13. ผู้สูงอายุและหน่วยฉุกเฉิน
Older patients (≥65 years) usually treated
by ED physicians are estimated to be “near 40%”.
In contrast, international epidemiological data show a
prevalence of elderly patients (about 18% of all users,
ranging between 11 and 23%)
Salvi, F., et al., Intern Emerg med 2007
14. 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.
15. 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
20. 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 Abuse
How many cases of elder abuse have you
reported over the past year?
Is an elder abuse protocol available in
your emergency department?
21. 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 Abuse
ส่วนใหญ่เป็น Psychological Abuse และ Neglect
25. Older Patients in the Emergency
Department…What Are the Risks?
Margaret R. Nolan, MSN, GNP-C
26. 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
27. 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
30. 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
31. Most probable cause of delirium
Three 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
32. 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
33. CAM Criteria
• Acute onset or Fluctuating Course
• Inattention
• Disorganized thinking
• Altered level of consciousness
34. CAM Worksheet
I. 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 YES
II. 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
35. CAM Worksheet
III. 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
36. CAM Worksheet
IV. ALTERED LEVEL OF CONSCIOUSNESS
Overall, 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 Yes
From 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
37. Mini-Mental State
Examination (MMSE)
Add points for each correct response Score Points
Orientation
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
38. Mini-Mental State
Examination (MMSE)
Registration Score Points
3. 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 calculation
4. Serial sevens. Give one point for each correct
answer. Stop after five answers. Alternate: ____ 5
Spell WORLD backwards.
39. Mini-Mental State
Examination (MMSE)
Recall Score Points
5. Ask for names of three objects learned in
question 3. Give one point for each correct ____ 3
answer.
Language
6. Point to a pencil and a watch. Have the patient
name them as you point. ____ 2
7. Have the patient repeat “No ifs, ands
or buts” ____ 1
40. Mini-Mental State
Examination (MMSE)
Score Points
8. 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. ____ 3
9. Have the patient read and obey the following
“CLOSE YOUR EYES.” (write it in large letters) ____ 1
10. 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
41. Mini-Mental State
Examination (MMSE)
Score Points
11. 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
42. Cognitive Testing
Normal placement of hands
Abnormal
“concrete” clock.
44. 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)
45. Geriatric Depression Scale:
GDS-Short Form
Choose the best answer for how you felt over the past week.
1. Are you basically satisfied with your life? yes/no
2. Have you dropped many of your activities and interests? yes/no
3. Do you feel that your life is empty? yes/no
4. Do you often get bored? yes/no
5. Are you in good spirits most of the time? yes/no
6. Are you afraid that something bad is going to
happen to you? yes/no
7. Do you feel happy most of the time? yes/no
45
46. Geriatric Depression Scale:
GDS-Short Form
8. Do you feel helpless? yes/no
9. Do you prefer to stay at home, rather than going our and
doing new things? yes/no
10. Do you feel you have more problems with memory
than most? yes/no
11. Do you think it is wonderful to be alive now? yes/no
12. Do you feel pretty worthless the way you are now? yes/no
13. Do you feel full of energy? yes/no
14. Do you feel that your situation is hopeless? yes/no
15. Do you think that most people are better off than
you are? yes/no
46
47. Geriatric Depression Scale:
GDS-Short Form
This is the scoring for the scale. One point for each of these
answers. 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
48. 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.65
Hoyl, MT et al. Development and Testing of a Five-item Version of the Geriatric Depression Scale. JAGS.
47:873-78, 1999.
