老人團隊合作照顧模式. Outline 周全性老年評估. 老人團隊照顧模式 (Geriatric interdisciplinary team care) Geriatric interdisciplinary team care

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1 Outline 老人團隊合作照顧模式 台大老年醫學部主治醫師周怡君 老人團隊照顧模式 老人團隊成員 團隊會議的要素 以老年醫學病房為例 案例討論 1 2 周全性老年評估 A multidimensional, interdisciplinary diagnostic process focusing on determining an older person s medical, psychosocial, and functional capabilities to develop a coordinated and integrated plan for treatment and long-term follow-up. Assessment, interpretation, intervention In general population: survival, QoL, physical function; hospitalization and nursing home placement QoL: quality of life J Am Geriatr Soc 39:8S-16S, 1991; discussion 17S-18S J Clin Oncol 25: Cochrane Database Syst Rev 7:CD006211, Hazzards Geriatric Medicine And Gerontology 6 th Edition 4 老人團隊照顧模式 (Geriatric interdisciplinary team care) In 1995, The American Geriatrics Society developed a position statement: 1. Interdisciplinary care meets the complex needs of older adults with multiple, interacting comorbidities. 2. Interdisciplinary care improves health care processes and outcomes for geriatric syndromes. 3. Interdisciplinary care benefits the health care system as well as caregivers of older adults. 4. Interdisciplinary training and education effectively prepares providers to care for older adults. Geriatric interdisciplinary team care Essential to manage the complex syndromes experienced by frail older adults Effective geriatric interdisciplinary team care: improvement of Functional status Perceived well-being, Mental status Depression Also: patient readmission rates numbers of physician office visits 5 6 1

2 Effective team 不同的老年周全性團隊模式 Require a structure and an understanding of group process Emphasize: Multidimensional geriatric assessment Interdisciplinary team care planning Maximization of self-care and function Self-determination in the care plan Improving quality of life Effectiveness based: The outcome of team meetings The ability of the team to address and improve the patient s and the family s needs 7 J Clin Oncol 32: 周全性老年評估的內容 病史 藥物評估 營養評估 身體評估 平衡及步態評估 認知評估與情感評估 老年症候群評估 日常生活功能評估 家庭支持及經濟評估 Hazzards Geriatric Medicine And Gerontology 6 th Edition 9 10 Often shared 2 care providers 11 Hazzards Geriatric Medicine And Gerontology 6 th Edition 老人團隊成員 醫師 護理師 / 專科護理師 社工師 復健團隊 : 復健科醫師 物理治療師 職能治療師 語言吞嚥治療師 Coordination of services Shared responsibility Communication 老年精神科醫師 臨床心理師 營養師 藥師 其他醫療專業人員 12 2

3 團隊會議的要素 (Elements of team meeting) 1. Agenda (what do we expect to accomplish?) 2. Estimated timeline for completing agenda (reasonable time frames) 3. Establishment of meeting roles. Members can and should rotate the following roles but every meeting should include: a. leader (calls meeting to order, has agenda, and sets expectations), b. timekeeper (keeps group on task), c. recorder (keeps track of agreements about the care plan and modifications and is responsible for recording changes to care plan). 4. Summary of agreements (recorder reports agreements). 5. Evaluation/reflection on team process (both team process and outcome of the meeting are discussed). 13 Also include: 1. Review meeting objectives 2. Review agenda and order of items 3. Assign timekeeper, recorder, and leader roles 4. Report follow-up from last meeting 5. Discuss issues or patients as listed on the agenda 6. Summarize action items from this meeting 7. Decide what the objectives and agenda items will be for the next meeting 8. Evaluate the meeting 14 Geriatric Interdisciplinary Team Training: The GITT Kit (2nd ed.) 15 Geriatric Interdisciplinary Team Training: The GITT Kit (2nd ed.)

4 較適合老年醫學病房照護對象 年齡 65歲或以上 功能 近期功能下降 問題 一般急症 老年症候群 包括膽妄 失智症 憂鬱 尿失禁 跌倒 褥瘡 多重藥物 高危險藥物使用 獨居 缺乏社會支持 經常住院治療者 常有非計劃性住院 懷疑有被虐待或輕忽 80歲以上 老年醫學照顧團隊 較不適合一般老年醫學病房照顧的對象 社工人員 營養師 經由積極的且完整的老年醫學評估及處置仍無法恢復其 功能者 病情嚴重需接受緊急加護照護者 末期疾病而需住安寧病房者 等待轉床至長期照護機構者 僅具單純某一器官系統問題 只需該專科醫師照護者 其他 藥師 病人 及 家屬 醫師 個案管理師 職能治療師 護理人員 專科護理師 21 物理治療師 22 現行老年疾病篩檢表 I N D EE P

5 病房定期老年醫學團隊會議 針對近期出現功能下降者, 進行周全性老年評估, 由照護團隊進行後續評估與處置 團隊成員 : 醫師 護理師 / 專科護理師 臨床藥師 復健科共同照護醫師 物理 職能 語言治療師 營養師 社工師 臨床心理師 每周定期團隊會議討論複雜老年個案 多重老年症候群 多項共病症 多重用藥 近期失能 案例討論 Geriatric Interdisciplinary Team Meeting Primary care team: resident/visiting staff Date of presentation: 2015/08/25 老年醫學團隊會議 : 討論時程 簡要病史及醫療問題評估功能性回顧 各專業人員評估及建議問題討論 總結及相關文獻回顧 20 分鐘 20 分鐘 15 分鐘 Timeline Basic information Chief complaint Name: 吳 華 Chart No: 6244xx2 Age: 82 years old Gender: male Education: 師專畢 Occupation: 國小老師退休 Religion: 道教 Marital status: married Residency: 台南透天 1F/ 台北電梯大樓 Date of admission: 2015/7/31 Severe back pain, insomnia, depressive mood for > 2 months Reasons for CGA Polypharmacy Functional decline Depression Caregiver burden 有別傳統疾病為中心的思維內科問題? 急性問題? 5

6 Present illness /6 2015/4/ /5/20 Fell down when riding a bicycle and caused spinal fracture s/p vertebroplasty at CGMH Low back pain developed since then 2013/3 Fell down again when riding a bicycle 2015/4 Mild left limbs weakness, lower > upper Unsteady gait and frequent falls since then Insomnia occurred Cataract s/p op at 柳營奇美佳里奇美 MRI showed old CVA Admitted to 佳里奇美 Hyponatrimia, pneumonia during admission Disorientated during and after admission Frequent falls Possible delirium 2015/5/ /6/ /7 Present illness Acupuncture therapy for persistent left side weakness and general soreness Severe pain over left popliteal area after that, Became irritable and depressed Pain Admitted to 麻豆新樓 hospital, spine X ray showed: spinal plasty L1-L2, multiple osteophytes, compression fracture, L2 spondylolithesis. Suicidal ideation during hospitalization? Depression Visited NTUH OPD x 6 times(ortho, Neuro, FM) Popliteal pain relieved by Triamicinolone + xylocaine local injection at Ortho OPD Back pain still persisted, also pain at neck, upper back, and knees 2015/7/31 Admitted to geriatric ward High health care utilization Past history T-L junction compression fracture s/p vertebroplasty at CGMH in 2010 OA knee Hypertension BPH CVA (2015/4/25 MRI) Hyponatremia (2015/5/20) Gastric ulcer Neurotic depression Personal history Herbs: nil Substance: Cigarette: denied Alcohol: denied Betel nut: denied Allergy: nil Past medication record at OPD (11): Zoloft 1# QD, Xanax 0.5# BID, Sleepman 1# HS 松德門診 Diovan(80) 1# BID, Felodipine 1# BID, Crestor 1# QD, Alinamin 1# BID, Ginko 1# BID, Arcoxia 1# QD, Acetaminophen+meophenoxalone 1# TID, Urief 1# BID 奇美 Polypharmacy Family history Social history 台北 台中 美國 台北 Main caregiver: 大女兒 三女兒 外籍看護 Main medical decision maker: 大女兒 Activity: walker, wheel chair Economic situation: fair Housing situation: 電梯大樓 Current long-term care services: nil Caregiver burden 6

7 Physical examination Height: 160 cm; BW: 50 kg; BMI: 19.5 Pain score: 9/10 (fluctuating) Ability to follow commands: yes Speech: fluent Consciousness: clear Vital signs: TRP:36.1/66/19; BP:108/53 mmhg HEENT: grossly normal, conjunctiva: pink, sclera: anicteric Pupil: isocoric; Light reflex: L/R: +/+, EOM: full Neck: supple, LAP(-), Goiter(-), Carotid bruit(-) Chest: symmetric expansion, breath sounds: clear Heart: RHB, no murmur Abdomen: soft and flat, normoactive bowel sound, tenderness Extremities: four limbs muscle atrophy, unable flexion of fingers Muscle power: Right: upper limb:4+; lower limb:4+ Left: upper limb:4+; lower limb:4+ Laboratory tests Normocytic anemia Anemia of chronic disease Relatively low Vit. B12 Tentative diagnosis on admission Spinal plasty L1-L2, multiple osteophytes, compression fracture, L2 spondylolithesis. Active problems Neurotic depression Four extremities atrophy & weakness, cause unknown Generalized pain Occult GIB Recent functional decline Underlying diseases Lumbar spine fracture s/p Hypertension Old CVA BPH OA knee 41 7

8 Treatment Course: work up of anemia & occult GIB 7/31 8/3 8/6 Stool OB: 3+, Hb:11.1 No tarry stool or epigastralgia Takepron 30 mg PO QD Hb:10.2 Iron profile: chronic disease pattern CFS failed due to intolerance 8/7,11,17 Hb: , OPD F/u Treatment Course: bacteremia 8/7 8/9 Fever(+), WBC:12380 N/L:96.5/1.7, no pyuria, R/O iatrogenic infection Ceftazidime Fever subsided B/C : Klebsiella oxytoca, resistent to Ceftazidime 8/10 Shifted antibiotics to Ertapenem 8/11 WBC:3840 N/L:55.6/30.7 8/13 Echo: Hepatic tumor 5.9 mm probably hemangioma; Tiny GB polyp, single 8/21 Abx completed Discharge Treatment Course: work up of muscle atrophy and weakness, functional decline 8/5 8/6 8/7 NCV (lower limbs): sensorimotor polyneuropathy with features of axonal loss SSEP: Upper limbs normal. Relatively attenuated responses of cortical SEPs from the left tibial nerve. Cervical polyradiculopathy and entrapment of right median nerve and ulnar nerve, autonomic dysfunction Consult Neuro Lumbar puncture: infection or inflammation is not likely Neuro reply: limbs polyneuropathy may due to chronic HBV infection, previous L spine surgery or mild vitamin B12 deficiency Upper limb polyradiculopathy, no reversibal cause Plan: methylcobal, rehabilitation 8/12 Autoimmune profile: not contributable Viral infection: chronic HBV carrier Serum IFE: polyclonal gammopathy, may related to HBV infection Treatment Course: work up of depression Current Medication List 7/31 8/5 8/11 Depressed mood for 2 months seroquel 25 mg 2# HS + mesyrel 50 mg 1# HS GDS:11/15 Add Lexapro 10 mg 0.5# QD Mood and oral intake: all improve before discharge Ertapenem 1000 mg QD IV (12 days finished) Diovan FC 160 mg/tab 1 tab QD PO Plendil 5 mg/tab 1 tab BID PO Urief 4 mg/cap 1 cap BID PO Takepron 30 mg/tab 1 tab QD PO MgO 250 mg/tab 1 tab BID PO Sennapur 12.5 mg/tab 1 tab HS PO Mesyrel 50 mg/tab 1 tab HS PO Seroquel 25 mg/tab 1 tab HS PO Lexapro 10 mg/tab 0.5 tab QD PO Methycobal 500 mcg/tab 1 cap TID PO Paramol 500 mg/tab 1 tab BID PO 8

9 老年醫學團隊會議 : 討論時程 Functional Review 簡要病史及醫療問題評估功能性回顧 各專業人員評估及建議問題討論 總結及相關文獻回顧 20 分鐘 20 分鐘 15 分鐘 D: Dementia, Depression, Delirium E: Eyes E: Ears P: Physical performance, Falls, Polypharmacy, Pain, Pressure sore I: Incontinence, Iatrogenesis N: Nutrition Functional Review: Delirium Functional Review: Dementia Confusion Assessment Method (CAM) 1. Acute onset of fluctuation(+): at home, but gradually deteriorated 2. Inattention(+) 3. Disorganized thinking(+/-) 4. Altered level of consciousness(+/-) 1+2+(3 or 4) positive Functional Review: Depression Functional Review: Eyes & Ears Communication: Eyes: Visual impairment (-) Ears: Hearing impairment(+) 9

10 Functional Review: Physical Performance Physical activity: ADL (Barthel s Index) 2015/7/ /8/18 進食 5 10 移位 0 5 個人衛生 5 5 如廁 0 0 洗澡 0 0 平地走動 5 10 上下樓梯 0 5 穿脫衣褲鞋襪 0 0 大便控制 5 5 小便控制 總分 Functional Review: Physical Performance Physical activity: IADL (Lawton-Brody) 2015/8/4 購物 0 家務 0 理財 0 食物製備 0 交通 0 使用電話 1( 需擴音器 ) 洗衣 0 服藥 0 總分 1 Functional Review: Fall Symptom: 腳軟無力 Prior fall: >=1 time in one year Location: 馬路邊 Activity: 坐計程車 transfer Time: 2015/6 Trauma: no Pre-morbid mobility: went to temple and school by walker Attributed to unsteady balance and muscle weakness Train caregiver to fix environmental hazards Functional Review: Polypharmacy, Pressure sore, Pain Polypharmacy: > 8 Pressure sore: (-) Pain score: 3 (on 2015/8/5) Functional Review: Incontinence & iatrogenesis Urine incontinence: (-) Fecal incontinence: (-) Iatrogenesis: tube(-), restraint(-) Functional Review: Nutrition Height: 160 cm; BW: 50 kg; BMI: 19.5 Weight loss 5% in 1m: (-), 10% in 6m: (+) Albumin: 3.5 g/dl (2015/8/3) Swallowing/ Feeding problem: slow in oral phase, choking(+/-), poor appetite: (-) Current feeding status: oral feeding well 10

11 Functional Review High health care utilization Admission 2/year (+) ER visits 2/year (+) DNR Discussed (-), Accepted (-) Caregiver issue Main caregiver: 大女兒 三女兒 外籍看護 Decision maker: 大女兒 Socioeconomic issues Live alone: (-) Economic problem: (-) Final diagnosis Active problems Klebiesilla bacteremia, suspect gastrointestinal bactereia translocation Depression/ anxiety Polyneuropathy with muscular atrophy Bilateral cervical polyradiculopathy Right median entrapment neuropathy at wrist and Right ulnar entrapment neuropathy at elbow Anemia Occult GIB Underlying diseases Hypertension Old CVA BPH Spine compression fx, spondylosis OA knee 老年醫學團隊會議 : 討論時程 Discussion 簡要病史及醫療問題評估功能性回顧 各專業人員評估及建議問題討論 總結及相關文獻回顧 20 分鐘 20 分鐘 15 分鐘 Dietitian Pharmacist Physiatrist / PT / OT / ST Social worker Clinical psychologist Nurse practitioner / Nurse Physician / Geriatrician Dietitian: 1. 病人目前在醫院飲食狀況 : 早餐 : 鮪魚飯糰一個 + 半根香蕉 + 些許醫院的飯跟菜午餐及晚餐 : 醫院 diet, 視心情及胃口吃的量不一定 2. 病人在家飲食狀況 : 病人住南部, 三餐由外傭準備早餐 : 麥片 + 牛奶 + 三明治午餐及晚餐 : 飯半碗 + 青菜 2 樣 + 魚肉約三指 + 湯水果 : 每天會補充 2-3 種, 香蕉一次半根 3. 因為牙口不佳, 有時候沒辦法吃青菜 4. 因為心情較為憂鬱, 覺得胃口不佳 Lab 2015/08/11: 身高 =160.0cm, 體重 =50.0Kg, BMI=19.5, 標準體重 =50.7~62.0Kg, 嗜中性白血球 =0%, 肌酐酸 =0.5mg/dL, 血色素 =9.5g/dL, 白血球 =3.8K/μL Estimated energy requirement: 1650kcal/day Estimated protein requirement: 60g/day Body weight: in normal range. Nutrition knowledge: poor. 建議 : 衛教對象 : 病人女兒 1. 維生素 B12 含量高的以動物性食品為主, 一般成人每天應攝取 2.4 微克, 含量較高的包括鯖魚 四迫於魚 蛋 牛肉 鴨肉 豬肝等等 ( 已經整理上述食物的維生素 B12 含量表提供給病人女兒 ) 2. 均衡飲食衛教 (1) 六大類食物介紹 (2) 六大類食物代換概念 (3) Meal plan: 每餐至少攝取 7-8 分滿的飯或 1.5 碗稀飯和麵類 + 半碗青菜 + 一手掌心的肉, 另外補充 2-3 份水果 3. 因牙口不佳, 建議青菜可以瓜類為主, 葉菜類可準備食物剪刀幫病人剪碎 65 Pharmacist Lexapro 會有 hyponatremia 副作用, 在老年人易發生, 建議之後追蹤鈉離子 Lexapro 與 tramadol 仍會有交互作用, 產生 serotonin syndrome 的可能, 宜小心使用, 若疼痛改善可改為 paramol 66 11

12 Physiatrist 1.Low back pain, spondylosis, scoliosis, retrospondylolisthesis related 2.Sacropenia 3.Imbalance gait, high risk of falling 4.Bilateral PIP, DIP joint contracture, entrapment of right median nerve and ulnar nerve related 建議 : 1.Suggest Acetaminophen, muscle relaxant and hot packing for low back pain, if still poor controlled, local injection may be helpful. 2.Beware of side effect of Seroquel, Mesyrel for increasing falling risk. 3.Suggest ambulation with supervision and home modification for high risk of falling. 4.Arrange PT/OT programs, including bedside and home program education, especially for home modification recommendation PT/OT: PT: bed mobility 可在 contact guard 之下完成, sit to stand 扶扶手可自行完成, 可在 supervision 之下放手走 40-50m, 建議持 regular cane 增加穩定度, 上下樓需 minimal assistance, 建議持續門診追蹤 OT: dressing and toileting 需 min-mod assistance, transfer 需 min. A., bathing 需 mod A., bathing 需 mod. A., 鼓勵盡量自行做, 協助環境改造 Social worker 經濟狀況 : 病人為老師退休, 每月領有月退俸, 經濟無虞 照顧安排 : 主要照顧者為長女及外籍看護 家庭支持功能 : 佳, 女兒照顧用心, 但有過度負荷問題 轉介長照中心申請日間照顧, 居家服務, 同理個案女兒情緒 Clinical psychologist 1. Impairment of cognitive function by the screening of MMSE (23/30) 2. Demented picture of very mild dementia (CDR = 0.5) was suspected according to the family's report. 3. Behavioral and psychological symptom of mild apathy (loss of interest) was reported by the family. 4. 情緒明顯受生理影響, 彼此間有交互作用, 亦影響認知功能起伏, 入院前易怒及情緒低落, 目前已逐漸改善 總結 : 個案並未有明顯的內科問題, 但卻充滿著老年病症候群, 需要具備周全性老年評估的觀點才能看到問題癥結所在 吳先生的案例, 若非有效的團隊合作模式, 可能無法達成 團隊成員的需求視個案狀況而定 後續個案的照顧與追蹤 持續的復健仍是非常重要的, 只是場所由老年專科病房回歸到社區的模式 更有效的團隊會議?Case discussion 而非 case presentation! 老年連續性照護服務 特色一 : 結合醫學中心與地區醫院之照護資源, 提供涵括社區 急性 急性後期 長期照護之連續性照護服務 特色二 : 將周全性老年評估工具與團隊式照護運用於各個照護階段 周全性老年評估及團隊式照護 周全性評估門診整合門診 老年門診 總院老年醫學部急性病房 北護分院居家護理 老年健檢 急診 北護分院老年病房 ( 急性後期照護 ) 北護分院護理之家

13 Thanks for your attention! 73 13