..

2557

1
2
13

21

37

47

59

71

79

89

10

11

12

(Geriatric assessment)
..




(comprehensive geriatric assessment)

1.
2. (basic activity of daily living - BADL)
(instrumental activity of daily living - IADL)
3. (dementia; cognitive impairment)
4. (incontinence)
5. (fall)
6. (malnutrition)
7. (depression)

R-A-M-P-S
R - Reduced body reserve

A - Atypical presentation

13

 geriatric syndromes

big Is
Instability

Immobility

Incontinence

Intellectual impairment

(delirium) (dementia)

Iatrogenesis

(adverse drug reaction)

Inanition

M - Multiple pathology
P - Polypharmacy

(adverse drug reaction) (

)
S - Social adversity

(heterogeneity)

4

14

1. (physical assessment)


( get-up-and-go test )
( Mini-Nutritional Assessment : MNA
) bigs I (visual acuity)

1.

5D deafness () dysphasia () depression ()
delirium () dementia ()

2.

otoscope (ear wax impaction)
(presbycusis)

(hearing aids)

3.

4. motor aphasia

5. (recent memory)

6.

7.

Mini-Nutritional Assessment: MNA

15


1.

2. atherosclerotic cardiovascular disease

1.

80

2. (functional assessment) BADL IADL

ADL

BADL IADL

1. polypharmacy

2.

geriatric syndromes

bigs I

1. (vital signs)

1.1

10 / 5 .
10 10 .

16

atrial ibrillation

50

white-coat hypertension white-coat effect

- (Target organ damage)

- 2

(postprandial hypotension)

(postural hypotension)
end organ damage pseudohypertension white coat hypertension

1.2

atrial ibrillation

1.3 98oF hypothermia

1.4 Cheyne-Stokes respiration

2.
: parkinsonism, hypothyroidism, anemia, depression
: (visual acuity) fundoscopy

cataract pupillary constriction systemic illness glaucoma, senile macular

degeneration
: ear wax impaction, external otitis

17

 : periodontal disease
: range of motion cervical spondylosis thyroid, jugular
venous pressure , carotid bruit transmitted cardiac murmur

: aortic valve sclerosis murmur aortic stenosis

70 S4 acute ischemic
heart disease
: elasticity chest wall, crepitation
2 - 3 atelectasis
: ibrocystic disease nipple retraction
nipple
candidiasis
: spinous process compression fracture vertebrae, kyphosis, scoliosis
buttock, sacrum, trochanter
: anterior superior iliac spine multiple vertebral collapse

: full bladder fecal mass abdominal aortic aneurysm pulsation

antero-posterior lateral direction aneurysm

: (PR)

: cystocele urinary retention acute pyelonephritis

: (diabetic ulcer) (onychogryphosis) (callus), bunion
: mental status examination, sign absent ankle jerk, decreased

vibratory sense , frontal lobe releasing signs palmomental, grasping, glabella, snout relex

get-up-and-go test hemiplegic, par-

kinsonian, sensory ataxic, apraxic waddling gait

2. (mental assessment)
(delirium) (depression) (dementia)
20 1

(mental status) Abbreviated Mental Test (AMT), Thai Mental State

Examination (TMSE), Chula Mental test (CMT) Mini-Mental State Examination-Thai 2002 (MMSE-2002)

(Confusion Assessment Method : CAM) (Geriatric Depression Scale : GDS)
( clock drawing test, MoCA, ADAS-cog)

18

3. (Social assessment)

(carer caregiver)

bed-blocker

(nosocomial infection) (elderly abuse)

4. (functional assessment)

1. (BADL) Barthel index

()

2. (Instrumental ADL)

(multidisciplinary team
approach)

90

delirium, dementia

19

1. . . : ., .
2 : ; 2554. 1-14.
2. . . : .,
I. : ; 2552. 753-773.
3. Hodkinson, HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age and
Ageing. 1972;1(4): 2338.
4. Granger CV, Dewis LS, Peters NC, Sherwood CC, Barrett JE. Stroke rehabilitation: analysis of repeated Barthel index measures.
Arch Phys Med Rehabil. 1979;60:14-7.

20

..

21

22

23

24

25

26

27

28

29

30

4.6


(late age-related maculopathy) (optic atrophy)
(corneal opacity)
Snellens chart 5
6.116

16.3 12.5
2.7 8 4.317
presbycusis
otoscope audiometry

4.7


83.6
(varices) 18




4.8 ( 6 )

3.3 10
5 - 10 19
(subdural hematoma)
USPSTF (Mini-Mental State Examination : MMSE)

(cognitive impairment)

14 MMSE

31

4.9

7 1320
SIG: E-CAPS Sleep (), Interest ( ) Guilt
( ) Energy ( ) Concentration () Appetite (
) Psychomotor agitation and/or retardation ( )
Suicidality ()
1 - 2 (2Q)
2
2
1
9 (9Q) Thai Geriatric Depression Scale (TGDS)
4.10
(hypothyroidism)

Thyroid Stimulating Hormone (TSH)
(subclinical hypothyroidism) TSH
radioactive iodide

4.11

()

phenytoin, carbamazepine phenobarbital
(malabsorption)


USPSTF 65 60 - 65
9 National Osteoporosis Foundation
65 70 50-69
21 .. 2553
65 70 22

85

32


.. 2553
(clinical risk factors), Osteoporosis Self Assessment Tool for Asians (OSTA)
index, Khon Kaen Osteoporosis Score (KKOS), nomogram for osteoporosis Fracture Risk Assessment
Tools (FRAXTM)22 OSTA index 0.2 x ( - ) -4

OSTA index ( -4 -1)
65
5 2
4.12 ( 4 )



anticholinergic

(immobility)
1
get-up-and-go test
3

(orthostatic hypotension)

1.
(immunization)
(chemoprophylaxis) (screening)


2.


3.




4.

33

34

35

36

...

37

38

39

40

41

42

43

44

45

46

..

65 75 0.3 1.6
75 6
24.1 12.1 1
10.1 20 6
50

1
58
27

2
1. /


(accidental fall)

47



(spontaneous fall)

(predisposing factor)

"" ""
(precipitating factor)
2. spontaneous fall








1.
(cerebellar disease) normal pressure hydrocephalus deconditioning state

2. (postural hypotension)


3. (macular degeneration)

4.
(vasomotor syncope)


5.

6. cognitive impairment

48



1.

2.

3.

4. (hallux valgus)

5.

6. hyponatremia, hypokalemia

(delirium)

49





( : Timed
Up and Go Test (TUGT) (Falls Risk Assessment tool) )
Romberg
(proprioceptive sense)
postural relex
"startle reaction"
1-2
(dorsilexion)
basal ganglia
get-up-and-go test
3

postural hypotension

timed get-up and go test 10
29 (frail)
15
(gait assessment)

- Frontal lobe gait frontal apraxia
magnetic gait
(shufling and hesitant step)
(frontal lobe) normal pressure hydrocephalus
(vascular dementia)
- Spastic gait hemiparesis hemiplegia
(lexed hip, extended knee, plantar-lexed foot)
(circumduction)
visual neglect (hemianopia)

50

 paraparesis cervical spondylitic myelopathy, amyotrophic lateral sclerosis

(bilateral circumduction)
scissoring gait
- Cerebellar ataxic gait

(tandem gait)
(en bloc turn) spinocerebellar
atrophy, progressive supranuclear palsy
- Sensory ataxic gait proprioceptive sense
proprioceptive sense
Romberg posterior column, peripheral nerve,
dorsal root of spinal cord diabetic neuropathy, spinal cord compression, spinocerebellar degeneration
- Festinating gait
(shufling)

hydrocephalus
- Steppage gait

pretibial peroneal foot drop
- Waddling gait
(rotation)
gluteus limb girdle (hypothyroidism)
(hyperthyroidism) (osteomalacia) polymyositis




(thyroid function
test) creatine phosphokinase electromyography

51

52

53


3

1. (Primary prevention)

3

2. (Secondary prevention)

4

3. (Tertiary prevention)

.. 2008 Active Ageing

3

1.

2.

3.

54

.. 2551

55

56

57

58

..







(protein energy malnutrition)


sarcopenia (hypoalbuminemia)
(postural hypotension)

(cognitive function)
(pharmacokinetics)

sulfonylurea

1 - 2
15 23 62
85


(body mass index : BMI) 18.5 ./2
13-27 16-39
20-39 60 - 69 70 - 79 80

59

 60 69

5 - 24
11 - 39 18 - 54 60 - 69 70 - 79 80

4
1.

(xerostomia)
80 80

2.




3.

(bereavement)



(wandering)

60

4.






4.1

. digoxin, theophylline, luoxetine

. opioids

. anticholinergic, sympathomimetic

. metronidazole, metformin, angiotensin-converting enzyme inhibitor, calcium-channel blocker,


. digoxin, theophylline, opiate,
(nonsteroidal anti-inlammatory agent)


. theophylline, sertraline


4.2


4.3
(denture)
(xerostomia) anticholinergic


4.4 (chronic inlammatory bowel disease)


4.5
(, ephedrine) essential tremor, pheochromocytoma


4.6



4.7
5 3

61

(anthropometry)
Mindex () Demiquet ()
- (body mass index : BMI)

BMI =

/2

- Mindex

Mindex =

- Demiquet

Demiquet = /2

()2
/

(demispan )

(demispan )2

2

1.
(kyphosis) (scoliosis)

2.

(demispan)
Mindex Demiquet (demispan) suprasternal notch
metacarpophalangeal joint
(extensor surface)

62

3.5

5 () 3
10
(Body mass index : BMI) 18.5 ./2
Mindex Demiquet Mindex (
) Demiquet () 55.95 ( 56) . 75.6 ( 76)
.2

(anthropometry)
hemoglobin
prealbumin, transferrin, retinol-binding protein, insulin-like growth factor-1 ibronectin
(total cholesterol) 156 ./.

63

64

65



1. (Primary prevention)



2. (Secondary prevention)

3. (Tertiary prevention)





1.

2. (Demispan)

3.

4.
(Life style modiication)


5.




1

66



1
Mini-Nutritional Assessment (MNA)
15
(internet) http://www.mna-elderly.com/forms/MNA_thai.pdf

4 (anthropometry)

6 < 11
> 12
17 23.5 17
96 98 positive
predictive value 97 meta-analysis

MEALS - ON - WHEELS

(Mnemonics)

67



1.

MNA, MEALS ON - WHEELS

2.

(nasogastric tube)




(Parenteral nutrition)

3. (orexigenic drug)

megestrol acetate
HIV
(luid retention) (lushing) deep vein thrombosis adrenal
insuficiency cyproheptadine
anticholinergic
(Benign prostatic hypertrophy)

4. (antidepressant)
mirtazapine
62

68

 selective serotonin reuptake inhibitor

5.

1. , , .
. : ; 2542.
2. , .
. : ; 2542.
3. , .
. : ; 2542.
4. , .
. : ; 2543.
5. . . : .
. 4 : ; 2556. 369397.
6. Assantachai P. Anthropometric aspects and common health problems in older adults. In: Preedy VR, ed. Handbook of
Anthropometry: Physical Measures of Human Form in Health and Disease. London: Springer; 2012. p. 14151434.
7. Assantachai P, Yamwong P, Lekhakula S. The study of alternative anthropometric measurements for the Thai elderly:
mindex and demiquet. Asia Paciic J Clin Nutr. 2006;15:521-7.
8. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature--What does it tell us ? J Nutr Health Aging.
2006;10: 466-85.
9. Wilson M-MG, Morley JE. The diagnosis and management of protein energy undernutrition in older persons. In: Morley JE,
Miller DK, editors. Annual Review of Gerontology and Geriatrics Focus on Nutrition. New York: Springer; 1995. p. 110-42.

69

70

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|
(Dementia)

'B`h`iod(
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xz
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(

'x
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x}x
x

x
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x
x
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(visuospatial:
)


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}

z
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x
z x

z
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|

z z
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3

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cognitive function: ()
1.
n
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(the cognitive impairment should be acquired )
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2. (impair of multiple domains of cognitive function )
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3. (no impair of arousal )
1- x | 'dhkdm ja hpgodkg` _jhdin ja ^jbidodq` api^odji (

2-
(dementia) The Diagnostic and
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2

Statistical Manual of Mental Disorder (5th edition) (DSM-V )

x x} x}~ | '_`h`iod( x Rc`
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Qoodnod^g Kipg ja K`iog Bdnjm_`m '4oc `_dodji( 'BQK,T ('1(

1. (behavioral and psychological symptoms of dementia)
o {ns l |l \ knn n - z #-*1$ zn{

2. ( = visuospatial)
0- | x z x

3. (reasoning and justment/executive function)
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5. (memory)
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6. (attention)
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3- x x x 'gibpb`(
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4- |z } 'h`hjmt(
cognitive function
5- } }| 'oo`iodji(

z x | x y ||}x |z | x}~ |

~ '_`gdmdph( }}xxx}~z |x } x }x
Framingham cohort3 4
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7

64

71



cognitive impairment cognition
6 (perceiving) (remembering)
(imagining) (thinking) (reasoning) (judgment)

72


(Alzheimers disease : AD)
degenerative change 3-5% 65
35-40% 85 7 AD/DAT

45
3

(1-3 ) short term memory

AD/DAT


construction

(instrumental activities of daily living IADL) /
irritability sadness, apathy
rigidity awareness depression separation
motor system, EEG CT scan

(2-10 )



self hygiene (
() ) ()
(IADL)
motor system-restlessness, EEG CT scan

(3-12 )
/ /

() 2-20
8-10

AD/DAT

(visuospatial)

73

 AD/DAT ( )


AD/DAT

Degenerative Vascular dementia
reversible dementia complete ( dementia drugs, depression, metabolie, toxic and vitamin deiciency, normal pressure hydrocephalus

Test Folstein mini-mental state (MMSE) 9
cognitive function ( orientation, recall, registration, language
visuospatial ability) ( 3) MMSE score = 30


27-30 (Normal)


25-26 (Possible dementia)


10-20 (Mild-moderate dementia)


6-9 (Moderate-severe dementia)


< 6 (Severe dementia)

-



-



-

1. ()

( counseling )

2.
ABC


A = ADL (Activity of Daily living) :


B = Behavioral and psychological symptom of dementia :






C = Cognition :

B C ()

74

75


Sleep disturbances

cognitive function
1 reversible dementia

76

77

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72

78

(Adverse drug reactionin the elderly)

..


(pharmacokinetics)
(pharmacodynamics)
1 5 1 3
2 3 2 3
6.7 (adverse drug reaction)
(systematic review)4
10.7
16.6 2 88
1 4 2

5
(anticoagulant) (antiplatelet)
1 3
4 (delirium)
10-15

Gurwitz nursing home
6 ()
3
5
anticholinergic7

79


(delirium)



14
anticholinergic 8

Edward
(hazard)

9 6 1
1 ( 9)

80



10

(deinite diagnosis)
deinite diagnosis

11
11,12 2
(provider-based strategies) (system-based strategies)
13 (provider-based strategies)


1. (high risk drugs)
(inappropriate
medications for older persons)14,15 2 3

81


2.

3.

4. (interaction)

5.

6. (non-adherence)

82

 2 (potentially inappropriate medications, PIM)

( 7,14,15)

83

 3 (potentially inappropriate medications, PIM)

( 14)

(system-based strategies)

Medication Reconciliation (MR)
16
(
, /, , OPD) 17 MR
55 4

84

: medication reconciliation OPD review PIM
2
: medication reconciliation OPD IPD
review PIM 2 3

medication reconciliation (MR)


MR OPD 4

MR MR form

MR IPD 24
MR form admit


PIM 2 PIM 3

review potentially inappropriate medications Beers
criteria14

85

86

87

88

90

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91

92

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1.2



1.3 /

.......................................................
2.
10 /

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95

1-5 1

96

 14
1 1
2 1 2 1
3
4

97


: Abbreviated Mental Test (AMT)

98

: MMSE-Thai 2002

: MMSE-Thai 2002

99

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100

101

2 (2Q)

102

(2 )

 9 (9Q)

103

: Timed

: Timed Up and Go Test (TUGT)

Up and
Go Test (TUGT)

104

 :
:
( M : od Mass nde )
(BMI : Body Mass Index)

105

106

107

 (ADL)

108

109

110

111

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x
yx

- } |
- x xy | xy
- x x |z yx y | x
y
- |
-
- z |z|x| zyxy | xy
- |zx
- - | z
x
x x
} |{ | |
- - ~ x }
z
|
z
- - - x z
x x
z
- - - x |
z |x |z
x x
z
- - - -
| |xx
x x
- --- | -
z
x x
} |x
- |
x|y}-
x x

x x
- | }
} |{ | |
- | } ~

x x
} |{ | |
- |} --011

117

- |}

} |{

} |{

} |{

} |{

} |{

} |{

- | z
- | x
- | x

- | x
- |

x x
| |
x x
| |
x x
| |
| |
| |
| |

- } |
- } xy | xy
- x zy xy |
- | x | zx x
-

| |
|

- -

012

118

x

x

x
yx
x
yx
x
yx

2557

119

120