個案評估 黃安君醫師 台北榮總高齡醫學中心

個案評估 黃安君醫師 台北榮總高齡醫學中心 1

長命 好命 平均餘命 - 失能年數 = 健康餘命 約有 8 年是不健康狀況可能需要住院或長期醫療 女性 < 男性 2 台灣老人成功與活躍老化之健康餘命探討, 林正祥, 2013

老年人的健康觀點 世界衛生組織說 衡量老年人健康最好的指標是功能 身心的健康程度比疾病的數目更能反映出老年人健康與否, 也決定醫療支出的多寡 3

Hazzard WR, eds. Principles of Geriatric Medicine & Gerontology, 6th ed, New York: Mc Graw Hill, 4

成功的老化 5

影響老老人死亡率最大的是失能! 無失能, 沒有多重慢性病 無失能, 有多重慢性病 失能, 有多重慢性病 失能, 沒有多重慢性病 6 Journal of Clinical Epidemiology 63 (2010) 752-759

功能與住院 / 長照預後密切相關 Function predicts nursing home need and nursing home mortality M. Lichtenstein, JAGS 33:315, 1985 D. Reuben, Am J Med 93:663, 1992 Function predicts hospital survival better than medical diagnosis does A.Incalzi, J.Am.Gen.Soc. 40:34, 1992 P.Narain, J.Am.Gen.Soc. 36:775, 1988 7

合併越多老年照護問題 ( 尿失禁 譫妄 跌倒 營養不良等 ) 的病患, 一年內的死亡率越高 老年症候群對於機構住民的預後影響甚至比罹患的疾病更顯著 8 Chen LK et al, J Am Med Dir Assoc 2010;11:567-71

老年評估 / 照護的目標 維持生活品質 (Quality of life) 維持自我照護的能力 (Maintain self care) 維持功能 (Maintain function) 9

一般疾病的症候群 traditional medical syndrome 10

老年症候群 Geriatric Syndrome 11

老年症候群 Geriatric Syndrome Geriatric syndrome Falls 跌倒 Incontinence 失禁 Dizziness 頭暈 Frailty 衰弱 Delirium 譫妄 Cognition decline 認知功能下降 Many others Geriatric giants Postural instability Poor mobility (immobility) Cognitive impairment (intelligence) Incontinence Iatrogenesis 12

周全性評估的定義 一個多面向 跨領域的評估診斷過程 Screening Assessment Diagnosis 13

周全性評估的面向 Different models and definitions Evaluates different domains: medical 醫療, cognitive 認知功能, psychological 情緒, social 社會支持, physical 身體功能, nutritional 營養 Expands scope of interest to include caregiver and environment Emphasis on optimization of function and increase in active life expectancy 14

周全性評估與傳統醫學評估的差異 注重於功能狀態與生活品質 特重於虛弱之患者及其複雜之問題 需要跨領域團隊的協助 使用量化的評估工具 15

跨領域評估團隊 老年醫學科醫師 護理人員 社工人員 復健人員 : 包括復健科醫師及 / 或物理治療師 職能治療師 語言治療師 精神科醫師, 臨床心理師 營養師 臨床藥師 其他專業領域 : 如牙科醫師等 16

應接受周全性評估之患者 Multiple and/or complex diseases 多重共病 Acute/subacute functional decline ( 亞 ) 急性功能下降 Geriatric syndromes 老年症候群 Prepare to institution 入住長照機構前 Age > 80 超過 80 歲 Frail older patients 孱弱老年病患 17

Comprehensive geriatric assessment 改善照護過程, 預後, 以及減少花費 18

History Taking (I) The patient s chief complaint - The caregiver/family member observation/concerns - Present illness Common pathways: baseline and current status Change!! - Consciousness - Appetite - Mobility - Continence 19

History Taking (II) Past major systemic disease Functional change after recent or recurrent hospitalization or Emergency Department visits or major events Iatrogenesis: time, indication and contraindication of removal Current medication: CDC AIDS 20

Medication Review C: compliance D: drug list C: controlled or not A: adverse effect/ interaction: drug to drug I: indications D: drugs for diagnosis S: simplify medication: drugs, dose, frequency 21

History Taking (IV) Geriatric syndrome: DEEPIN ADL/IADL impairment ADL: DEATH IADL: SHAFT Family history: Where is the resources? Family members: age, occupation, residence relationship Who is living together / key person Care aid: communication, education 22

快速周全性評估 DEEP IN D Dementia 失智, Depression 憂鬱, Delirium 譫妄 E Eyes 視力 E Ears 聽力 P - Physical Performance 身體功能, Phalls, 跌倒, Pressue sores 壓瘡, Polypharmacy 多重用藥 I Incontinence 失禁 N Nutrition 營養 23 Sherman FT. Geriatrics 2001

ADL (Activity of Daily Living) 巴氏量表 個人維持基本生活所需之自我照顧能力 24

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IADL (Instrumental Activity of Daily Living) 個人獨立生活於家中所需具備的能力 備餐 洗衣服 理財 打電話 吃藥 操作家事 外出購物 搭乘交通工具 26

Dementia screen Three-item recall at one minute Clock completion test Mini-Cog Assessment SPMSQ Animal-naming test Four IADL score 27

Dementia screen Three-item recall at one minute 如 : 紅色, 快樂, 腳踏車 一分鐘後請受試者重複 Recall < 2 (1 OR 0): LR-3.1 -> 直接做失智症診斷性測驗 Recall 2: LR-0.5 -> Clock completion test Recall all 3 items: LR-0.06 -> low-risk 28

Dementia screen Clock completion test 畫時鐘測試法 Score 4 indicate presence of dementia Reliable method of identifying dementia Sensitivity 87%, Specificity 82% Not an accurate indicator of severity of dementia 29

Clock completion test 30

Dementia screen Mini-Cog Assessment=3-item recall+cdt CDT=clock drawing test 31 Borson S et al. Int J Geriatr Psychiatry 2000

SPMSQ 32

Dementia- MMSE 簡易智能狀態測驗 Mini-Mental Status Examination - 時間 / 地點定向力 (5/5) - 訊息登錄 (3) - 注意力及計算力 (5) - 短期回憶 (3) - 語言能力 (9) 33

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Depression screen Single Question: (Sen/Spec-.85/.65) Do You Often Feel Sad Or Depressed? Two Questions: (Sen/Spec-.96/.57) 1. During the past month have you often been bothered by feeling down, depressed, or hopeless? 憂鬱症狀 2. During the past month have you often been bothered by little interest or pleasure in doing things? 失去興趣 5 Item Geriatric Depression Scale (Sen/spe-.97/.85) 15 Item GDS (Sen/spec-.94/.83) 36

Depression screen 5 Item Geriatric Depression Scale 根據最近一星期內的情形回答 問題 是 否 1. 您對生活基本上滿意嗎? 0 1 2. 您是否常常感到厭煩? 1 0 3. 您是否常常感到無論做什麼事都沒有用? 1 0 4. 您是否比較喜歡待在家裡, 而不喜歡外出和做新的事? 1 0 5. 您是否覺得您現在活得很沒價值? 1 0 總分 2 分以下 : 正常大於或等於 2 分 : 可能憂鬱症 37

Depression screen 15 Item Geriatric Depression Scale (Short form) 根據最近一星期內的情形回答 #1 0-4 分 : 正常 5-10 分 : 可能憂鬱 11-15 分 : 憂鬱 #2 7 分以下 : 正常大於或等於 7 分 : 可能憂鬱症 38

Depression screen 30 Item Geriatric Depression Scale (Long form) 根據最近一星期內的情形回答 #1 0-9 分 : 正常 10-19 分 : 輕微憂鬱 20-30 分 : 嚴重憂鬱 #2 11 分以下 : 正常大於或等於 11 分 : 可能憂鬱症 39

Depression screen Brief Symptom Rating Scale, BSRS-5 ( 簡式健康表 ) 1) <6 分 : 一般正常範圍 2) 6-9 分 : 輕度 3) 10-14 分 : 中度 4) 15 分以上 : 重度 40

情緒憂鬱 人際關係不睦 不識字 認知功能減退, 均為社會互動下降之獨立危險因子 其中又以憂鬱造成之影響最大, 社會互動下降風險增為 6.6 倍! 41 Tsai CF et al, J Chin Med Assoc 2009;72:478-83

Drugs 4 Prescribed: increased risk for falls Any Of The Anti s Antipsychotics, antidepressants, antihypertensive Anticholinergic effect Long-acting Benzodiazepines Over-the-counter agents Alternative supplements 42

Drugs Beers criteria PIM ( 潛在不適當用藥 ) 43

Anticholinergic Burden Anticholinergic burden cumulative effect of multiple anticholinergic medicines indicator for inappropriate medication use in the elderly 30-50 % of the most commonly prescribed drugs for older people have anticholinergic properties Anticholinergic hypersensitivity in the elderly normal aging reduces the amount of acetylcholine particularly vulnerable to anticholinergic adverse effects Adverse effects of anticholinergic agents 44 Peripheral Central dryness of mouth, blurred vision, anhidrosis, flushing urinary retention, reduced gut motility, constipation tachycardia and possibly arrhythmia drowsiness, agitation, confusion, delirium, hallucination Lu et al, CMAJ, 2015, 3;187(4):E130-7

Delirium 譫妄 Consider any change in mental status to be a delirium until proven otherwise Especially in: ER, Hospital, Nursing home Quiet delirium CAM (Confusion Assessment Method) Meet the first two: Acute onset and fluctuating course Inattention And meet one of the other two: Disorganized thinking Altered level of consciousness 45

Common causes of delirium Metabolic Infection Drug: intoxication, withdrawl Pain Constipation, Urine Retention Sensory Deprivation Neurologic 46

Delirium Outcomes of 325 hospitalized older patients with delirium Complete resolution of delirium At hospital discharge: 4% After 3 months: 20% After 6 months: 17% Levkoff SE. Arch Intern Med 1992 47

Eyes Because of your eyesight, do you have difficulty with.... Driving Watching TV Reading Or Any Daily Activity 48

Visual impairment 標準篩檢方法 :Snellen eye chart 受測者與視力表相距 20 英呎 ( 約 6 公尺 ) 已佩戴眼鏡或隱形眼鏡者, 不必取下 視力 <0.5 者應進一步檢查 49

Ears 65 歲以上老人約 1/3 有聽力問題 可能影響其認知功能 情緒 社會功能 生理功能等 50

Hearing impairment 先清除耳垢 Whisper test Audioscope Hearing Handicap Inventory for the Elderly- Screening version (HHIE- S) 51

Hearing impairment Whisper test 面對患者, 坐著或站著, 請患者閉眼 蓋住對側耳 在患者面前 30 至 45 公分處, 以氣音說 4 個數字, 間隔 1 秒鐘 請患者複誦 若患者無法聽到至少 2 個數字, 則不通過 52

Hearing impairment Audioscope 可發出 500, 1000, 2000, 4000Hz 等 4 個頻率的聲音, 音量約 40dB 任一耳無法分辨 1000 或 2000Hz 的頻率者, 可能有 Hearing impairment 53

Physical Performance Upper extremities Hand grips strength( 握力 ) Lower grip strength reduced healthrelated quality of life in older men and women (Age and aging 2006;35:409-15) 54

Grip strength predicts mortality N=142861 in 17 countries Mean age: 50 Median F/U 4 0 years (IQR 2 9 5 1) 55 Lancet 2015; 386: 266 73

Fall/Physical Performance Gait Speed Get up and go test Standing balance Side-by-side stance, Semi-tandem stance, Tandem stance Unable to hold these stances > 10 sec: increased risk for falls 56

Gait Speed Predicts Survival in Old People N=34485, age: 73.5 (5.9) Follow-up 6-21 yrs JAMA. 2011;305(1):50-58. doi:10.1001/jama.2010.1923 57

起身行走測試 Timed Up and Go Test <10s: 一年內 IADL 可維持穩定 >=15s: 跌倒高危險群 <20s: independent of basic transfer, 可自行外出 >30s:dependent transfer on Podsiadlo et a, J Am Geriatr Soc. 1991 Feb;39(2):142-8. Shumway, et al, Phys Ther. 2000 Sep;80(9):896-903 58

SPPB- Short Physical Performance Battery Rodríguez-Mañas et al. Trials 2014, 15:34 59

Fall STRATIFY (St Thomas's risk assessment tool in falling elderly inpatients) STRATIFY risk assessment tool 1 Did the patient present to hospital with a fall or has he or she fallen on the ward since admission? (Yes=1, No=0) Do you think the patient is (questions 2-5) 2 Agitated? (Yes=1, No=0) 3 Visually impaired to the extent that everyday function is affected? (Yes=1, No=0) 4 In need of especially frequent toileting? (Yes=1, No=0) 5 Transfer and mobility score of 3 or 4? (Yes=1, No=0) Total score 60

Fall Schmid Fall Risk Assessment tool MOBILITY: (0) Ambulation with no gait disturbance (1) Ambulation or transfers with assistive devices or assist (1) Ambulation with unsteady gait and no assistance (0) Unable to ambulate or transfer MENTATION: (0) Alert, oriented X3 (1) Periodic confusion (1) Confusion at all times (0) Comatose/unresponsive ELIMINATION: (0) Independent in elimination (1) Independent, with frequency or diarrhea (1) Needs assistance with toileting (1) Incontinence PRIOR FALL HISTORY: (1) Yes?Before admission (home or previous inpatient care) (2) Yes?During the admission Date: (0) No (1) Unknown CURRENT MEDICATIONS: (1) Anti-convulsants/tranquilizers or psychotropics/hypnotics (0) No Anti-convulsants/tranquilizers or psychotropics/hypnotics 61

跌倒的危險因子 不可逆 年紀 >80 歲 (OR 1.1-1.3) 女性 (OR 2.1-3.9) 認知功能異常 (OR 1.9-2.1) 過去曾跌倒過 (OR 1.9-6.6) 神經肌肉骨骼問題 平衡不佳 (OR 1.8-3.5) 上或下肢肌肉力量不夠 (OR 1.2-1.9) 步態不穩或行走困難 (OR 2.7) 關節炎 (OR 1.2-1.9) 其他 視力不良 (OR 1.5-2.3) 藥物 ( 大於 4 種或是 psychoactive 藥物 ) (OR 1.7-2.7) 憂鬱 (OR 1.4-2.2) 暈眩或姿勢性低血壓 (OR 1.6-2.6) 體重過輕 (OR 3.1) 尿失禁 (OR 1.3-1.8) 糖尿病 (OR 2.8) 疼痛 (OR 1.7) 有許多可介入及矯正的危險因子! JAMA, January 20, 2010 Vol 303, No. 3 62

美國老年醫學會 / 英國老年醫學會跌倒評估流程圖 老年病人至醫療單位, 需篩檢 : 1. 過去一年是否跌倒二次以上? 2. 因跌倒前來就診? 3. 行走或平衡困難? 是 無 單次跌倒 是 步態 / 平衡問題 是 完整評估 無 無 需進一步介入 是 否 定期評估 多因子介入 63 Adapted from JAGS 2011, 59:148-157 Slide 63

Pressure ulcer Braden scale 64

Pressure ulcer Stage 1 Stage 2 Stage 3 Stage 4 Nonblanchable erythema of intact skin Partial thickness skin loss involving epidermis and/or dermis Extend into subcutaneous tissues to deep fascia Involve muscle and/or bone 65

Pressure ulcer Should improvement within 2-4 weeks Reduction in ulcer size over 2- week period predict complete healing If no evidence of ulcer improvement Consider changes in management strategy 66

Incontinence Two Questions: (1)In The Last Year, Have You Ever Lost Your Urine And Gotten Wet? (2)Have You Lost Urine On At Least 6 Separate Days? If Yes To Both? PPV-.86/NPV-.96 Next: Urologic assessment 67

Nutrition / Unintentional weight loss Ask: Have you lost 10 pounds over the past 6 months without trying to do so? - >10 lb wt loss over 6 m/o? (RR of death 2.0) - Body weight < 100 pounds? (PPV= 0.99 for malnutrition) - BMI< 22? 68

整體死亡率 心血管疾病死亡率 1. Excess body weight increases the risk of death from any cause and from CVD in adults between 30 and 74 years of age. 2. The relative risk associated with greater body weight is higher among younger subjects N Engl J Med. 1998 Apr 16;338(16):1159 69

Malnutrition/ Weight loss Body mass index Body weight trend Serum markers (albumin, total cholesterol, total lymphocyte count, prealbumin) Nutrition Screening Initiative s 10-item checklist ( 簡易型社區營養篩檢表 ) SGA (Subjective Global Assessment) MNA (Mini-Nutritional Assessment) 70

社會資源評估 (OARS, Social Resource Scale) 71

照顧者壓力指數 Caregiver strain index 若有七題或以上的答案是 經常 或 有時, 即表示屬於 高負荷 的一群 (high strain 72

Summary about comprehensive assessment High effective in outpatient setting, inpatient setting, long-term care setting and communities More than merely an assessment Intervention program matters! Determinants of success Selection of cases: frail patients Long-term follow-up 73

黃安君醫師 An-chun Hwang, MD 台北榮總 高齡醫學中心 Email: anchun.hwang@gmail.com 74