'' MD FRCP London

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• ??.??. ???????? ?????????? MD FRCP (London)
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????????? 93 ??
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  ???????????? NPO - BS

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Symptoms - weakness - fatigue - anorexia -
undernutrition - weight loss Signs - physiologic
changes - balance gait -deconditioning

• 1.Decline in physiologic
• function reserve
• 2.Disease

- falls - injury - acute illness -
hospitalization - disability - dependency - death
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• ?????????????? 20.
• ???????????? 279-387 ?????? 1000 ??.
• ????????? 6 ?????????????? 24.1 (????)
  12.1(???)
• ????????????????????????????????? 2.23
  ?????????

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  ?????????? ??????? 75
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• ?????
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• ??????????? (Hypothermia)
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• delirium
• loss of confidence
• anxiety
• depression

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• carers anxiety
• increased demand of social support
• need safer environment

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Aging Changes Fall

• ???????????????????
• Sensory inputs
• Vision
• Proprioceptive sense mechanoreceptor
• Vestibular function moving head
• Central information processing
• cerebrum, cerebellum, basal ganglia, brain stem
• Muscular activity

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CAUSES of FALLS

• 1.Insufficient lighting 1.Orthostatic
  hypotension
• 2.Unfamiliar surroundings 2.Circulatory
  disorders
• 3.Slippery floor 3.Neurological
  diseases
• 4.Objects in awkward 4.Musculo-skeletal
  disease
• places 5.Acute illness

EXTRINSIC
INTRINSIC
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• Orthostatic Hypotension
• -Low cardiac output
• Volume depletion diuretics, potent
  vasodilators, prolonged bed rest, impaired
  venous return
• ANS dysfunction DM, Parkinsons
  disease
• -Drug-induced antihypertensives,
• antipsychotics, sedatives,
  hypoglycemics,
• alcohol, tricyclic antidepressants

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• Circulatory system diseases
• Vasomotor syncope micturition, defecation, cough
• Arrhythmias
• Myocardial ischemia / infarction esp. silent MI
• Valvular heart disease aortic stenosis

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• Neurological diseases
• -Stroke / TIA both anterior and posterior
  circulations
• -Cerebellar disease
• -Parkinsons disease
• -Seizure
• -Vestibular disease
• -Peripheral nervous system disease peripheral
  neuropathy, cervical / lumbar spondylosis

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• Vision
• Cataract
• Macular degeneration
• Presbyopia
• Inappropriate spectacles
• Adverse drug reaction
• Benzodiazepine
• - chlormethiazole, lormetazepam, temazepam,
  midazolam, Iorazepam,
• - nitrazepam, flurazepam, flunitrazepam,
  diazepam,
• nordazepam

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• Acute illness Final Straw Syndrome
• Infection UTI, pneumonia
• Hypoxemia CHF, PTE
• Musculoskeletal arthritis, muscle wasting,
  proximal myopathy
• Chiropody corn, in-growing toe nail, bunion
• Metabolic hypo/hyperglycemia, acute renal
  failure
• Electrolyte imbalance hyponatremia

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• Dementia
• Depression
• Phobia
• Secondary gain

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Physical Examination of Fall

• Complete and thorough examination
• - Degree of injury
• - Physiologic aging changes
• - Precipitating factors
• Some special tests
• - Get-up-and-go test
• - Performance-oriented mobility assessment
• - Rombergs sign with slight push rollator

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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, NPH

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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, chronic
  alcoholism, progressive supranuclear palsy,
  thiamin deficiency, 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 peripheral neuropathy, prolonged pressure,
  DM, alcoholism, B12 deficiency
• 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
• Dementia-related gait
• Slow speed, decreased step length, increased
  double-support time, increased step-to-step
  variability, increased postural sway
• Marked flexed posture
• Gait apraxia but must exclude frontal lobe
  lesion, NPH

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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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Multisensory Deficit Gait

• Concurrent visual and proprioceptive impairment,
  vestibular dysfunction
• Dizzy, lightheadedness when walk or turn around,
  using canes or touch walls or other furnishings
• DM
• Antalgic Gonalgic Gait
• Painful hip and knee conditions, reluctant to
  place weight on the affected limb, avoid heel
  strike and push-off, less knee extension during
  gait

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• ??? ???????????
• ???????????????????? 2 ??????
• ???????? ???????????????????? (spontaneous fall)
• primary prevention health promotion
• secondary prevention risk factors
• ???????????????????????? (accidental fall)

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Accidental fall__environment

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• 1043 elderly subjects living in the urban area
  around Siriraj Hospital Medical School, Bangkok.
• 585 -- study group vs. 458 -- control group.
• A leaflet containing information on important
  risk factors of fall within their community. In
  addition, this particular group was allowed free
  access to the geriatric clinic at Siriraj
  Hospital if there was any health problem.
• Followed up every 2 months for 1 year

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• The Kaplan-Meier survival analysis of fall

P 0.012
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???????????????????

• RAMPS
• The big Is
• Abnormal gait balance ? falls ? morbidity
  mortality
• Screening those at risk during clinical practice
• - Get-up-and-go test
• - Performance-oriented mobility assessment
• Treat correct predisposing precipitating
  factors
• intrinsic extrinsic factors

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Incontinence

• ???????
• Involuntary and inappropriate passage of urine
  and/or feces
• ???????
• Urinary incontinence 10-15
• Fecal incontinence 3-7

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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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• ?????????????????????

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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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Drugs affect Continence

• Diuretics Polyuria
• Anticholinergics Urinary retention, Fecal
  impaction
• Antidepressants Anticholinergic, Sedation
• Tranquilizers Anticholinergic, Sedation,
  Rigidity
• Narcotic analgesics Urinary retention, Fecal
  impaction
• Alpha-blockers Urethral relaxation
• Alpha-agonists Urinary retention
• Beta-agonists Urinary retention
• Calcium channel blockers Urinary retention
• Alcohol Polyuria, Sedation, Delirium

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Persistent Incontinence

• 1. Stress Leakage of urine (small amounts)
  with increases in intraabdominal pressure
• 2. Urge Leakage of urine (larger volume) due
  to inability to delay voiding after sensation of
  fullness
• 3. Overflow Leakage of urine (small amounts)
  from urinary retention
• 4. 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

• 1. Stress Pelvic floor, Bladder outlet or
  Urethral sphincter weakness
• 2. 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, Multiple
  sclerosis
• 4. Functional Severe dementia, Depression,
  Impaired mobility, Environmental barriers

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??????????????????????????????????

• ????????
• BMI lt 18.5
• ???????????????????????????
• ?????????
• 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)