Nationwide Survey of Health Status and Quality of Life of Thai Elderly in the Elderly Club

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  ???????????? NPO - BS

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Philosophy in Preventive Geriatrics

• Primary prevention (Health promotion)
• Secondary prevention
• Tertiary prevention

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Action Plan in Preventive Geriatrics

• Comprehensive geriatric assessment
• Appropriate intervention and monitoring
• (according to the findings in assessment)

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Comprehensive geriatric assessment

• Physical assessment
• Mental assessment
• Social assessment
• Functional assessment

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Comprehensive geriatric assessment

• Physical assessment
• History of fall, incontinence
• Pain assessment
• Drug history polypharmacy!
• Nutritional history
• Life-style smoke, drink, exercise, aids
  appliances
• Vaccinations influenza, tetanus, pneumococcal ?

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Geriatric Giants - atypical presentation

• Instability (Fall)
• Immobility
• Intellectual impairment
• Incontinence
• Inanition
• Iatrogenesis

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Innovation in Get-up-and-go-test

• Timed get-up-and-go test
• sit, stand from arm-chair, walk 3 meters,
  turn, walk back to chair and sit down
• one trial run before timed test
• Categorical scale scoring
• lt 10 sec. freely mobile
• lt 20 sec. mostly independent
• 20-29 sec. variable mobility
• gt 29 sec. impaired mobility

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Abnormal Gait in Old Age

• Frontal lobe gait (frontal ataxia or apraxia)
• Difficult gait initiation and sway, wide-based,
  flexed posture, small shuffling, hesitant step
• Magnetic gait, slipping clutch syndrome
• DDx Alzheimers disease
• Vascular dementia
• Normal pressure hydrocephalus

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Abnormal Gait in Old Age

• Sensory Ataxic Gait
• Wide-based, foot stamping walk with high stepping
  due to loss of proprioceptive input, constantly
  observe the foot position
• Rombergs sign positive
• DDx - Thiamin deficiency
• - Subacute combined degeneration of spinal
  cord
• - Spinal cord compression
• - Diabetic neuropathy

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Cerebellar Ataxic Gait

• Wide-based, small irregular unsteady, staggering,
  sudden lurching to either side, forward or
  backward like being drunk
• Abnormal tandem gait, en bloc turning
• Poor coordination proprioceptive, labyrinthine,
  visual
• DDx vestibular damage, stroke, thiamin
  deficiency
• chronic alcoholism, progressive supranuclear
  palsy, hypothyroidism, drug intoxication

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Spastic Gait

• Hemiplegia
• - Stiff, flexed hip, extended knee,
  plantar-flexed foot
• - Affected arm flexed elbow across abdomen,
  impaired arm swing, toe scraping or dragging
  across the floor
• - Visual neglect or hemianopia
• Paralegia (scissoring gait)
• - Cervical spondylitic myolopathy, Subacute
  combined degeneration of spinal cord, chronic
  cord compression, lacunar infarcts

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Steppage gait

• Lifting the feet hight off the ground due to foot
  drop (pretibial, peroneal muscle weakness)
• DDx (peroneal nerve injury)
• Lumbar disc herniation(L4, L5, S1),
• Sciatic nerve trauma, spondylolisthesis,
• spinal stenosis, spinal cord injury,
• bone fractures (leg, vertebrae),
• stroke, tumor, DM,
• prolonged pressure

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• Festinating Gait
• Symmetric rapid shuffling of feet,
• stooped posture, flexed hip and knee
• Centre of gravity shifted forward
• DDx Parkinsonism, vascular dementia,
  hydrocephalus

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Podalgic Gait

• Foot disorders corns, calluses, in-growing toe
  nails, bunion, atrophy of plantar pads
• Loose or tight-fitting footwear

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Wadding Gait

• Duck or penguins walk
• Limb girdle muscle weakness, lateral trunk
  movement away from the foot as it lifts
• Difficulty climbing stair, getting up from
  low-seated chair
• DDx hypo / hyperthyroidism,
• polymyositis, osteomalacia
• proximal myopathy

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Urinary incontinence

• - Urine secretion - 100 ml / hour
• - Fullness - 300 ml
• - Normal bladder capacity - 300-600 ml
• - Discomfort - 600 ml
• - Desperate or desire to micturate - 750 ml
• - Bladder pressure lt 15 cm of water
• - Postvoid residual volume lt 100 ml

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Mechanism of Micturition
Spinal cord
Hypogastric Plexus
C
T 11
T 12
L 1
L 2
B
D
Bladder
A
S 2
S 3
S 4
E
Pelvic floor
A Parasympathetic cholinergic . Bladder
contraction
B Sympathetic .... Bladder relaxation
C Sympathetic .... Bladder relaxation
D Sympathetic .. Bladder neck and urethral
contraction
E Somatic (Pudendal nerve) .... Contraction of
pelvic floor musculature
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Urinary Incontinence

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Causes of Acute Reversible Forms of Urinary
Incontinence

• D Delirium
• R Restricted mobility, Retention
• I Infection, Inflammation, Impaction (fecal)
• P Polyuria, Pharmaceuticals

Urinary Tract Infection, Atrophic vaginitis,
urethritis.
Hyperglycemia, Congestive heart failure.
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Persistent Incontinence

• Stress Leakage of urine (small amounts) with
  increases in intraabdominal pressure
• Urge Leakage of urine (larger volume) due to
  inability to delay voiding after sensation of
  fullness
• Overflow Leakage of urine (small amounts) from
  urinary retention
• Functional Leakage of urine (larger volume)
  with inability to toilet due to impaired
  cognition, physical function, psychological,
  environmental barriers

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Causes of Persistent Incontinence

• Stress Pelvic floor, Bladder outlet or
  Urethral sphincter weakness
• Urge Overactive bladder, Detrusor
  hyperreflexia due to Cystitis, Urethritis, Tumor,
  Stone, Diverticuli,Stroke, Dementia,
  Parkinsonism, Suprasacral spinal cord injury
• 3. Overflow Obstruction by Prostate,
  Stricture, Cystocele
• DM, spinal cord injury
• Detrusor-sphincter dyssynergy
• 4. Functional severe dementia, depression,
  impaired mobility, environmental barriers

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• BMI lt 18.5
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• BMI gt 22.9
• ?????????? abdominal circumference
• 90 cm. ????? 80 cm. ??????

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?????????????????????????? MEALS ON WHEELS

• M medications
• E emotional (depression)
• A alcoholism, anorexia, abuse of the elders
• L late-life paranoia
• S swallowing problems (dysphagia)
• O oral problems
• N no money (poverty)

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• W wandering and other dementia-related problems
• H hyperthyroidism, pheochromocytoma
• E enteric problems (malabsorption)
• E eating problems
• L low salt, low cholesterol diet
• S shopping and meal preparation problems

3 common causes malignancy
depression GI problems
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• Mini Nutrition Assessment
• (MNA)

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Mental assessment

• Abbreviated mental test (AMT)
• Standard mental tests
• Thai Mental State Examination (TMSE)
• Chula Mental Test (CMT)
• Mini Mental State Examination-Thai 2002

Pay attention to recent loss of mind and family
member !!
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Abbreviated Mental Test.Age.Time (to the
nearest hour).Address for recall at end of test
should be repeated.Year.Name of
institution.Recognition of two persons (doctor,
nurse, etc.).Date of Birth (day and month
sufficient).Year of marry, important event.Name
of present monarch.Count backwards 20 to 1
Scoring 0-3 severe, 4-7 moderate,
8-10 normal
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Screening for depression

• In practice ask 2 questions
• Over the past 2 weeks, have you felt down,
  depressed, or hopeless?
• Over the past 2 weeks, have you felt little
  interest or pleasure in doing things?

If yes for both questions, proceed to Thai
Geriatric Depression Scale
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Thai Geriatric Depression Scale Train the
Brain Forum

• http//www.si.mahidol.ac.th/project/geriatrics/Res
  earch/research2.htm

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Comprehensive geriatric assessment

• Social assessment - relationship in family
• Caregiver aware of elder abuse in dementia
• Physical abuse
• Caring abuse nutrition, drug compliance,
  pressure ulcer, incontinence, instrumentation
• Financial family support, welfare
• Environment housing, neighbor, elderly club,
  community

Pay attention to living alone, poor !!
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Comprehensive geriatric assessment

• Functional assessment
• Basic activity of daily living (basic ADL)
• transfer, mobility, toilet use, grooming,
  urine, stool, bathing, dressing, eating, stairing
• Instrumental activity of daily living (iADL)
• washing cleaning, cooking, shopping,
  financial, transport communication, drug use

Pay attention to recent loss of ADL !!
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Comprehensive geriatric assessment- Examination

• Blood pressure ? ? hypertension
• (2 positions) postural hypotension
• Body weight ? ? under-nutrition
• Special sense ? ? disability, fall
• (VA, hearing)
• Breast examination ? ? breast cancer
• Get-up-and-go test ? ? fall, immobility

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Comprehensive geriatric assessment- Laboratory

• Pap smear ? ? CA cervix
• Fecal occult blood ? ? CA colon
• Fasting blood glucose ? ? DM
• Cholesterol ? ? dyslipidemia
• TSH ? ? hypothyroidism
• Osteoporosis screen ? ? fracture
• NB PSA ??

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