Demiquet = BW (kg)/demi-span (m)2 n< 75.6

Aspects ExamplesS Screening Comprehensive geriatric assessmentI Immunization Recommended vaccinesC Chemoprophylaxis Aspirin for high risk of CVDA Advice/counseling S: smoking (SNAP+MIDS) N: nutrition A: alchohol use P: physical activity M: medication I: injury D: dental S: safe sex พฒั นศ์ รี ศรีสุวรรณ. คลนิ ิก 2559.



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

Rubentein LZ, et al. Clin Geriatr Med 2002. Moncada L. Am Fam Physician 2011.

HistoryInjuries Detail Pre Event Previoussymptom fallsPanel on prevention of falls in older persons AGS & BGS. J Am Geriatr Soc 2011.

Fallaccidental spontaneousExtrinsic Intrinsic Precipitatingfactors factors factors

Extrinsic risk factors Environment Unsafe Activities Inappropriate

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

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

Management¨Injuries¨Risk¨Osteoporosis¨Prevention

Fall prevention¨ Exercise ¤ Strengthening & balance training¨ Medication: avoid ¤ Anticholinergic drugs ¤ Sedative drugs¨ Environment ¤ Safety¨ Vision ¤ Correct vision www.hitap.net

Category Exampleantihistamines Chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzineH2 histamine blockers Cimetidine, ranitidinetricyclic antidepressants Amitryptyrine, imipramineantipsychotics Chlorpromazine, clozapine, olanzapineantiparkinsonians Benztropine, trihexyphenydylmuscle relaxants Orphenadrineantiemetics Dimenhydrinategastrointestinal/urinary/antispasmodic Atropine, hyoscyamine, oxybutynin, tolterrodineSeritan A. Current Psychiatry 2008.

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.

Immobility AssessmentNutrition BADLs(Barthel index), IADLs(Lawton), fall BMI,MNA, food frequency & amount questionnairesHome environment (FAQ)Other people Home for the elderlyMedication Family genogram, Zarit Burden InterviewExamination Drug, vitamin, herb, Beer criteriaSafety Comprehensive Geriatric AssessmentSpiritual health Home safety (fall)Services FICA (faith, importance, community, address) Health care access, resources

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

www.hitap.net/

¨ 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; 2007:67-105.¨ 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):1309-17.¨ Pereles L. Home visits: An access to care issue for the 21st century. Can Fam Physician 2000;46:2044-48.¨ 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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