老年医学的误区-卒中.ppt

Click to edit Master title style,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,正确对待老年,-,医学,2007,年,7,月美国医学会,(AAMC),和,John A.Hartford Foundation,确认老年病医生掌握老年医学知识最低标准,:,认知和行为疾病,药物管理,自我管理,跌倒,平衡,步态疾病,疾病非典型表现,舒缓治疗,住院病人照料,健康促进与管理计划,健康与长寿,老年生理,疾病表现与评估,老年社会学,老年口腔问题,谵妄,营养不良,疼痛与临终管理,老人卫生管理,老年糖尿病,睡眠障碍,老年医疗误区,痴呆、卒中与治疗,老年人口学,老年流行病学,老年伦理,褥疮管理,跌倒与骨折,震颤与巴金森病,老年护理,老年用药,老年健康服务与政策,健康服务的计划与财务,老年病培训内容,(,联合国老年研究所,),误区一,以为老人的实际年龄,与生理年龄一样,Assuming all older people are alike,mistaking chronological age for physiological age,实际年龄、生理年龄与心理年龄,不同年龄段男女性别差异,能否以年龄决定老年医疗服务模式,老年妇女的实际状况是,85,岁以上老人中仅有,36%,是男性,85%,的尿失禁病人是女性,75%,住护理院老人是妇女,80%,妇女患有骨质疏松者,80%,独居老人是妇女,90%,已婚妇女存活时间超过配偶,误区三,关注治愈疾病而不是,管理慢病,Focusing on curing disease rather than managing chronic diseases which cant be cured,老年医学的目的,照料与治疗,促进功能改善，提高生存质量,三级预防,个案管理,Case management,疾病管理,Disease/care management,自我管理,Self-care support/management,Level 1 （65%）,单一慢病患者,Level 2（30%）,重病患者,Level 3（5%）,多重疾病患者,基础预防,老年病管理,误区四,用一元化解释老年病因,Assuming that there is always just one etiology responsible for illness in an older patient,老年病的特点,慢病急性发作,多病共存,非典型发作,老年医学原则,以病人为本,多学科模式,病人主动参与,误区五,没有认真评估听力和视力,Not carefully evaluating hearing,and vision,听觉损害,发病率,:,65-74 years=24%,75 years =40%,国家卫生干预研究,:,30%of community-dwelling older adults,30%of,85 years are deaf in at least one ear,Nadol,NEJM,1993,Moss Vital Health Stat,1986.,视觉损害,严重视力障碍,(,差于,20/200),71-74 years 1%,90 years17%,patients17%,视力障碍发病率,71-74 years 7%,90 years39%,Nursing home patients19%,Salive ME Ophthalmology,1999.,误区六,不了解老人住院会出现许多潜在问题,Not being aware of the many potential problems that often develop when an older person is hospitalized,老人常见疾病发病率,抑郁,15%,步态不稳,8-19%,听力问题25-30%,视力问题,26%,性功能障碍,25-50%,营养不良,20%,尿失禁,30%,认知障碍,12%,虐待老人,3-10%,误区七,以为卧床休息是老年患者恢复的良好方式,Assuming that bedrest is a beneficial intervention in the ill older person,长期卧床并发症,褥疮,骨吸收,体位性低血压,肺炎,血栓性静脉炎和血栓栓塞,尿失禁,便秘,肌肉挛缩,Dr.Blooms,老年病人住院的十条诫律,尽早让病人下床活动,简化药物方案,尽早去除静脉和其它导管,避免束缚,评估和监测智能和认知状况,Bloom P.Mount Sinai School of Medicine,6),谵妄是急症表现，镇静药慎用,7),催眠药不要过量,8),关注抑郁症,9),注意营养，补充营养素,10),在住院时决定出院标准，与病人和家属共同决定治疗方案。,Bloom P.Mount Sinai School of Medicine,Dr.Blooms,老年病人住院的十条诫律,误区八,以为选用药物和使用计量对老人和成人是相同的,Assuming that the choice and dosing of medications is the same in older persons as in younger adults,老人药效改变,Pharmacodynamic Alterations,受体数量和功能的改变,靶器官反应程度改变,自我调节机制改变,-,体位控制,-,直立循环反应,-,体温调节,-,内脏平滑肌功能,常见药物副作用,疲倦,嗜睡,反应下降,便秘,腹泻或失禁,食欲下降,混乱,跌倒,抑郁或失去兴趣,虚弱,震颤,幻觉,焦虑或兴奋,晕厥,性欲下降,皮疹,误区九,没有认识和适当的治疗,抑郁症,Not recognizing and not properly treating depression,痴呆、抑郁和谵妄,Dementia,Depression,Delirium,Depression:Burden,65,岁以上老人发病率为,1%:,女性中,1.4%,男性中,0.4%,发病,(Weissman et al 1988).,2%,老人有精神抑郁,4%,老人有适应障碍,(Blazer et al,1987),15%,老人有抑郁症状但没达到诊断标准,(Koenig and Blazer,1992).,住院老人,:,最高到,40%,护理院,:12-16%,之间,(Weissman et al,1991).,误区十,过度诊断或,未能诊断痴呆,Over-diagnosing or under-diagnosing dementia,误区十一,忽略营养的重要性,Ignoring the importance of nutrition,误区十二,低估尿失禁的发病率,和不良影响,Underestimating the prevalence and negative impact of urinary incontinence,误区十三,未能作出疼痛诊断,和不适当治疗,Under-diagnosing and inadequately treating pain,影响疼痛管理的因素,(1),没有进行疼痛评估,(2),老人药物治疗存在潜在风险,(3),不了解非药物治疗疼痛方法的效果和老人的态度,误区十四,对气候变化没有足够关注,Not paying enough attention to the devastating effects of extremes in hot or cold weather,误区十五,以为睡眠障碍是衰老的,正常现象,Assuming that sleep problems are a normal part of aging,Ancoli-Israel S,Roth T.,SLEEP,.1999;22(Suppl 2):S347-S353.,Ancoli-Israel.,SLEEP.,2000;23:S23-S30.,Ancoli-Israel S,Cooke JR.,J Am Geriatr Soc.,2005;53:S264-271.,老人睡眠障碍的影响,注意力下降,反应力下降,记忆下降,动作准确力下降,抑郁与焦虑,可能误认为是痴呆,嗜睡,Alzheimers Disease,Parkinsons disease,Psychiatric disorders,Stroke,Arthritis,Prostate disease,Heart disease,Reflux,Peptic ulcer,Respiratory,diseases,Hypertension,Sleep apnea,Restless Legs,REM Behavior Disorder,Renal Disease,Diabetes,Immune,Diseases,Conditions Associated With Sleep Disturbances in the Elderly,Nocturia,原发睡眠疾病发病率,疾 病,成人,老人,睡眠呼吸暂停,1%-8%24%-40%,周期性肢体运动,5%30%-45%,不宁腿综合征,2%-15%12%-30%,Young T,Ancoli-Israel S,et al.,SLEEP.,2001.Mant E,et al.,Age and Ageing.,1992.Ancoli-Israel S,et al.,SLEEP.,1993.Phillips BA,et al.,SLEEP.,1994.Hoch CC,et.al.,SLEEP.,1994.OKeefe ST,et al.,Age and Ageing.,1994.Phillips B,et al.,Arch Int Med.,2000.Allen R,et al.,Arch Int Med.,2005.,误区十六,没有采取预防措施,Not having enough time to do important preventive measures,美國預防服務工作小組（,USPSTF,）,:65+,老人干预,摄用物质,戒烟,开车,游泳和驾船时戒酒,戒药,运动和饮食,控制脂肪和胆固醇,;,保持热量平衡,;,保证谷物,蔬菜和水果,足量的钙,(,特别是妇女,定期运动,美國預防服務工作小組（,USPSTF,）,:65+,老人干预,(contd),预防损伤,膝盖肩膀护带,摩托自行车头盔,防跌倒,烟感器,设置热水器低于,50C,家庭成员进行心肺复苏训练,口腔卫生,定期看口腔医生,含氟牙膏,关注疾病而,忽视身体和认知功能,Paying too much attention to diseases and not enough attention to physical and cognitive functioning,误区十七,老年综合评估,老年病评估是关于老人智能、情感、功能、社会、经济、环境，以及心理方面的全面评估，其目的是合理的利用医疗保健资源,改善生活品质，减少住院需求，促使其独立生活。,老年病房常用评估量表，包括日常生活活动量表、简易智能状态测验、老年人精神忧郁量表，跌倒评估表、吞咽困难及营养评估表等。,Table.Screening Tools for Geriatric Assessment,最大独立最小依赖,Maximization of independenceMinimization of dependence,误区十八,没有足够重视运动或身体活动的重要性,Not adequately emphasizing the importance of exercise or physical activity,活动方式：,有氧运动加速心跳和呼吸，有益于心血管功能。,强度和柔韧性运动可保持强壮的骨骼和肌肉,。,规律活动的益处：,增强体能,保持健壮的骨骼，肌肉和关节,增加肌肉的耐力和强度,控制体重,减少心血管病，结肠癌和糖尿病的危险因素,控制血压,促进心理健康和自信心,减少压抑和忧郁,误区十九,我能治好老人的病,Trying to deliver care by oneself.,老 年 医 学,多学科团队模式,谢谢关注,