老年人的預防性健康照護－從指引到臨床實務

Preventive Health Care in the Elderly-From Guideline to Clinical Practice

吳晉祥(Jin-Shang Wu) ； 黃盈翔(Ying-Hsiang Huang) ； 張智仁(Chih-Jen Chang)

《台灣老年醫學雜誌》 2卷3期 (2007/02) Pp. 145-163

https://doi.org/10.29462/TGG.200702.0001

摘要

台灣地區在1993年9月底，65歲以上的人口佔總人口之7.09%，達到高齡化社會之後，老年人口就逐年增加，慢性疾病已成爲老年人的主要健康問題。最近文獻顯示預防醫學上的定期檢查可以增進臨床上預防性健康照護的實施，並提供週期性評估在臨床應用的實證與正當性。目前國內由政府主導之全民健保成人預防保健服務、國民健康局各項癌症篩檢及醫院或健檢中心之自費健檢服務，提升了預防性健康照護的水平，然而仍有部份項目並無實證的支持。本文所敘述的預防性健康照護相關檢查是以看似健康的無症狀者爲主，另外本文也從臨床處置的角度，將老年人預防性健康照護的內容分爲病史詢問、身體檢查、實驗室篩檢、衛教諮詢介入、與預防性疫苗與用藥，其中比較有實證依據的項目如下：1)病史詢問與身體檢查：一般族群血壓、身高及體重常規檢測、憂鬱症及Snellen視力常規篩檢、詢問是否有聽力障礙、以及飲酒者的酒癮評估；2)實驗室篩檢：一般族群血清總膽固醇及高密度脂蛋白膽固醇常規篩檢、結腸／直腸癌、及乳癌篩檢，65歲之前未規則接受子宮頸抹片檢查者的子宮頸癌篩檢，高血壓及高血脂者的血糖篩檢，65至75歲曾抽菸者的腹主動脈瘤超音波篩檢，老年女性股骨頸之骨質疏鬆篩檢；3)衛教諮詢介入：一般族群喝酒不開車、乘坐汽車安全帶及騎機車安全帽使用之衛教諮詢介入，一般族群跌倒預防的運動訓練，跌倒高危險群的居家個別化多因子介入，對有高血壓、高血脂、其他心血管疾病危險因子及飲食相關慢性病患的密集式健康飲食行爲諮詢，對肥胖老年人加強飲食運動衛教諮詢及行爲介入，戒菸者之衛教諮詢及或藥物治療。4)預防性疫苗與用藥：一般族群流行性感冒疫苗、肺炎雙球菌疫苗及追加破傷風/白喉疫苗接種，對無水痘發病或預防接種史者的水痘疫苗接種，到開發中國家旅遊者的A/B型肝炎的疫苗接種，所有老年男性及十年內心血管疾病發生機率大於6%的老年女性之阿斯匹靈於心血管疾病初級預防的使用與討論，對於無子宮且無血栓栓塞之虞的乳癌高危險群以雌激素接受體調節劑（Tamoxifen或Raloxifene）作乳癌初級預防，但反對停經後女性之賀爾蒙補充治療。雖然國外已有老年人預防性健康照護的相關指引，但其與應用在臨床的實務上仍有所差距，因此可以從實證醫學的角度去追求本土經驗、異中求同，並考量實際臨床需要，提供早期診斷與早期治療，達到疾病預防與健康促進的目標。

關鍵字

老年人 ； 預防性健康照護 ； 指引 ； 臨床實務

並列摘要

In Taiwan, the population aged 65 years or older continues to increase, and the chronic conditions are the major health problems in the elderly. Recently, the evidence from a systematic review demonstrated that periodic health examination has a beneficial effect on the delivery of several clinical preventive services, justifying thereby the continued implementation of periodic health examination in clinical practice. Therefore, the need for preventive health care in older adults is expected to grow continuously and become more important in the future. In Taiwan, preventive health care has become increasingly popular as it is now covered by the National Health Insurance Program (NHIP) and private services. However, while certain guidelines have been established for the preventive services, some of the practice is not evidence-based. There remains a gap between guideline and clinical practice in the field of preventive geriatrics. A preventive service might lack evidence either because no effective studies have been performed or because the evidence is insufficient to recommend for or against the service. In this study, we focus on the evidence in asymptomatic elderly and present the content of preventive health care from the perspective of history taking, physical examination, laboratory screening, immunization, and chemoprevention. Existence of inconsistencies in some of the guidelines proposed by different medical sub-specialties in respect of preventive geriatrics makes universal recommendations difficult. History taking and physical examination form the basis of preventive health care despite of clinical evidence. We render screening recommendations for various conditions and diseases, including depression, visual and hearing impairment, cardiovascular disease, hypertension, hyperlipidemia, diabetes mellitus, obesity, and cancer. We emphasize counseling for health promotion, especially counseling on lifestyle issues, such as smoking cessation, treatment of problem drinking, proper nutrition, and exercise. Issues about immunization and chemoprevention are also discussed. The recommendations of our study derive from available evidence-based guidelines, especially those by the U.S. Preventive Services Task Force (USPSTF); other issues not recommended by the present guidelines are discussed on the basis of best current thinking.

並列關鍵字

elderly ； preventive health care ； guideline ； clinical practice