高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程高齡友善健康照護之照護流程住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護住院老年病患之友善照護

ChiaChiaChiaChiaChiaChiaChiaChia--------Ming Chang, Ming Chang, Ming Chang, Ming Chang, Ming Chang, Ming Chang, Ming Chang, Ming Chang, MDMD

張家銘張家銘張家銘張家銘張家銘張家銘張家銘張家銘

國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院國立成功大學醫學院附設醫院

內科部內科部內科部內科部內科部內科部內科部內科部 老年科老年科老年科老年科老年科老年科老年科老年科

大綱大綱

老年人疾病的特徵老年人疾病的特徵

老年人住院的危險性老年人住院的危險性

周全性老年醫學評估周全性老年醫學評估

跨專業的照護團隊跨專業的照護團隊

診斷診斷 檢驗及治療的考量檢驗及治療的考量

符合老年病患生理特性的病房符合老年病患生理特性的病房

A Story from Pictures and FamilyA Story from Pictures and Family

A 88 A 88 y/oy/o women, admitted to a hospital women, admitted to a hospital

because of fever, chills, and weaknessbecause of fever, chills, and weakness

PremorbidPremorbid ADL: totally independentADL: totally independent

DxDx: pneumonia: pneumonia

Condition at discharge: walk with frameCondition at discharge: walk with frame

Resided to nursing homeResided to nursing home::

Current conditionCurrent condition::, HI , HI cardcard

老年人疾病的特徵老年人疾病的特徵

多重病因多重病因

潛隱性疾病潛隱性疾病

低報疾病低報疾病，，常被歸因於老化常被歸因於老化

常見疾病的非典型表現常見疾病的非典型表現

若無立即治療時，病況會急速惡化若無立即治療時，病況會急速惡化

疾病治療反應的改變疾病治療反應的改變-- 療效較差，復原緩慢療效較差，復原緩慢-- 疾病及治療的後遺症發生率高疾病及治療的後遺症發生率高-- 容易產生醫源性問題容易產生醫源性問題

常需復健常需復健

Hazards of Hospitalization in the ElderlyHazards of Hospitalization in the Elderly

bed restbed rest

functional declinefunctional decline

restraintsrestraints

fallsfalls

pressure sorespressure sores

urinary incontinenceurinary incontinence

deliriumdelirium

depressiondepression

iatrogenic illnessiatrogenic illness

–– nosocomialnosocomial infections infections

–– fluid/electrolyte fluid/electrolyte disturbancesdisturbances

–– complications of complications of proceduresprocedures

–– side effects of drugsside effects of drugs

malnutritionmalnutrition

overzealous labelingoverzealous labeling

nursing home placementnursing home placement

Common Adverse Events in Common Adverse Events in

Hospitalized PatientsHospitalized PatientsIncidentIncident Patients with a major event (%)Patients with a major event (%)

InfectionInfection 10.810.8

SurgerySurgery 9.29.2

ConfusionConfusion 5.55.5

Drug reactionsDrug reactions 5.15.1

Invasive proceduresInvasive procedures 2.52.5

TraumaTrauma 1.81.8

Pressure ulcersPressure ulcers 1.51.5

Fluid imbalanceFluid imbalance 1.11.1

Any major eventAny major event 22.022.0

JAGS 1982;30:387-90

Interaction of Aging and Hospitalization

Ann Intern Med 1993:118

Ann Intern Med 1993:118

Changes in ADL Function During Changes in ADL Function During

Hospitalization (N=1279)Hospitalization (N=1279)

5555 7777 1919191959595959

8888 1111 11110000101010102020202030303030404040405050505060606060-5~6-5~6-5~6-5~6 -3~4-3~4-3~4-3~4 -1~2-1~2-1~2-1~2 0000 1~21~21~21~2 3~43~43~43~4 5~65~65~65~6

No. of ADLNo. of ADLNo. of ADLNo. of ADLNo. of Activities of Daily Living

% o

f Po

pu

lation

Arch Intern Med 1996;156

PrePre--Admission and Discharge ADL Admission and Discharge ADL

Function During Hospitalization Function During Hospitalization 7373737319191919

8484848436363636

93939393 46464646 92929292 47474747 92929292 56565656 94949494 7272727200002020202040404040

6060606080808080100100100100BathingBathingBathingBathing DressingDressingDressingDressing TransferringTransferringTransferringTransferringWalkingWalkingWalkingWalking ToiletingToiletingToiletingToileting EatingEatingEatingEatingPre-admissionDischarge

Arch Intern Med 1996;156Activity of Daily Living

Percen

t Ind

epen

den

t

33--Month Functional OutcomesMonth Functional Outcomes

Change in ADL Function During Index

Hospitalization, No. (%)

Decline

(N=320)

Same

(N=656)

Improve

(N=96)

Total

(N=1072)

3-Month ADL outcomes

Decline 130 (41) 56 (9) 22 (23) 208 (19)

Same 157 (49) 573 (87) 15 (16) 745 (70)

Improve 33 (10) 27 (4) 59 (61) 119 (11)

3-Month IADL outcomes

Decline 169 (53) 224 (34) 33 (34) 426 (40)

Same 92 (29) 281 (43) 31 (33) 404 (38)

Improve 59 (18) 151 (23) 32 (33) 242 (22)

Arch Intern Med 1996;156

Acute Illness vs. FunctionAcute Illness vs. Function

Time

Fu

nct

ion

Bed

bound

Chair

bound

Normal

Acute

event 1

Acute

event 2

Acute

event 3

Conceptual Model of the Conceptual Model of the Dysfunctional SyndromeDysfunctional Syndrome

Physical

Impairment

Functional

Older Person

(↓physiologic

reserves)

Dysfunctional

Older Person

Depressed

Mood, Negative Expectations

Hospitalization

Hostile Environment

DepersonalizationBedrest Starvation

Medicines

ProceduresAcute Illness, Acute Illness,

Possible Possible

ImpairmentImpairment

Clin Geriatr Med 1998;14

RestraintsRestraints

Incidence: Incidence:

–– Overall, 6~13%; elderly, 18~22%Overall, 6~13%; elderly, 18~22%

Types of restraints:Types of restraints:

–– physical (including wrist or leg restraints, physical (including wrist or leg restraints, hand mitts, bedrails, recliners, IV pools, Ohand mitts, bedrails, recliners, IV pools, O22))

–– chemical (sedatives, chemical (sedatives, neurolepticsneuroleptics))

Reasons for restraintsReasons for restraints

–– prevent falls, prevent disruption of therapy, prevent falls, prevent disruption of therapy, management of confusion, protect from management of confusion, protect from injury (wandering), maintain body position, injury (wandering), maintain body position, compensate for inadequate staff levelscompensate for inadequate staff levels

Restraint ReductionRestraint Reduction

The major barrier to restraint reduction is the The major barrier to restraint reduction is the perception that restraints contribute to safety.perception that restraints contribute to safety.

Nursing home:Nursing home:–– Reduction from 39% to 4% in 3 yearsReduction from 39% to 4% in 3 years

–– No change in the rate of prescribing psychotropic No change in the rate of prescribing psychotropic medications medications

–– No change in the rate of falls or fall related injuries.No change in the rate of falls or fall related injuries.

Systemic approach to manage confusion, fallsSystemic approach to manage confusion, falls……

Use of anchoring and camouflaging techniques to Use of anchoring and camouflaging techniques to secure the device against dislodgementsecure the device against dislodgement

周全性周全性周全性周全性周全性周全性周全性周全性老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學評估評估評估評估評估評估評估評估跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊

與老年人的溝通方式與老年人的溝通方式

你的臉面向光你的臉面向光、、面對病人面對病人

坐著傾聽坐著傾聽

給他們時間瞭解給他們時間瞭解

表示尊敬表示尊敬

使用簡單的聲音放大器使用簡單的聲音放大器((助聽器助聽器))

以低頻聲調以低頻聲調、、輕聲慢輕聲慢慢講慢講 ((字詞之間略作停字詞之間略作停

頓頓) )

老年患者周全性評估的基本原則老年患者周全性評估的基本原則

使用觀察性的技巧使用觀察性的技巧

讓長者覺得舒服被尊重讓長者覺得舒服被尊重、、避免造成不適或避免造成不適或

傷害自尊傷害自尊

評估生理評估生理、、心智心智、、社會功能社會功能

找出疾病的徵候找出疾病的徵候

消除醫源性的因素消除醫源性的因素

觀察性的技巧觀察性的技巧

整體印象整體印象: : 觀察進門至坐下的過程、面部觀察進門至坐下的過程、面部

表情、衣著狀況、化妝打扮、使用的語言表情、衣著狀況、化妝打扮、使用的語言

問診時問診時: : 觀察臉、手及腳的皮膚及指甲色觀察臉、手及腳的皮膚及指甲色

澤外觀、呼吸情形等，也觀察病患的視澤外觀、呼吸情形等，也觀察病患的視

力、聽力、發音清晰度、記憶力及理解力力、聽力、發音清晰度、記憶力及理解力

等功能，甚至與家屬的互動等等功能，甚至與家屬的互動等

理學檢查理學檢查

基本上和年輕人的檢查並無不同基本上和年輕人的檢查並無不同

保持誠懇保持誠懇是很重要的是很重要的

要特別注意退化要特別注意退化、缺血、慢性感染、缺血、慢性感染及腫瘤及腫瘤的徵候的徵候

在某些部位對老人家要比年輕人特別檢查在某些部位對老人家要比年輕人特別檢查仔細仔細 ((如腳如腳))

對功能上的評估要量化對功能上的評估要量化 ((穿衣穿衣、、 站立站立、、行行走走、、轉身轉身))

Physical ExaminationPhysical Examination

Misleading findingsMisleading findings

Inelastic skin mimics decreased Inelastic skin mimics decreased turgorturgor; ; Assess over cheeksAssess over cheeks

Mouth breathing mimics dehydrationMouth breathing mimics dehydration

Pedal edema from inactivity, dependent Pedal edema from inactivity, dependent positioning of feetpositioning of feet

NonNon--pathological pathological ralesrales in lung basesin lung bases

Peripheral pulses difficult to feelPeripheral pulses difficult to feel

Pertinent Areas of ConcernsPertinent Areas of Concerns

Current/baseline functional statusCurrent/baseline functional status

Geriatric syndromesGeriatric syndromes

Home environmentHome environment

Support systems at homeSupport systems at home

PatientPatient''s & familys & family''s goals for treatments goals for treatment

Advance directivesAdvance directives

周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估周全性老年醫學評估

A multidimensional, usually interA multidimensional, usually inter--disciplinary, disciplinary,

diagnostic process intended to determine a frail diagnostic process intended to determine a frail

elderly personelderly person’’s medical, psychosocial, and s medical, psychosocial, and

functional capabilities and problems.functional capabilities and problems.

((以多元性的評估及處置以多元性的評估及處置，來，來改善虛弱老人的身體、改善虛弱老人的身體、

心理、社會、經濟及功能狀態的問題心理、社會、經濟及功能狀態的問題))

Merck Manual of Geriatrics 1995

周全性周全性周全性周全性周全性周全性周全性周全性老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學評估評估評估評估評估評估評估評估

包含評估和處理包含評估和處理

耗費時間與精力耗費時間與精力，，但不一定合乎成本效益但不一定合乎成本效益

依目的、時間、狀況來決定評估方式依目的、時間、狀況來決定評估方式

以發現個案或篩選問題為起始以發現個案或篩選問題為起始

在病況變化或改變治療處所之際執行評估在病況變化或改變治療處所之際執行評估

採取多次、短時間的訪談方式採取多次、短時間的訪談方式

Merck Manual of Geriatrics 1995

Essentials of Clinical Geriatrics 2000

功能狀況環境

老年醫學評估面向間的相互關係老年醫學評估面向間的相互關係老年醫學評估面向間的相互關係老年醫學評估面向間的相互關係

社會支持

醫療 情緒

心靈

認知

經濟

Principles GM & G 1999; p.467

老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估(1)(1)(1)(1)(1)(1)(1)(1)

疾病狀態疾病狀態：：急性期首要處理，找出致病原因急性期首要處理，找出致病原因–– 傳統病史及理學檢查傳統病史及理學檢查

–– 視力及聽力檢查視力及聽力檢查

功能狀態功能狀態：：ADLADL評估評估((包括病前、住院期間至出院包括病前、住院期間至出院前前))：瞭解功能狀況之變化，預期治療目標。：瞭解功能狀況之變化，預期治療目標。––ADLADL差者須評估壓瘡危險性差者須評估壓瘡危險性 (Norton)(Norton)

心智狀態心智狀態：：先排除先排除deliriumdelirium、再評、再評MMSEMMSE––排除其他疾病，區分血管性失智症與阿茲海默症排除其他疾病，區分血管性失智症與阿茲海默症

精神狀態精神狀態：：老年人憂鬱量表老年人憂鬱量表(GDS)(GDS)––排除甲狀腺功能低下及家庭問題排除甲狀腺功能低下及家庭問題

失禁評估失禁評估

老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估老年病患住院時之評估(2)(2)(2)(2)(2)(2)(2)(2)

營養營養及飲食狀況及飲食狀況：體重減輕：體重減輕、、 BMIBMI、、cholesterolcholesterol、、albuminalbumin、、total lymphocyte counttotal lymphocyte count––會診營養師會診營養師

––口腔及吞嚥狀態評估口腔及吞嚥狀態評估

跌倒危險性跌倒危險性––跌倒危險評估表跌倒危險評估表

––起身起身--行走測試行走測試

–– TinettiTinetti平衡及步態評估表平衡及步態評估表：半年內：半年內跌倒兩次以上者跌倒兩次以上者

社交及社交及家庭支持家庭支持：：社交史社交史–– 社交史社交史、、價值觀及預立醫囑價值觀及預立醫囑、評估家庭照顧狀況、、評估家庭照顧狀況、照顧者負荷、經濟情況及預計出院後安置計劃照顧者負荷、經濟情況及預計出院後安置計劃

居住環境安排的適當性居住環境安排的適當性

Up and Go TestUp and Go Test-- 起身、行走測驗起身、行走測驗

叫病人坐在直椅背且高座位的椅子叫病人坐在直椅背且高座位的椅子

指示病人作以下動作指示病人作以下動作

––起立起立 ((如果可以儘可能不需任何協助如果可以儘可能不需任何協助))

––快速站起快速站起

––走走1010呎呎 (3 (3 公尺公尺))

––轉身並走回原來的椅子轉身並走回原來的椅子

––轉身並坐下轉身並坐下

Functional Reach Test身體前傾測試身體前傾測試身體前傾測試身體前傾測試

�手杖手杖手杖手杖（（（（canecanecanecane））））的適用對象的適用對象的適用對象的適用對象

�使用者幾乎能完全承重，只需部份幫助來維持穩定

�手杖的位置手杖的位置手杖的位置手杖的位置1.1.1.1.腳掌外側腳掌外側腳掌外側腳掌外側 10 10 10 10 公分公分公分公分2.2.2.2.把手與股骨大轉子同高把手與股骨大轉子同高把手與股骨大轉子同高把手與股骨大轉子同高3.3.3.3.手肘彎曲手肘彎曲手肘彎曲手肘彎曲 20202020----30 30 30 30 度度度度弱側

周全性老年評估表周全性老年評估表

周全性老年評估表周全性老年評估表

老年科門診的初診病歷

Key Elements of Team Care Key Elements of Team Care

Data gatheringData gathering

Discussion among the teamDiscussion among the team

Development of a treatment planDevelopment of a treatment plan

Implementation of the treatment planImplementation of the treatment plan

Monitoring response to the treatment planMonitoring response to the treatment plan

Revising the treatment planRevising the treatment plan

Principles of GM & G p.477

主動篩選主動篩選主動篩選主動篩選 評估評估評估評估

執行執行執行執行

追蹤追蹤追蹤追蹤修訂討論討論討論討論

計畫計畫計畫計畫

預測預後預測預後預測預後預測預後老年病症候群老年病症候群老年病症候群老年病症候群

跌倒跌倒跌倒跌倒

老年失智老年失智老年失智老年失智

老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學老年醫學--------跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊跨專業的照護團隊

核心團隊核心團隊核心團隊核心團隊•老年科醫師老年科醫師老年科醫師老年科醫師•護理人員護理人員護理人員護理人員•社工師社工師社工師社工師•物理治療師物理治療師物理治療師物理治療師•職能治療師職能治療師職能治療師職能治療師支援團隊支援團隊支援團隊支援團隊•營養師營養師營養師營養師•臨床藥師臨床藥師臨床藥師臨床藥師•足部治療師足部治療師足部治療師足部治療師•語言治療師語言治療師語言治療師語言治療師•義肢及輔具專家義肢及輔具專家義肢及輔具專家義肢及輔具專家•老年精神科醫師老年精神科醫師老年精神科醫師老年精神科醫師•臨床心理師臨床心理師臨床心理師臨床心理師•志工志工志工志工

核心團隊成員核心團隊成員核心團隊成員核心團隊成員

社工師社工師社工師社工師老年科醫師老年科醫師老年科醫師老年科醫師

護理人員護理人員護理人員護理人員 老年病患老年病患老年病患老年病患

職能治療師職能治療師職能治療師職能治療師物理治療師物理治療師物理治療師物理治療師

會診會診會診會診

•其他各醫療次專科其他各醫療次專科其他各醫療次專科其他各醫療次專科•其他專業其他專業其他專業其他專業

MultiMulti-- vs. Intervs. Inter--disciplinary teamsdisciplinary teams

Multidisciplinary teamsMultidisciplinary teams

Work in parallel, without Work in parallel, without

integrated care into an integrated care into an

overall planoverall plan

Learn to work together, Learn to work together,

with little or no formal with little or no formal

trainingtraining

Leader is assumed to be Leader is assumed to be

a physiciana physician

Patients are not Patients are not

considered team considered team

membersmembers

Interdisciplinary teamsInterdisciplinary teams

Work in an integrated, Work in an integrated, cooperative manner with cooperative manner with agreedagreed--on goalson goals

Attend regular meetings Attend regular meetings to discuss team goals, to discuss team goals, process and process and communicationcommunication

Leaders may not be Leaders may not be physiciansphysicians

Patients are considered Patients are considered team membersteam members

TransdisciplinaryTransdisciplinary teamsteams

Report for ACE Team RoundsReport for ACE Team RoundsPatient/room/physicianPatient/room/physician

DiagnosisDiagnosis

New problemsNew problems

Current ADLCurrent ADL

Treatment planTreatment plan

ACE care plans:ACE care plans:––selfself--care, mobility, care, mobility, potential for injury, skin, potential for injury, skin, nutrition, urinary nutrition, urinary elimination, depression, elimination, depression, anxiety, altered thought anxiety, altered thought processprocess

Educational Educational requirements for requirements for patients/caregiverspatients/caregivers

Equipment and Equipment and services neededservices needed

Projected LOS / Projected LOS /

discharge plansdischarge plans

Team suggestionsTeam suggestions

Clin Geriatr Med 1998;14

Investigation is an essential tool in the diagnosis Investigation is an essential tool in the diagnosis of elderly patients.of elderly patients.

One must try to get the diagnosis right, as wrong One must try to get the diagnosis right, as wrong diagnosis is harbinger of wrong treatmentdiagnosis is harbinger of wrong treatment

Under or over investigations to be avoided.Under or over investigations to be avoided.

Know the age related variables while interpreting Know the age related variables while interpreting the results.the results.

NonNon--invasive tests are preferred than invasive.invasive tests are preferred than invasive.

The objective of the investigations is to improve The objective of the investigations is to improve the quality of life.the quality of life.

InvestigationsInvestigations

基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗基本的實驗室檢驗

對於初診的老年病人應做多少基本的實驗室檢驗對於初診的老年病人應做多少基本的實驗室檢驗目前仍有爭議。由於基本的篩選性檢驗可發現一目前仍有爭議。由於基本的篩選性檢驗可發現一些潛在的問題。些潛在的問題。

若需更進一步的檢驗時，則需考量該檢驗對病人若需更進一步的檢驗時，則需考量該檢驗對病人的危險性、疾病的可治療性及治療後對病人預後的危險性、疾病的可治療性及治療後對病人預後和生活品質的影響，另需了解病人與其家屬的期和生活品質的影響，另需了解病人與其家屬的期望。因此在做進一步的檢驗，特別是具侵襲性的望。因此在做進一步的檢驗，特別是具侵襲性的檢查時，請先思考「該檢驗結果是否會改變或影檢查時，請先思考「該檢驗結果是否會改變或影響後續的處置方向？」，就可減少非必要或有侵響後續的處置方向？」，就可減少非必要或有侵入性的檢驗對老年病人的傷害，但年紀並非是主入性的檢驗對老年病人的傷害，但年紀並非是主要的決定因素。要的決定因素。

老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目老年人初次的實驗室檢驗項目

多數病人多數病人 特定病人特定病人

全血球計數全血球計數 甲狀腺刺激素甲狀腺刺激素(TSH)(TSH)

肝、腎功能肝、腎功能 腎上腺皮質素腎上腺皮質素((cortisolcortisol))

空腹血糖空腹血糖 電解質電解質

血脂肪血脂肪 白蛋白白蛋白

尿液分析尿液分析 葉酸葉酸

胸部胸部XX光光 維生素維生素BB1212

心電圖心電圖 結核菌素測試結核菌素測試

主要問題列表主要問題列表

主要的急性健康問題及重要的慢性問題主要的急性健康問題及重要的慢性問題

內科、外科及精神方面問題內科、外科及精神方面問題

功能自主方面問題功能自主方面問題

與家屬及其他人際關係問題與家屬及其他人際關係問題

生活及居生活及居住環境問題住環境問題

P & P of GM 4th Ed

Problem ListProblem ListGo beyond “formal” diagnoses

確立診斷確立診斷

((以無法行走為例以無法行走為例))

缺血性心臟病缺血性心臟病

慢性支氣管炎慢性支氣管炎

營養不佳營養不佳

缺鐵性貧血缺鐵性貧血

軟骨症軟骨症

膝蓋退化性關節炎膝蓋退化性關節炎

腳趾外翻腳趾外翻

慢性青光眼慢性青光眼

鞋子不合腳鞋子不合腳

不適當的輔具不適當的輔具

屋內有樓梯屋內有樓梯

到屋外有階梯到屋外有階梯

Challenge of Geriatric Medicine

Admission beyond Traditional Admission beyond Traditional

Problems / DiagnosisProblems / Diagnosis除了一般常見的急性問題外，有些虛弱的老年病人前來除了一般常見的急性問題外，有些虛弱的老年病人前來求診的原因，並非是傳統上大家慣用的診斷病名或問求診的原因，並非是傳統上大家慣用的診斷病名或問題，例如：題，例如：

–– 惡病質惡病質((cachexiacachexia, 799.4, , 799.4, R54R54,,RR6644))、存活不良、存活不良(failure to thrive, (failure to thrive, ICD 783.4, ICD 783.4, R62.7R62.7))、營養不良、營養不良(malnutrition, 263.9, E46, E43)(malnutrition, 263.9, E46, E43)、、體重減輕體重減輕(weight loss, 783.2, (weight loss, 783.2, RR63.63.44))、功能退化、功能退化(decline, (decline, debility, 797, debility, 797, R54R54))、不活動、不活動(immobility, 728.3, M62.3)(immobility, 728.3, M62.3)

–– 單純的主訴或症狀表現，如衰弱單純的主訴或症狀表現，如衰弱(weakness, 780.79, R53.1)(weakness, 780.79, R53.1)、、不適不適(malaise, 780.79, R53.81)(malaise, 780.79, R53.81)、食慾不振、食慾不振(anorexia, 799.0, (anorexia, 799.0, R09.01 R09.01 ))、疲倦、疲倦(fatigue (senile), 797, R53.83)(fatigue (senile), 797, R53.83)、意識紊亂、意識紊亂(delirium, 298.9, R41.0)(delirium, 298.9, R41.0)、跌倒、跌倒(Falling (Falling R29.6R29.6,,R26.81R26.81,accidental falls, ICD E880~E888),accidental falls, ICD E880~E888)等等

Multiple diagnosis or problems in frail elderly: Multiple diagnosis or problems in frail elderly:

the "sumthe "sum"" is greater than the is greater than the ""partsparts““–– No single diagnosis alone might justify an admissionNo single diagnosis alone might justify an admission

–– A multitude pf diagnoses might equal an A multitude pf diagnoses might equal an ““acuteacute”” admissionadmissionPractical Geriatric Assessment 1998

Overzealous LabelingOverzealous Labeling

OverdiagnosisOverdiagnosis �� overtreatmentovertreatment

–– Disorientated Disorientated �� dementia dementia ��

–– A urinary accident A urinary accident �� incontinence incontinence ��

–– Acute urinary retention Acute urinary retention �� neurogenicneurogenicbladder bladder ��

Diagnostic labels implying incurable Diagnostic labels implying incurable problems (e.g., dementia & incontinence) problems (e.g., dementia & incontinence) should should notnot be used until a careful search be used until a careful search for correctable causes has been for correctable causes has been undertakenundertaken

Features of Acute Care for the ElderlyFeatures of Acute Care for the Elderly

Comprehensive assessmentComprehensive assessment

Multidisciplinary approachMultidisciplinary approach

Avoidance of Avoidance of iatrogenesisiatrogenesis

Review of medical careReview of medical care

Early rehabilitationEarly rehabilitation

Independence in self careIndependence in self care

Discharge planningDischarge planning

Advance directivesAdvance directives

Environmental modificationEnvironmental modification

Prescribing in the ElderlyPrescribing in the Elderly

DonDon’’t t

Never start treatment without clear Never start treatment without clear

endpoints in mindendpoints in mind

Start lowStart low

Go slowGo slow

Always return to measure the outcomeAlways return to measure the outcome

Protocols in Primary Care Geriatrics

Prescribing in the ElderlyPrescribing in the Elderly

Beware of enforced complianceBeware of enforced compliance

Review outpatient medications for Review outpatient medications for

appropriateness and efficacyappropriateness and efficacy

One thing at a timeOne thing at a time

Keep it simpleKeep it simple

Risk reducing drugs regularlyRisk reducing drugs regularly

Protocols in Primary Care GeriatricsClin Geriatr Med 1998;14(4)

Prevention of the Prevention of the

Dysfunctional SyndromeDysfunctional Syndrome

Reduced

Impairment

Functional

Older Person

Improved Mood,

Positive

Expectations

Prehab Program for

Patient-Centered Care

Prepared Environment

Interdisciplinary Collaborative Care

Multidimentional Assessment

Nonpharmacologic Prescription

Medical Review

Home Planning

Informal Network

Transitional Care

Decreased Decreased

Iatrogenic Iatrogenic

Risk FactorsRisk Factors

Clin Geriatr Med 1998;14

SUBACUTE

RE

QU

IRE

ME

NT

OF

RE

HA

BIL

ITA

TIO

N

TIME OF ADMISSION

AC

UT

E I

LL

NE

SS

ACUTE CHRONIC/REHAB

Activity Orders for Activity Orders for Hospitalized Medical PatientsHospitalized Medical Patients

If bed rest is indicated for medical condition:If bed rest is indicated for medical condition:–– Active/passive ROMActive/passive ROM to limbs q2h while awaketo limbs q2h while awake

If bed rest is not indicated for medical condition:If bed rest is not indicated for medical condition:–– Q2h position change into Q2h position change into upright positionupright position; progress ; progress

from bed to chair during day as much as toleratedfrom bed to chair during day as much as tolerated

–– Active ROM for ankles and knees q2h while awakeActive ROM for ankles and knees q2h while awake

–– Progress to Progress to q2h ambulate with assistanceq2h ambulate with assistance; progress to ; progress to independence in transfer and ambulation as toleratedindependence in transfer and ambulation as tolerated

–– q2h toiletingq2h toileting while awake (use bedside commode as while awake (use bedside commode as needed, progress to bathroom as tolerated)needed, progress to bathroom as tolerated)

–– Toileting q2Toileting q2--4h during night as needed4h during night as needed

Clin Geriatr Med 1998;14(4)

Questions Considered to Facilitate Questions Considered to Facilitate

DecisionsDecisions

What will happen if the patient is untreated?What will happen if the patient is untreated?

Will Will nontreatmentnontreatment lead to increased suffering?lead to increased suffering?

What are the possible indirect consequences What are the possible indirect consequences

of of nontreatmentnontreatment??

What are the treatment options?What are the treatment options?

Are there reasonable alternative treatments?Are there reasonable alternative treatments?

Would Would ““slowing downslowing down”” a disease be a a disease be a

reasonable alternative to attempting cure?reasonable alternative to attempting cure?

Taking Care: Ethical Caregiving in our Aging Society

The President’s Council on Bioethics, 2005

Information Most Important to Patients Information Most Important to Patients

Facing a LifeFacing a Life--threatening Illnessthreatening Illness

Most ImportantMost Important

–– chances of surviving chances of surviving

–– resultant health state resultant health state

Moderate Importance Moderate Importance

–– Impact on familyImpact on family''s livess lives

Least Important Least Important

–– Length of hospital stay,Length of hospital stay,

–– probability of institutionalizationprobability of institutionalization

–– amount of painamount of pain

–– ICUs, ventilators etc. ICUs, ventilators etc.

HeylandHeyland Chest 2006Chest 2006

After After ExplanantionExplanantion ……

* * 最後與病人及其照顧者，共同擬訂照護計畫最後與病人及其照顧者，共同擬訂照護計畫

Procedures with Potential ComplicationsProcedures with Potential Complications

Diagnostic proceduresDiagnostic procedures

–– Cardiac catheterizationCardiac catheterization

–– ArteriographyArteriography

–– Computed tomographyComputed tomography

Therapeutic proceduresTherapeutic procedures

–– Intravenous therapyIntravenous therapy

–– Urinary cathetersUrinary catheters

–– NasogastricNasogastric tubetube

–– TransfusionTransfusion

– Dialysis

– Fluid aspiration

– Surgery

– Colonoscopy

– Biopsy

– Blood drawing

Markers for Initiation of Palliative Markers for Initiation of Palliative

Care in GeriatricsCare in Geriatrics

DiseaseDisease--independent independent

markersmarkers

–– FrailtyFrailty

–– Functional dependenceFunctional dependence

–– Cognitive impairmentCognitive impairment

–– Symptom distressSymptom distress

–– Family support needsFamily support needs

DiseaseDisease--specific markersspecific markers–– Symptomatic congestive Symptomatic congestive

heart failureheart failure

–– Chronic lung diseaseChronic lung disease

–– StrokeStroke

–– CancerCancer

–– Recurrent infectionRecurrent infection

–– Degenerative joint disease Degenerative joint disease causing functional disability causing functional disability and chronic painand chronic pain

–– EndEnd--stage liver diseasestage liver disease

–– EndEnd--stage renal diseasestage renal disease

Geriatric Palliative Care 2003

高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點高齡友善健康照護的優點

增進病患的身體、心增進病患的身體、心

理及社會功能理及社會功能

降低死亡率降低死亡率

減少住院天數或次數減少住院天數或次數

避免不必要的護理之避免不必要的護理之

家的安置家的安置

不增加醫療成本不增加醫療成本

可增進診斷的正確性及可增進診斷的正確性及

整體性整體性

偵測出可處理的新問題偵測出可處理的新問題

減少藥物的過度使用減少藥物的過度使用

減少住院的後遺症減少住院的後遺症

提供病患社會資源需求提供病患社會資源需求

Lancet 1993;342:1032-6 J Am Geriatr Soc 2002;50:792

NEJM 2002;346:905

NEJM 1984;311:1664

NEJM 2002;346:905

Issues in Discharge Planning (1)Issues in Discharge Planning (1)

Patient wishes and valuesPatient wishes and values

PrognosisPrognosis

Functional status on dischargeFunctional status on discharge

Need for aidesNeed for aides

Social support systemSocial support system

Financial resourcesFinancial resources

Primary Care Geriatrics

Issues in Discharge Planning (2)Issues in Discharge Planning (2)

Availability of communityAvailability of community--based servicesbased services

Home modifications needed for safetyHome modifications needed for safety

Need for skilled home medical servicesNeed for skilled home medical services

Need for transitional living arrangement Need for transitional living arrangement

(nursing home, assisted living)(nursing home, assisted living)

FollowFollow--up medical careup medical care

Primary Care Geriatrics

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