高齢者救急のガイドラインや論文資料のまとめです

1. Ayako Shibata
Image: Photo AC
Geriatric Emergency
Department Guidelines
高齢者とER
the American College of
Emergency Physicians

2. 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

3. 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

4. 高齢者救急アセスメント表

5. 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 light
as 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

6. 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

7. フォーリー
適用を
厳格に

8. 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

9. Beers criteria polypharmacy
http://tinyurl.com/BeersMeds2012

11. 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

12. 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

13. 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

14. 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

15. 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