Ayako Shibata

Image: Photo AC

Geriatric Emergency Department Guidelines

高齢者とER

the American College of Emergency Physicians

ERと高齢者

• On average, the geriatric patient

20% longer ED length of stay

50%more lab/imaging services

400% more likely to require social services

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

高齢者の定義

• WHO

defined the older population starting at age 60

・Fries, et alの３つの分類

1. 65-74 yo : the young old

2. 75-85yo : the middle old

3. >85 yo : the oldest old

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

高齢者救急アセスメント表

高齢者にやさしいER設計

• 座りやすい・立ち上がりやすい椅子・ベット

• 滑りにくい床・マット

• 高齢者に配慮したライト(soft light )

While older adults require three to four times as much lightas young adults for visual clarity. soft light is recommended, but

exposure to natural light is also shown to be beneficial for recovery

times and decreasing delirium

• 聴覚補助デバイス

・ 室温の調節・体温調節用ブランケット

• 褥瘡予防マット

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

高齢者と配色

■見にくい色 ：cool colors 緑 青

■見やすい色：warm colors 黄色 オレンジ

■暗いところでも目立つ ：黄色

■注意を集める ：オレンジ 赤

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

フォーリー適用を厳格に

Polypharmacy～高齢者と内服薬

・Taking 5 medications

50-60%chance of a drugdrug interaction

・Taking 10 or more medications

90% chance of a drug-drug interaction

“Beers criteria” でチェックする

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

Beers criteria polypharmacy

http://tinyurl.com/BeersMeds2012

高齢者の転倒時アセスメント

・年齢・転倒歴・靴や服装は歩行に適切だったか・日常のADL・歩行困難度・バランス(小脳・体幹失調)

・転倒場所・理由・倒れていた時間・失神・起立性低血圧・意識障害の有無・下血・黒色便・基礎疾患 dementia, Parkinson’s,stroke,

diabetes, hip fracture and depression

・視覚障害・神経障害(抹消神経障害)

・飲酒内服薬・心電図・採血(貧血・電解質異常)

・外傷・骨折

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

認知症とせん妄

せん妄は、入院高齢患者の25%に起こると言われている

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

高齢者のせん妄疑いでは1. MUST Rule OUT

・感染症(特にUTI、肺炎)

・薬物(抗コリン薬、新規薬)

・電解質異常

・アルコールwithdrawal

・脳梗塞・脳卒中

2.評価

脱水、視野・聴覚障害(メガネ・補聴器)、認知症

http://www.annemergmed.com/article/S0196-0644(14)00118-8/abstract

1.Don’t recommend percutaneous feeding tubes in patients

with advanced dementia; instead offer oral assisted feeding.

2.Don’t use antipsychotics as first choice to treat behavioral and

psychological symptoms of dementia.

3.Avoid using medications to achieve hemoglobin A1c <7.5%in most adults age 65 and older; moderate control is generally better.

4.Don’t use benzodiazepines or other sedative-hypnotics

in older adults as first choice for insomnia, agitation or delirium.

5.Don’t use antimicrobials to treat bacteriuria in older adults

unless specific urinary tract symptoms are present.

http://www.americangeriatrics.org/files/documents/

Five_Things_Physicians_and_Patients_Should_Question.pdf

1.Don’t prescribe cholinesterase inhibitors for dementia

without periodic assessment for perceived cognitive benefits and adverse

gastrointestinal effects.

2.Don’t recommend screening for breast or colorectal cancer, nor prostate

cancer (with the PSA test) without considering life expectancy and the

risks of testing, overdiagnosis and overtreatment.

3.Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize

social supports, provide feeding assistance and clarify patient goals and

expectations.

4.Don’t prescribe a medication without conducting a drug regimen review.

5.Avoid physical restraints to manage behavioral symptoms

of hospitalized older adults with delirium.

http://www.americangeriatrics.org/files/

documents/5things_list_PART.pdf