老年住院患者的综合管理

衰老、共病、老年综合征、老年问题等多方面因素共同作用,影响老年人的健康情况和功能状态,需要进行全面的老年综合评估来发现老年住院患者各个方面的问题,针对可以处理、能够逆转的问题进行个体化的干预,才能使老年患者真正获益。除了针对入院疾病的诊疗之外,还要重视相关的老年问题,采取跨学科团队干预,可以有效地处理其健康问题,改善老年患者的功能状态、提高生活质量。     

Improving influenza vaccination rates for high-risk inpatients.

PURPOSE: In 1987, the Minneapolis Veterans Affairs Medical Center implemented an ongoing, multifaceted influenza vaccination program that targeted all high-risk outpatients followed at the medical center. While the program achieved and sustained vaccination rates of 60% or more for high-risk outpatients, vaccination rates for high-risk inpatients continued to be 25% or less. Beginning with the 1989-1990 immunization season, the "flu shot" program was extended to include all high-risk inpatients. Both the outpatient and inpatient components of the Minneapolis Flu Shot Program emphasized administrative and organizational elements. The program's goal was to achieve vaccination rates of at least 60% for both high-risk outpatients and inpatients. This study assesses the effectiveness of the inpatient program among elderly patients hospitalized on the medical service during the immunization season. PATIENTS AND METHODS: To estimate patient risk characteristics and vaccination rates, 50% of elderly patients who were discharged from the medical service during the immunization season were surveyed using a validated postcard questionnaire. Their responses were compared with the responses of elderly patients to the annual outpatient survey conducted to assess the "flu shot" program. RESULTS: Overall, 78.6% of elderly respondents discharged from the medical service during the immunization season were vaccinated. Vaccination rates within various high-risk subgroups all exceeded 70%. None of these vaccination rates for inpatient groups differed significantly from the rates for corresponding outpatients. CONCLUSION: An outpatient "flu shot" program that emphasizes administrative and organizational elements can be successfully expanded to high-risk inpatients. The vaccination rates attained with such a program may not only achieve but exceed the national health objective for influenza vaccination.     

Graduated compression stocking thromboprophylaxis for elderly inpatients

BACKGROUND: Graduated compression stockings (GCS) are often used for deep vein thrombosis prophylaxis in nonsurgical patients, although evidence on their effectiveness is lacking in this setting. OBJECTIVE: To determine whether prophylaxis with GCS is associated with a decrease in the rate of deep vein thrombosis in nonsurgical elderly patients. METHODS: Using original data from 2 multicenter nonrandomized studies, we performed multivariable and propensity score analyses to determine whether prophylaxis with GCS reduced the rate of deep vein thrombosis among 1,310 postacute care patients 65 years or older. The primary outcome was proximal deep vein thrombosis detected by routine compression ultrasonography performed by registered vascular physicians. RESULTS: Proximal deep vein thrombosis was found in 5.7% (21/371) of the GCS users and in 5.2% (49/939) of the GCS nonusers (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.64-1.84). Although adjusting for propensity score eliminated all differences in baseline characteristics between users and nonusers, the OR for proximal deep vein thrombosis associated with GCS remained nonsignificant in propensity-stratified (adjusted OR, 1.11; 95% CI, 0.59-2.10) and propensity-matched (conditional OR, 0.92; 95% CI, 0.42-2.02) analysis. Similar figures were observed for distal and any deep vein thrombosis. The rates of deep vein thrombosis did not differ according to the length of stockings. CONCLUSIONS: Prophylaxis with GCS is not associated with a lower rate of deep vein thrombosis in nonsurgical elderly patients in routine practice. Randomized studies are needed to assess the efficacy of GCS when properly used in this setting.     

老年性痴呆的合理用药

阿尔茨海默病（AD）是最常见的老年期痴呆类型。人们对此病的认识越来越深入,但迄今针对AD的药物治疗种类尚比较有限,且总体欠缺规范化。本文对AD的合理用药进行了较系统的讨论,以期通过相对合理化的用药尽可能改善或延缓AD的症状进展。     

Inappropriate medication prescribing for elderly ambulatory care patients

BACKGROUND: Inappropriate medication use in elderly patients has been linked to a large share of adverse drug reactions and to excess health care utilization. METHODS: Trends in the prevalence of potentially inappropriate drug prescribing at ambulatory care visits by elderly persons from 1995 to 2000 were examined with data from office-based physicians in the National Ambulatory Medical Care Survey and from hospital outpatient departments in the National Hospital Ambulatory Medical Care Survey. Explicit criteria were used to identify potentially inappropriate prescribing. Multivariate regression was used to identify related factors. RESULTS: In 1995 and 2000, at least 1 drug considered inappropriate by the Beers expert panel was prescribed at 7.8% of ambulatory care visits by elderly patients. At least 1 drug classified as never or rarely appropriate by the Zhan expert panel was prescribed at 3.7% and 3.8% of these visits in 1995 and 2000, respectively. Pain relievers and central nervous system drugs were a large share of the problem. The odds of potentially inappropriate prescribing were higher for visits with multiple drugs and double for female visits. The latter was due to more prescribing of potentially inappropriate pain relievers and central nervous system drugs. CONCLUSIONS: Potentially inappropriate prescribing at ambulatory care visits by elderly patients, particularly women, remains a substantial problem. Interventions could target more appropriate drug selection by physicians when prescribing pain relievers, antianxiety agents, sedatives, and antidepressants to elderly patients. Such behavior could eliminate a large portion of inappropriate prescribing for elderly patients and reduce its higher risk for women.     

The efficacy of influenza vaccine among geriatric inpatients

To investigate the efficacy of influenza vaccine in the elderly, hemagglutination inhibition (HI) antibody titer for the three types of influenza viruses were measured and the influenza infection rate was determined serologically in geriatric inpatients. Influenza vaccination was done for inpatients. For patients who had influenza vaccination in the year prior to the study, influenza vaccine was administered once or twice, and the number of injections were determined randomly. Influenza vaccine was injected twice to those had not received influenza vaccine in the previous year. Serum samples were collected from 166 vaccinated and 104 unvaccinated patients before and after 1996/1997 influenza season. In the vaccinees who had been vaccinated the previous year, 56 patients were injected once and 58 patient were injected twice. Fifty-two patients had not been vaccinated the previous year. Serologically diagnosed influenza infection rate in the 104 unvaccinated patients was 16.3% for influenza A/H3N2 and 8.7% for influenza B. The infection rate was 3.0% for influenza A/H3N2 and 0.6% for influenza B in the 166 vaccinated patients. The infection rates were significantly lower in the vaccinees than in the unvaccinated patients (p < 0.001 with A/H3N2 and p < 0.01 with B). There was no significant difference in the infection rate among the three vaccinated groups. These results suggest that the influenza vaccination had significant protective efficacy for influenza infection in the elderly. Prior vaccination did not diminish the efficacy of the influenza vaccine. The efficacy of a single influenza vaccine injection was equivalent to that of two injection.     

老年人脑血管病的合理用药

脑血管疾病是一类发病率高、致残率高和死亡率高的疾病,急性脑血管病又称为脑卒中。老年卒中患者较青年卒中患者预后较差。规范化诊疗有利于降低其死亡率和致残率。药物治疗为脑血管病治疗的主要方式之一,但老年人存在代谢慢、血管弹性差、常并发多器官疾病等特点,应考虑其特殊性给予合理用药。急性缺血性脑卒中（AIS）和脑出血（ICH）为老年人中最常见的脑血管病,本文主要针对其合理药物治疗进行总结和概述。     

Antidepressant use in elderly medical inpatients

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was halted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was cnducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antide-pressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy. Supported by the Sandoz Pharmaceutical Corporation, Center for the Study of Aging and Human Development, Duke University Medical Center (grant #AG00371), the Mellon Foundation, and the Clinical Research Center for the Study of Depression in the Elderly, NIMH (grant #MH40159).     

Dysgraphia in elderly delirious medical inpatients

BACKGROUND AND AIMS: Dysgraphia is a recognized clinical finding in delirium, but few studies have evaluated handwriting, and results have been inconsistent. In particular, handwritten signatures, which may be a motor automatism, have not been previously evaluated in delirious patients. The aim was to assess abnormalities of signature and spontaneous writing in delirious patients and to investigate their clinical utility in the detection of delirium. METHODS: Secondary analysis of data was collected from a prospective observational study of acutely ill inpatients 70 years or older. Mini-Mental State Examination, Confusion Assessment Method, Delirium Rating Scale, Activities of Daily Living, and APACHE II were administered to each subject, their signatures were evaluated from the consent form, and their handwriting from the spontaneous sentence written as part of the MMSE. RESULTS: The signatures of patients with delirium were significantly more impaired than those without (Chi-square= 14.749, df=1, p<0.0001). The sensitivity of the signature for delirium as defined by CAM was 0.54, with specificity of 0.88. Handwriting abnormalities of omission (p=0.018), illegibility (p=0.034) and spelling (p=0.035) were significantly more common in delirious patients than others (Chi-square with Fisher's Exact tests. This difference was mainly attributable to the fact that a large number of delirious patients were unable to provide any response to the handwriting questions. CONCLUSIONS: An abnormal signature may be an indicator of delirium. People with delirium have handwriting problems, which may be partly caused by cognitive impairment but also by disorders of motor function.     

老年脑卒中住院患者12OO例治疗模式分析

目的 比较老年脑卒中住院患者普通模式和卒中单元模式治疗结果的差异,探讨脑卒中治疗的规范化管理模式,提高疗效,减轻病残程度,降低病死率.方法 2002年4月至2007年4月入住我院的急性脑血管病患者1200例,按单双数入住卒中单元和普通病房.观察指标包括病死率、住院时间、生活能力评价(BI)、神经功能评价(NIHSS)、社会功能评价(OHS),出院时患者或家属满意度评分,分析卒中单元的效果.结果 卒中单元组并发症和病死率明显低于普通病房组,病死率分别为5.0%和13.5%(χ2=26.66,P<0.01);出院时BI、NIHSS、OHS、满意度评分比较,卒中单元组明显优于普通病房组(P<0.05);卒中单元组住院时间短于普通病房组,分别为(24.1±9.1)d和(25.3±10.5)d(t=2.12,P<0.05),但两组住院费用差异无统计学意义(P>0.05).结论 卒中单元模式有利于脑卒中患者治疗和康复,可改善患者肢体活动能力,提高生活质量,降低病死率;与传统疗法相比,不会增加患者费用.     

Efficacy and safety of influenza vaccination to elderly patients with neurological diseases]

Influenza vaccination is strongly recommended for the elderly persons. Especially elderly patients with neurological diseases are at the high risk because they have more tendencies to develop pneumonia than healthy elderly persons. We vaccinated 105 elderly patients with neurological diseases (cerebrovascular disease, Parkinson disease etc.) and 134 people of a control group. Both groups were inoculated with influenza HA vaccine once. The HI titer increase in elderly patients with neurological diseases was equally good enough in the control group and no significant differences was shown in both groups. No severe side effects and adverse reactions were observed in the elderly patient group. This study shows that influenza vaccination is effective and safe for elderly patients with neurological diseases as the well as healthy elderly person and the HI titer increase after a single influenza vaccine injection is expected to be effective to protect influenza infection.     

综合医院老年住院患者联络会诊精神医学服务模式探讨

目的：通过对某三级甲等医院老年病房的住院患者进行老年综合评估CGA,并在此基础上提供联络会诊精神医学服务（CLPS）,对如何提高综合医院老年住院患者精神医学服务的可及性进行探索。方法回顾性地分析2009年9月至2012年8月期间入住该医院老年示范病房的患者（年龄≥65岁）,入院时接受CGA（Zung自评抑郁量表和Zung自评焦虑量表）,必要时进行老年多学科团队查房和精神医学会诊。由精神科医师根据国际疾病分类标准-10（ICD-10）做出精神科诊断。经过上述CLPS的老年患者与同期其他病房接受应邀精神科会诊的老年患者（年龄≥65岁）进行比较。结果老年病房共146例患者接受CLPS,其他病房共520例患者接受应邀会诊精神医学服务。老年病房的会诊率为28.2%,显著高于其他病房1.5%的会诊率（P＝0.000）。接受精神医学服务的前3位原因在老年病房分别为情绪问题（44.5%）、随诊问题（16.4%）和内科疾病无法解释的症状（10.3%）;在其他病房分别为情绪问题（37.9%）、精神问题（20.4%）和内科疾病无法解释的症状（10.1%）,两者比较差异有统计学意义（P＝0.000）。老年病房前3位精神科诊断为神经症及应激相关障碍（29.7%）、情感障碍（26.9%）和器质性精神障碍（21.4%）;其他病房为神经症及应激相关障碍（35.0%）、器质性精神障碍（28.8%）和情感障碍（16.5%）,两者比较差异有统计学意义（P＝0.001）。结论以CGA、精神科访谈和多学科治疗团队联合查房模式进行的CLPS可提高综合医院老年住院患者的精神科会诊率,上述医学服务模式值得在综合医院推广。     

住院患者老年综合评估规范及初步效果分析

目的：探讨在老年住院患者中进行老年综合评估（CGA）对于老年人全面综合管理的作用。方法制定标准的CGA流程,采用标准流程对北京协和医院老年病房2013年9月至2014年9月连续入院的≥65岁患者进行CGA,分析其筛查老年综合征的效果。结果标准化的评估流程便于临床使用,接受评估的179例患者中,年龄（72.5±8.1）岁。通过CGA发现,视力异常患者占62.0%,睡眠障碍41.3%,听力异常40.8%,慢性疼痛34.6%,跌倒25.7%,多重用药23.5%,便秘21.8%,抑郁焦虑18.4%,尿失禁16.2%,谵妄10.6%。以不同主诉入院的15例患者最终诊断为老年综合征,占8.4%。结论老年综合征在老年患者中普遍存在,运用标准化的CGA方法可以进行有效筛查,有利于老年患者的全人管理。     

老年住院患者自我忽视的现状调查

目的 探讨老年住院患者自我忽视的现状及影响因素,为自我忽视的预防和干预提供依据。方法 采用便利抽样法选取临沂市3所医院2019年6月至9月收治的320例老年住院患者为研究对象,进行自我忽视情况的调查及影响因素分析。采用SPSS 25.0统计软件进行数据分析,采用logistic回归分析自我忽视的相关因素。 结果 老年人自我忽视量表应用于老年住院患者的Cronbach′s α 系数为0. 886,提取5个公因子的累计贡献率为75%。老年住院患者自我忽视总分为11.00(5.00,15.00)分,5个维度中得分最高的是卫生自我忽视3.00(0.00,4.00) 分,其次分别是情感自我忽视2.00(1.00,4.00) 分、医疗自我忽视2.00(0.75,4.00)分、安全自我忽视1.50(0.00,4.00)分、社会交往自我忽视1.00(0.00,3.00)分。logistic 回归分析结果显示,年龄、性别、经济压力、文化程度、独居是老年住院患者自我忽视的危险因素。结论 老年人自我忽视量表应用于老年住院患者的信效度良好。老年住院患者自我忽视的水平较高,相关医疗部门应采取措施,加强预防和干预,降低其自我忽视的水平,促进老年住院患者的身心健康。     

Suicide attempts in elderly psychiatric inpatients.

OBJECTIVE: To describe the psychopathological characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit. DESIGN: Retrospective chart review. PATIENTS: All 168 patients age 60 years and over treated on the adult psychiatric inpatient unit of Yale-New Haven Hospital from 1979 to 1984. Twenty-five made a suicide attempt. MAIN OUTCOME MEASURES: Presence and severity of suicide attempts were rated and compared with demographic, clinical, and functional data. RESULTS: (1) Eighty percent of the attempters had a major depressive syndrome; (2) among patients with affective disorders, presence of an attempt was significantly associated with a later age of onset; (3) patients who had made more severe attempts were more likely to be diagnosed as psychotic depression, although this trend was not significant; (4) substance abuse and dementia were uncommon diagnoses; (5) symptomatic and functional outcome of hospitalization was as favorable for the attempters as for the entire elderly cohort. CONCLUSIONS: Affective illness, especially late-onset major depression, was the major association with suicide attempts.