ผู้สูงอายุและหน่วยฉุกเฉิน Older patients (≥65 years) usually treated by ED physicians are estimated to be “near 40%”.In contrast, international epidemiological data show aprevalence of elderly patients (about 18% of all users, ranging between 11 and 23%) Salvi, F., et al., Intern Emerg med 2007
ผู้สูงอายุและหน่วยฉุกเฉิน Only infants go to the emergency department at a higher rate than people 75 and older, according to a recent US. Federal Government Survey.Many hospitals have set up separate emergency rooms just for kids. Now, several hospitals set up an ER specifically for patients 65 and older.
Issues related to Elderly & Emergency care• Older people are referred to the ED for medical reasons rather than for injuries• Takes longer to triage them and they spend more time in the ED• Consume more resources (laboratory studies, X-ray studies) during a clinical course• They are also more frequently admitted (30– 50% vs. 10–20% of young/adults
Case history: Mrs. A• 1991 - ED visit - Hip Contusion• 1992 - ED visit - Jaw Contusion• 1992 - ED visit - Colles’ Fracture• 1993 - ED visit - Low back pain Falls - Clumsiness ED treatment of injury• 1995 - Hip Fracture Home Visit - Elder AbuseHow many cases of elder abuse have you reported over the past year?Is an elder abuse protocol available in your emergency department?
Elder Abuse • Estimated 1 -2 million victims each year in the U.S. • Less than 10% are reported – How does this model of care contrast to our approach to child abuse? ประเทศไทยยังมีการรายงานน้อยเรื่อง Physical Abuseส่วนใหญ่เป็น Psychological Abuse และ Neglect
Older Patients in the EmergencyDepartment…What Are the Risks? Margaret R. Nolan, MSN, GNP-C
สิ่งแวดล้อมของหน่วยอุบัติเหตุและฉุกเฉิน ED Environment• Uncomfortable for older persons• High volume, high stress• Anxious, worried patients• Little privacy• Limited ED provider time• Beds, lighting, noise• Modifications can make a difference 26
ทัศนคติและการมองผู้สูงอายุเชิงลบ Attitudes and Ageism• Negative View of Aging • frail, disabled elderly • language • distorted view of elderly persons• Aging - deterioration to be avoided and feared• Aging - state of life• Misperceptions i.e., incontinence, confusion
ED Mental Status Exam• Delirium/Dementia missed in ED• Reliability of history• Symptom of medical emergency• Reversible causes Delirium - acute confusional state Dementia - impairment in memory and intellectual function
Most probable cause of deliriumThree clinically useful acronyms to take into account the most probable cause of delirium: the 7 I’s (left), DELIRIUMS(centre) and VINDICATE (right) ที่มา Salvi, F., et al., 2007
CAM Assessment• History - consistency from patient, family, caregiver, medical record• Observation over time• Structured questions • Orientation • Three-item recall • Days of week backward • Months of year backward
CAM Criteria• Acute onset or Fluctuating Course• Inattention• Disorganized thinking• Altered level of consciousness
CAM WorksheetI. ACUTE ONSET OR FLUCTUATING COURSE• Is there evidence of an acute change in mental status from the patient’s baseline? OR• Did the (abnormal) behavior fluctuate during the day (I.e., tend to come and go or increase and decrease in severity)? NO YESII. INATTENTION• Did the patient have difficulty focusing attention (e.g., being easily distractible or having difficulty keeping track of what was being said)? NO YES
CAM WorksheetIII. DISORGANIZED THINKING• Was the patient’s thinking dis- organized or incoherent (e.g., rambling or irrelevant conversa- tion, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? No Yes
CAM WorksheetIV. ALTERED LEVEL OF CONSCIOUSNESSOverall, how would you rate the patient’s level of consciousness?____ Alert (normal)____ Vigilant (hyperalert)____ Lethargic (drowsy, easily aroused)____ Stupor (difficult to arouse)____ Coma (unarousable)Do any checks appear in this box? No YesFrom Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method-a new method for detection of delirium. Ann Intern Med 1990;113:941-948
Mini-Mental State Examination (MMSE)Add points for each correct response Score PointsOrientation 1. What is the : Year? ____ 1 Season? ____ 1 Date? ____ 1 Day? ____ 1 Month? ____ 1 2. Where are we? State? ____ 1 County? ____ 1 Town or city? ____ 1 Hospital? ____ 1 Floor? ____ 1
Mini-Mental State Examination (MMSE)Registration Score Points3. Name three objects, taking one second to say each. Then ask the patient to repeat all three after you have said them. ____ 3 Give one point for each correct answer. Repeat the answers until patient learns all three.Attention and calculation4. Serial sevens. Give one point for each correct answer. Stop after five answers. Alternate: ____ 5 Spell WORLD backwards.
Mini-Mental State Examination (MMSE)Recall Score Points5. Ask for names of three objects learned in question 3. Give one point for each correct ____ 3 answer.Language6. Point to a pencil and a watch. Have the patient name them as you point. ____ 27. Have the patient repeat “No ifs, ands or buts” ____ 1
Mini-Mental State Examination (MMSE) Score Points8. Have the patient follow a three-stage command: “Take a paper in your right hand. Fold the paper in half. Put the paper on the floor. ____ 39. Have the patient read and obey the following “CLOSE YOUR EYES.” (write it in large letters) ____ 110. Have the patient write a sentence of his or her choice. (The sentence should contain a subject and an object and should make sense. Ignore ____ 1 spelling errors when scoring.)Instructor’s Manual-Case Study 40
Mini-Mental State Examination (MMSE) Score Points11. Have the patient copy the design. (Give one point if all sides and angles are preserved and ____ 1 if the intersecting sides form a quadrangle.) ___ = Total 30 In validation studies using a cutoff acore of 23 below, the MMSE has a sensitivity of 87% , a specificity of 82%, a false-positive ratio of 39.4%, and a false-negative ratio of 4.7%. These ratios refer to the MMSE’s capacity to accurately distinguish patients with clinically diagnosed dementia or delirium from patients without these syndromes. 41
Cognitive Testing Normal placement of hands Abnormal “concrete” clock.
DEPRESSION• Single Question: Do You Often Feel Sad Or Depressed? (Sen/spe-.85/.65)• 5 Item Geriatric Depression Scale (Sen/spe- .97/.85)• 15 Item GDS (Sen/spec-.94/.83)
Geriatric Depression Scale: GDS-Short FormChoose the best answer for how you felt over the past week.1. Are you basically satisfied with your life? yes/no2. Have you dropped many of your activities and interests? yes/no3. Do you feel that your life is empty? yes/no4. Do you often get bored? yes/no5. Are you in good spirits most of the time? yes/no6. Are you afraid that something bad is going to happen to you? yes/no7. Do you feel happy most of the time? yes/no 45
Geriatric Depression Scale: GDS-Short Form8. Do you feel helpless? yes/no9. Do you prefer to stay at home, rather than going our and doing new things? yes/no10. Do you feel you have more problems with memory than most? yes/no11. Do you think it is wonderful to be alive now? yes/no12. Do you feel pretty worthless the way you are now? yes/no13. Do you feel full of energy? yes/no14. Do you feel that your situation is hopeless? yes/no15. Do you think that most people are better off than you are? yes/no 46
Geriatric Depression Scale: GDS-Short FormThis is the scoring for the scale. One point for each of theseanswers. Cutoff: normal (0-5), above 5 suggests depression. 1. No 6.Yes 11. No 2.Yes 7. No 12.Yes 3.Yes 8.Yes 13. No 4.Yes 9.Yes 14.Yes 5. No 10.Yes 15.Yes Courtesy Jerome A Yessvage, MD. 47
5 ITEM GDS Yes No(1) Are you basically satisfied with your life?(2) Do you often get bored? (3) Do you often feel helpless? (4) Do you prefer to stay at home rather than going out and doing new things?(5) Do you feel pretty worthless the way you are now? 0- 1 = not depressed > 2 = depressed*Sens. 97 (.94)/Spec. 85(.83) PPV - .85 (.82) NPV - .97 (.94)Single Question Sen .85/Spec.65Hoyl, MT et al. Development and Testing of a Five-item Version of the Geriatric Depression Scale. JAGS. 47:873-78, 1999.
ประเมินผู้ดูแลและความ รุนแรงต่อผู้สูงอายุCaregiver Stress and Abuse