周全老年评估CGA之运用.ppt

1、周全性老年评估(CGA)之运用,高雄荣民总医院急诊部高龄医学中心廖美珍医师,1/46,齐步走-逛花园,Royal Botanic Gardens Kew 伦敦,Royal Botanic Gardens 剑桥,2,前言,老年人疾病特质-多重疾病典型/非典型疾病表现及影响周全性老人評估量表周全性老人评估之应用多重用药,3,老年人疾病之特质,合并多重疾病,高血压-合并症糖尿病-合并症心脏病-冠心病/瓣膜疾病慢性肺阻塞肾功能下降视力/听力关节炎腦卒中,Quino,4,HealthCapacity,Time,失能(Disability),急性事件,情况渐差,生病事件发生,公共卫生,第一线照护,急性照护

2、,长期照顾,正常老化,Complex care management,Interrelated needs require ongoing, coordinated care interventions,肥胖 烟 /酒 空气污染 高血压 快速体重增加/减少 高血糖 髋骨骨折 中风 心衰竭 慢性肺气肿 失禁 意识改变 照顾者疲惫 日常功能退化(ADL/IADL ),健康与老化,5,典型疾病表现,主诉及病史(征象),理学检查(症状),疾病,治疗,明确的诊断者处置方向,6,非典型临床表现,不符合疾病分类合并多重疾病和预后差,任何急症,immobility,instability,Impaired c

3、ognition,incontinence,7,非典型表现之影响?,Quino,OK!没问题!,?,8,腹痛,3,2,1,4,5,6,1,2,9,打完点滴后手痛,10,Tourniquet,11,非典型表现与非预期死亡,急诊出院7天内非预期死亡(十年) 86,859人 387,334 人次(反复急诊)61%一次/ 18%两次/ 8%三次/ 4%四次2.8%是72小时内返回急诊，4.7%在7日内非预期死亡率: 117人(30/100,000)非预期死亡率:(9人(13/100,000)Milwaukee，USA主动脉破裂为主因(3人),Sklar DP et al (2007) Ann Emer

4、g Med,Kefer MP et al (1994) Ann Emerg Med,12,功能-老年人健康的最佳测量方法(WHO),功能可以预测护理之家的需求与死亡率. Lichtenstein, JAGS 33:315, 1985D. Reuben, AM J Med 93:663, 1992功能预测住院后的死亡比疾病别更佳A Incalzi J Am. Gen. Soc. 40:34 1992P. Narain, J AM. Gen. Soc. 36:775, 1988,13,无法在家照顾,非特异主诉(无诊断)去向?,住院,急诊滞留,反复急诊,14,老人医学全方面评估Vs.医学诊断,15,

5、周全性评估/多科团队会议,周全性老人评估个人家庭社会特质-个人简史老人症候群跌倒失禁认知功能失能忧郁营养多重用药疼痛等等,16,Kew Garden简易周全性老人量表,高雄榮民總醫院高齡醫學科,17/60,Karz ADL,老年人精神抑郁量表（Geriatric Depression Scale）,19/46,等于或1分以下：正常等于2分或大于2分或：忧郁情形,认知功能评估：,迷你心智状态检查(Mini-Mental State Examination, MMSE),20/46,起立行走测试(Times “up and go” test / TUG ）,3 meters,30sec活动障碍,P

6、ratical Neurology 2007;7;158-171Identifying a cut-off point for normal mobility: a comparison of the timed up and go test in community-dwelling and institutionalised elderly women Age and Ageing 2003; 32: 315-320,周全性老人评估运用,Quino,22,0,2,4,20,90,97/01,97/02,97/04,97/06,97/07,急诊滞留(小时/次),泌尿科住院,卧床三天/压疮,8

7、4岁单荣失禁到失能,丛集性急诊频诊(个案3),23,渐进性失能-潜藏问题,单荣独居,邻居看护,丛集性急诊频诊(个案3),PFT: FEV1/FVC=0.9/2.28(39%),陈旧性心肌梗塞，冠心病经支架治疗，中度主动脉瓣逆流，心衰竭(LVEF 38%),心房颤动,24,介入,急诊滞留,反复急诊,Geriatric Giants,周全性老人评估,immobility,instability,impaired cognition,incontinence,25,26,82岁男性独居 军鉴轮机退休 跌倒,厌世自杀住院出院,整型科-门诊追踪， 若有其它科收治可以开刀清创,急诊滞留9小时无法判科,26

8、,周全性老人评估-伍xx,Physical performance & Fall riskBarthel index :100/100(入院前2week ) 80/100IADL: 5/8 (入院前)4/8Time get up to & go test:14”Hand grip: 20.7 Kg/ 19.3 Kg ( L/R)STRATIFY risk: 0/5 Urine incontinence screening: NoNutritional assessment:MNA:19(risk)Pressure ulcer risk: braden scale:16/23Pschy-ment

9、al assessment:GDS 6/15，suicide idea(+) MMSE:23/30(edu:?)Pain :VAS: wound:nil,27,捐活体解剖 器官捐赠龙泉(摄护腺手术，疝气修补术),抗忧郁药,28,65岁女性丧偶,门诊,胸闷,冠心病经绕道术后,丛集性急诊频诊(个案1),CGA+MDT,29/46,周全性老人评估-何利xx,Physical performance & Fall riskBarthel index :90/100(入院前 ) 90/100IADL: 4/8 (入院前) 4/8Time get up to & go test: 28”Hand grip

10、:9 Kg/ 10.4 Kg( L/R)STRATIFY risk:0/5(high risk for falls)Urine incontinence screening: NoNutritional assessment:MNA:19(risk)Pressure ulcer risk: braden scale:21/23Pschy-mental assessment:GDS 12/15 MMSE:17/30 (edu:6)Pain :VAS: ? (unable scale),30/46,丛集性急诊频诊(个案1),31/47,80岁男性-头晕,CGA+MDT,就诊日期,滞留时间/次,32

11、,周全性老人评估-张x,Physical performance & Fall riskBarthel index :100/100(入院前2week ) 85/100IADL: 6/8 (入院前)1/8Time get up to & go test:25”Hand grip: 22.5 Kg/ 20.7 Kg ( L/R)STRATIFY risk:1/5Urine incontinence screening:YesNutritional assessment: MNA:26Pressure ulcer risk: braden scale: 23/23Pschy-mental asse

12、ssment: GDS 0/15MMSE:7/30 (edu12)Pain :VAS: nil,早期失智/失禁/家属漠视,33,78岁独居婆婆-痛,96年10月丧偶,腹痛/下背痛、左腿痛Buscopan, Ketoprofen,腰椎退化，椎间盘突出,CGA+MDT,34,周全性老人评估-许x,Physical performance & Fall riskBarthel index :100/100(入院前2week ) 100/100IADL: 6/8 (入院前) 6/8Time get up to & go test:22”Hand grip: 17.6 Kg/ 21.8 Kg ( L/R

13、)STRATIFY risk: 0/5Urine incontinence screening: NoNutritional assessment: MNA:27Pressure ulcer risk: braden scale: 23/23Pschy-mental assessment: GDS 0/15MMSE:22/30 (edu:6)Pain :VAS: Left knee: 8,35,78岁独居婆婆-痛,96年10月丧偶,腹痛/下背痛、左腿痛Buscopan, Ketoprofen,腰椎退化，椎间盘突出,左股骨颈无血管坏死并骨折,CGA+MDT,36,林伯伯-反复跌倒,病史:高血氨症

14、，疑肝硬化所致，常因肝昏迷入院,Doxaben,On Foley removed Foley 2 days later,37,周全性老人评估-林,Physical performance & Fall riskBarthel index :100/100(入院前2个月 ) 75/100（目前）IADL: 7/8 (入院前2个月)3/8（目前）Time get up to & go test:30”Hand grip:13.4 Kg/ 16.9Kg ( L/R)STRATIFY risk:3/5(high risk for falls)Urine incontinence screening:

15、NoNutritional assessment: MNA:14Pressure ulcer risk: braden scale:20/23Pschy-mental assessment:GDS: cannt , MMSE:8/30 (no education)Pain:VAS: wound:nil,38,反复跌倒,病史:高血氨症，疑肝硬化所致，常因肝昏迷入院,逛诊所/感冒药(-agonist , Anti-histamine),Doxaben,39,急性谵妄,急性尿滞留:尿量2400mL,83岁单荣,40,刘xx 83岁，单荣,心脏科住院,反复性头晕一周在外院治疗无效，头晕及步态不稳/无力

16、/恶心/呕吐/昨夜腹泻病史:多年慢性心律慢、摄护腺肥大、右肾肿瘤并右肾切除术后(20年)无过敏史,11/5-9 (2009)病窦症候群 永久性心脏节律器植入(DDD),11/10急诊返诊,11/1急诊(2类),头晕/步态不稳/跌倒,姿势性低血压,倾斜床肌力训练,41,七十九岁男性双脚无力,98/11急诊Acute renal failure (cr2.4),94/9冠心病经遶道手术后，心外/心内门诊追踨,97/07肾内住院:急性肾衰竭 , favor AINRemoved all anti-HTN agent,Postural hypotension,42,反复晕厥-起立性低血压,阮综合,Vi

17、ta min D3Thyroxin 1# QDCimetidine 1# BIDOlmesartan 120 mg QDDipyridamole 1# BIDHydrochloroquine (20)1#BIDCerimeline 1# BIDAmbroxol 1# BIDPrednisolone 1# QD,高荣,Calbo 1# BIDLevothyroxine 1# QDCimetidine 1# BIDDoxaben 1# HSHydrocholothiazide 1# QDTiclopidine 1# BIDDipyridamole 1 # BIDBenbromarone 1# QDSemi-Nax 1# HS,43,平均余命,75.88,81,83,85,75.8,77,70.8,71.9,65,67,69,71,73,75,77,79,74年,84年,82.46,88年,79.6,79.9,80.2,80.3,71,71.3,71.5,72.1,73.8,74.1,74.6,74.8,66.8,66.8,67.1,67.1,90年,92年,94年,98年,数据源:行政院主计处,-健康余命=失能余命,=6.6年/=5年,44,医疗: 平均寿命目标:压缩失能,古埃及木乃伊,赡养中心住民,45,谢谢聆听,Quino,46,47/46,