{"id":573,"date":"2024-04-16T10:25:54","date_gmt":"2024-04-16T07:25:54","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=573"},"modified":"2024-04-16T10:25:55","modified_gmt":"2024-04-16T07:25:55","slug":"yaslilarda-klinik-kirilganlik-olcekleri-ve-mental-degerlendirme-araclari","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yaslilarda-klinik-kirilganlik-olcekleri-ve-mental-degerlendirme-araclari\/","title":{"rendered":"Ya\u015fl\u0131larda Klinik K\u0131r\u0131lganl\u0131k \u00d6l\u00e7ekleri ve Mental De\u011ferlendirme Ara\u00e7lar\u0131"},"content":{"rendered":"\n

Giri<\/strong>\u015f<\/strong><\/p>\n\n\n\n

Son y\u00fcz y\u0131lda modern t\u0131bb\u0131n geli\u015fmesi ve hayat standartlar\u0131n\u0131n y\u00fckselmesiyle beraber art\u0131k g\u00fcn\u00fcm\u00fczde insanlar\u0131n \u00e7o\u011fu 70\u2019li ya\u015flar\u0131 ve \u00f6tesini ya\u015famay\u0131 beklemektedir. Neredeyse t\u00fcm \u00fclkeler n\u00fcfuslar\u0131ndaki ya\u015fl\u0131 pop\u00fclasyonunda art\u0131\u015f tecr\u00fcbesini ya\u015famaktad\u0131r. Ya\u015flanan toplumlardaki bu demografik ge\u00e7i\u015f s\u00fcreci beraberinde kronik hastal\u0131klar, fiziksel k\u0131s\u0131tl\u0131l\u0131klar, mental yetersizlikleri de getirmektedir [1]. Acil servisler ya\u015fl\u0131 hastalar i\u00e7in 24 saat eri\u015filebilir bir giri\u015f kap\u0131s\u0131 olarak sa\u011fl\u0131k bak\u0131m\u0131n\u0131n geli\u015ftirilmesinde e\u015fsiz bir role sahiptir. \u2018Ya\u015fl\u0131 dostu acil servisler\u2019 in \u00f6neminin ve say\u0131s\u0131n\u0131n g\u00fcn ge\u00e7tik\u00e7e artt\u0131\u011f\u0131 geli\u015fmi\u015f sa\u011fl\u0131k sistemlerinde geriatrik hastalar\u0131n klinik k\u0131r\u0131lganl\u0131k d\u00fczeylerinin ve akut mental durum de\u011fi\u015fiklerinin belli skorlamalarla \u00f6l\u00e7\u00fclmesi adeta alt\u0131nc\u0131 vital bulgu haline gelmi\u015ftir [2]. Bu blog yaz\u0131m\u0131zda klinik k\u0131r\u0131lganl\u0131ktan ve mental durum \u00f6l\u00e7me ara\u00e7lar\u0131ndan s\u00f6z edece\u011fiz.<\/p>\n\n\n\n

K\u0131r\u0131lganl\u0131k Kavram\u0131<\/strong><\/p>\n\n\n\n

K\u0131r\u0131lganl\u0131k; ya\u015flanman\u0131n etkisiyle geli\u015fen metabolik, genetik, \u00e7evresel ve davran\u0131\u015fsal fakt\u00f6rlerin rol oynad\u0131\u011f\u0131 bir s\u00fcreci ifade eder. Bu s\u00fcre\u00e7te multisistemik fonksiyonlarda ve fonksiyonel rezervlerde azalma, d\u0131\u015f stres\u00f6rlerin etkisiyle ortaya \u00e7\u0131kan advers olaylarda art\u0131\u015f g\u00f6r\u00fcl\u00fcr. Gold standart bir tan\u0131mlama yap\u0131lamad\u0131\u011f\u0131 i\u00e7in, klinik pratikte hastalar\u0131 \u2018k\u0131r\u0131lgan\u2019 ya da \u2018k\u0131r\u0131lgan de\u011fil\u2019 olarak dikotomik bir ay\u0131r\u0131ma tutmak m\u00fcmk\u00fcn de\u011fildir. Elbette ki klinik \u00e7al\u0131\u015fmalarda belli e\u015fik de\u011ferler baz al\u0131narak bu ay\u0131r\u0131ma gidilse de, klinik pratikte as\u0131l \u00f6nemli olan k\u0131r\u0131lganl\u0131\u011f\u0131n d\u00fczeyidir. \u201cFried\u2019in k\u0131r\u0131lganl\u0131k fenotipi\u201d bu subjektif k\u0131r\u0131lganl\u0131k kavram\u0131n\u0131 bir tak\u0131m klinik \u00f6zellikler ile de\u011ferlendirerek belli bir \u00e7er\u00e7eve i\u00e7ine koymak i\u00e7in faydal\u0131d\u0131r. Fried fiziksel k\u0131r\u0131lganl\u0131\u011f\u0131 \u015f\u00f6yle a\u00e7\u0131klam\u0131\u015ft\u0131r; (1) istemsiz olarak bir y\u0131lda v\u00fccut a\u011f\u0131rl\u0131\u011f\u0131n\u0131n %5\u2019ten fazlas\u0131n\u0131n kaybedilmesi, (2) hastan\u0131n kendi bildirdi\u011fi t\u00fckenmi\u015flik hissi, (3) tutma-kavrama becerilerinde zay\u0131flama, (4) yava\u015flam\u0131\u015f y\u00fcr\u00fcme h\u0131z\u0131, (5) d\u00fc\u015f\u00fck fiziksel aktivite. Bu 5 fakt\u00f6rden en az 3\u2019\u00fcn\u00fcn bulunmas\u0131 ya\u015fl\u0131 bir hastada fiziksel k\u0131r\u0131lganl\u0131\u011f\u0131 tan\u0131mlar. Fried\u2019in k\u0131r\u0131lganl\u0131k fenotipi sayg\u0131n ve ge\u00e7erli bir tan\u0131mlama olsa da, eksik yanlar\u0131 hastalar\u0131n mevcut komorbiditelerinin, aktif hastal\u0131k durumunun, kognitif defisitlerin ve fizikososyal fakt\u00f6rlerin hesaba kat\u0131lmam\u0131\u015f olmas\u0131d\u0131r [3].<\/p>\n\n\n\n

\u0130<\/strong>leri ya<\/strong>\u015f <\/strong>ve K\u0131r\u0131lganl\u0131k<\/strong><\/p>\n\n\n\n

\u0130leri ya\u015f ve klinik k\u0131r\u0131lganl\u0131k aras\u0131ndaki ili\u015fki h\u0131zl\u0131 bir \u015fekilde ya\u015flanan toplumlar i\u00e7in olduk\u00e7a \u00f6nemlidir. 2019 Birle\u015fmi\u015f Milletler \u2018World Population Aging\u2019 raporuna g\u00f6re 2050 y\u0131l\u0131na kadar \u015fu anki 65 ya\u015f ve \u00fczeri pop\u00fclasyonun 2 kat\u0131na \u00e7\u0131kmas\u0131 beklenmektedir. Ya\u015fl\u0131 n\u00fcfustaki bu art\u0131\u015f\u0131n toplumlar\u0131 daha k\u0131r\u0131lgan hale getirece\u011fi tahmin edilmektedir. Bu ama\u00e7la, k\u0131r\u0131lganl\u0131\u011f\u0131n epidemiyolojisi, yayg\u0131nl\u0131\u011f\u0131 ve insidans\u0131 d\u00fcnya \u00e7ap\u0131nda bir\u00e7ok n\u00fcfus temelli \u00e7al\u0131\u015fmada belirlenmi\u015ftir. 65 ya\u015f ve \u00fcst\u00fc pop\u00fclasyonda klinik k\u0131r\u0131lganl\u0131\u011f\u0131n ortalama prevalans\u0131 ~%10′ dur,<\/p>\n\n\n\n

ancak kullan\u0131lan k\u0131r\u0131lganl\u0131k kriterlerine ba\u011fl\u0131 olarak %4.0 ila %59.1 aras\u0131nda geni\u015f bir aral\u0131kta de\u011fi\u015febilir. 28 \u00fclkede 120.805 yeti\u015fkin \u00fczerinde yap\u0131lan bir meta-analiz, toplumda ya\u015fayan ya\u015fl\u0131 yeti\u015fkinlerde (bu \u00e7al\u0131\u015fmada 60 ya\u015f ve \u00fczeri hastalar al\u0131nm\u0131\u015f) Fried Fenotipi’ ne g\u00f6re belirlenen klinik k\u0131r\u0131lganl\u0131\u011f\u0131n k\u00fcresel insidans\u0131n\u0131, 1.000 ki\u015fi ba\u015f\u0131na 40 vaka olarak rapor etmi\u015ftir (%95 G\u00fcven Aral\u0131\u011f\u0131, 34.5-48.5; I = %98.2). K\u0131r\u0131lganl\u0131\u011f\u0131n artan yayg\u0131nl\u0131\u011f\u0131 ile ili\u015fkilendirilen fakt\u00f6rler aras\u0131nda d\u00fc\u015f\u00fck gelir ve e\u011fitim d\u00fczeyi, k\u00f6t\u00fc sa\u011fl\u0131k durumu, daha y\u00fcksek oranda komorbid kronik hastal\u0131klar ve engellilik yer al\u0131r [4] .<\/p>\n\n\n\n

Klinik K\u0131r\u0131lganl\u0131k \u00d6l\u00e7e<\/strong>\u011f<\/strong>i (KK\u00d6)<\/strong><\/p>\n\n\n\n

Geriatrik hasta pop\u00fclasyonuyla yap\u0131lan ve klinik prati\u011fimize okyanus \u00f6tesinden dahil olan bir \u00e7ok \u00e7al\u0131\u015fma gibi bu \u00f6l\u00e7ek de Kanada\u2019dan, alan\u0131nda tecr\u00fcbeli klinisyen Rockwood ve arkada\u015flar\u0131 taraf\u0131ndan geli\u015ftirilmi\u015ftir. KK\u00d6 ilk defa 2005 y\u0131l\u0131nda Kanada Sa\u011fl\u0131k ve Ya\u015flanma \u00c7al\u0131\u015fmas\u0131\u2019nda k\u0131r\u0131lganl\u0131\u011f\u0131 ve din\u00e7li\u011fi g\u00f6zlemsel olarak \u00f6l\u00e7en bir fizik muayene y\u00f6ntemi olarak tan\u0131t\u0131ld\u0131. Asl\u0131nda KK\u00d6, yine ayn\u0131 \u00e7al\u0131\u015fma grubu taraf\u0131ndan daha \u00f6nceleri olu\u015fturulan ve kapsaml\u0131 geriatrik hasta de\u011ferlendirme modeli temel al\u0131narak haz\u0131rlanm\u0131\u015f\u00a092 de\u011fi\u015fkenli \u2018Toplam Defisit Modeli\u2019nin k\u0131sa ve pratik bir kullan\u0131m\u00a0\u015feklidir. \u00d6zet bir model olmas\u0131na ra\u011fmen, KK\u00d6 k\u0131sa s\u00fcrede klinik pratikte g\u00f6zleme dayal\u0131 bir tarama y\u00f6ntemi olarak yayg\u0131nla\u015ft\u0131 ve ya\u015fl\u0131 hastalar\u0131 \u2018\u00e7ok ciddi k\u0131r\u0131lgan\u2019 ve \u2018\u00e7ok din\u00e7\u2019 olarak s\u0131n\u0131fland\u0131rmak i\u00e7in klinisyenlerin ba\u015fvurdu\u011fu yayg\u0131n bir y\u00f6ntem haline geldi. Orijinal halinde 7 puanl\u0131 bir skala olarak tan\u0131t\u0131lan KK\u00d6, 2020 y\u0131l\u0131nda Pulok ve ark. taraf\u0131ndan modifiye edilerek 9 puanl\u0131 bir skala haline geldi (Tablo-1) [5].<\/p>\n\n\n\n

Tablo-1:\u00a0<\/strong>Klinik K\u0131r\u0131lganl\u0131k \u00d6l\u00e7e\u011fi*<\/p>\n\n\n\n

\"\"
*\u00a0https:\/\/www.dal.ca\/sites\/gmr\/our-tools\/clinical-frailty-scale.html\u00a0\u00f6l\u00e7e\u011fin orijinal hali ve\u00a0\u0130ngilizce tan\u0131t\u0131m metni.<\/figcaption><\/figure>\n\n\n\n

Ge\u00e7ti\u011fimiz g\u00fcnlerde (\u015eubat, 2024) Avrupa Acil T\u0131p Cemiyeti (EUSEM) Geriatrik Acil T\u0131p \u00e7al\u0131\u015fma grubu taraf\u0131ndan y\u00fcr\u00fctl\u00fclen ve \u00fclkemiz de dahil olmak \u00fczere 14 Avrupa \u00fclkesini kapsayan FEED (Prevalance of Frailty in European Emergency Departments) \u00e7al\u0131\u015fmas\u0131n\u0131n sonu\u00e7lar\u0131 yay\u0131nland\u0131. \u00c7al\u0131\u015fman\u0131n amac\u0131 Avrupa\u2019n\u0131n acil servislerine ba\u015fvuran geriatrik hastalar\u0131n k\u0131r\u0131lganl\u0131k prevalans\u0131n\u0131 belirlemekti. \u00c7al\u0131\u015fmaya e\u015f zamanl\u0131 olarak 14 Avrupa \u00fclkesinin 62 farkl\u0131 b\u00f6lgesindeki belli hastanelere 24 saatlik s\u00fcre i\u00e7inde (g\u00fcn olarak 04 temmuz 2023 belirlenmi\u015f) ba\u015fvuran 65 ya\u015f ve \u00fczeri 3479 hasta dahil edildi. K\u0131r\u0131lganl\u0131k d\u00fczeyini \u00f6l\u00e7mek i\u00e7in KK\u00d6 kullan\u0131ld\u0131 ve 5 ve \u00fczeri puan alan ya\u015fl\u0131 hastalar k\u0131r\u0131lgan olarak kabul edildi. \u00c7al\u0131\u015fman\u0131n sonucuna g\u00f6re Avrupa genelinde acil servislere bir g\u00fcnde ba\u015fvuran ya\u015fl\u0131 hastalar aras\u0131nda k\u0131r\u0131lganl\u0131k prevalans\u0131 %40 (\u00fclkeden \u00fclkeye %26 ile %51 aras\u0131nda de\u011fi\u015fmektedir) olarak bulundu. T\u00fcrkiye, FEED \u00e7al\u0131\u015fmas\u0131na Birle\u015fik Krall\u0131k\u2019tan sonra en fazla veri aktaran 2. \u00fclke oldu. 7 farkl\u0131 b\u00f6lgeden 514 hastan\u0131n dahil edildi\u011fi T\u00fcrkiye alt grubunun k\u0131r\u0131lganl\u0131k prevalans\u0131 da %41 olarak raporland\u0131 [6] . Bir ba\u015fka meta analiz \u00e7al\u0131\u015fmas\u0131nda KK\u00d6 puan\u0131 5 ve \u00fczeri olan geriatrik hastalarda 1 ayl\u0131k mortalite riski 1.56 ile 2.7 aras\u0131nda de\u011fi\u015fen oranlarda art\u0131\u015f g\u00f6stermektedir. Kan\u0131tlar g\u00f6stermektedir ki KK\u00d6 k\u0131sa s\u00fcreli mortaliteyi \u00f6n g\u00f6rmede ge\u00e7erli ve g\u00fcvenilir bir ara\u00e7t\u0131r [7].<\/p>\n\n\n\n

Mental Durum De<\/strong>\u011f<\/strong>erlendirme Ara\u00e7lar\u0131<\/strong><\/p>\n\n\n\n

Akut konf\u00fczyonel durum ya da akut beyin disfonksiyonu acil servislerde s\u0131k kar\u015f\u0131la\u015f\u0131lan bir klinik tablodur. Bilin\u00e7 d\u00fczeyindeki ani de\u011fi\u015fiklikler deliryum, stupor ve koma haline ikincildir. Bu klinik tablonun altta yatan bir \u00e7ok nedeni oldu\u011fu gibi, hayat\u0131 tehdit edici sonu\u00e7lar\u0131 da bulunmaktad\u0131r. \u00d6zellikle ya\u015fl\u0131 hastalarda bilin\u00e7 d\u00fczeyi ve mental durum saatler ve dakikalar i\u00e7erisinde de\u011fi\u015fkenlik g\u00f6sterebilir. Bu nedenle acil servislerde bilin\u00e7 d\u00fczeyinin ve bili\u015fsel durumun rutin olarak kaydedilmesi bir kalite standart\u0131 haline gelmi\u015ftir. Bu standart\u0131 tutturmak i\u00e7in yo\u011fun bak\u0131m \u00fcniteleri ve acil servisler gibi kritik hasta takibinin yap\u0131ld\u0131\u011f\u0131 b\u00f6l\u00fcmlerde kullan\u0131lmak \u00fczere basit, duyarl\u0131, zaman ve maliyetten kazan\u00e7 sa\u011flayan tarama testleri geli\u015ftirilmi\u015ftir [8].<\/p>\n\n\n\n

Deliryum; temel olarak bir veya birden \u00e7ok patolojik stres fakt\u00f6r\u00fcne verilen yan\u0131t\u0131n dekompanzasyonuna ba\u011fl\u0131 olarak ortaya \u00e7\u0131kan beyin fonksiyonlar\u0131nda gerilemedir. Deliryum ve ajitasyon hospitalize edilen ya\u015fl\u0131 hastalar\u0131n yakla\u015f\u0131k %25\u2019inde g\u00f6r\u00fcl\u00fcr. Hipoaktif, hiperaktif ve mikst tip olarak ayr\u0131ca \u00fc\u00e7 psikomotor alt tipte s\u0131n\u0131fland\u0131r\u0131labilir. Hipoaktif deliryum, \u201csessiz\u201d deliryum olarak tan\u0131mlan\u0131r ve psikomotor gerilik ile karakterizedir. Bu gruptaki hastalar uykuya meyilli, uyu\u015fuk veya sersemlemi\u015f halde g\u00f6r\u00fcnebilir. Klinik prezentasyon \u00e7ok silik olabilece\u011finden, hipoaktif deliryum s\u0131kl\u0131kla klinisyenler taraf\u0131ndan atlan\u0131larak, depresyon veya yorgunluk gibi di\u011fer etyolojilere ba\u011flan\u0131r. Hiperaktif deliryumu olan hastalar ise; artm\u0131\u015f psikomotor aktivitede, huzursuz, endi\u015feli, ajite veya sald\u0131rgan g\u00f6r\u00fcnebilir. Bu nedenle hiperaktif alt tip, klinisyenler taraf\u0131ndan daha kolay tan\u0131n\u0131r. Mikst tip deliryumda psikomotor aktivitede dalgalanma seviyeleri g\u00f6r\u00fcl\u00fcr; hasta bir anda hipoaktif \u00f6zellikler g\u00f6sterirken birka\u00e7 saat hatta birka\u00e7 saniye sonra hiperaktif semptomlar g\u00f6sterebilir. Hipoaktif deliryum ve mikst tip deliryum,<\/p>\n\n\n\n

deliryum \u00f6zellikleri g\u00f6steren ya\u015fl\u0131 hastalarda bask\u0131n olan alt tiplerdir. Deliryum tan\u0131s\u0131nda alt\u0131n standart olarak kabul edilen y\u00f6ntem bir psikiyatri uzman\u0131n\u0131n Amerikan Psikiyatri Birli\u011finin Mental Bozukluklar\u0131n Tan\u0131 ve\u00a0\u0130statisti\u011fi K\u0131lavuzu 5. revizyonu (DSM-V)\u2019nda yer alan spesifik kriterlere g\u00f6re de\u011ferlendirmesi olarak kabul edilir (Tablo-2). Bunun yan\u0131nda acil servis ve yo\u011fun bak\u0131m \u00fcnitelerinde kullan\u0131lmak \u00fczere bir\u00e7ok alternatif test geli\u015ftirilmi\u015ftir. Modifiye edilmi\u015fRichmond Ajitasyon-Sedasyon Skalas\u0131 (mRASS), yo\u011fun bak\u0131m \u00fcniteleri i\u00e7in konf\u00fczyon de\u011ferlendirme metodu (Confusion assessment method for Intensiv Care Units-CAM-ICU), bCAM ve 4AT testi ge\u00e7erlili\u011fi g\u00fcvenilirli\u011fi g\u00f6sterilmi\u015f\u00a0alternatif mental durum de\u011ferlendirme ara\u00e7lar\u0131d\u0131r.<\/p>\n\n\n\n

Tablo-2:\u00a0<\/strong>DSM-V Deliryum tan\u0131 kriterleri.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

mRASS:\u00a0<\/strong>Orijinal olarak mekanik ventilat\u00f6re ba\u011fl\u0131 derin sedasyon alt\u0131ndaki hastalar\u0131n bilin\u00e7 d\u00fczeyinin kantitatif olarak ifade edilebilmesi i\u00e7in geli\u015ftirilmi\u015ftir. Bu skala hastalar\u0131 -5 (yan\u0131ts\u0131z, derin uyku halinde) ve +4 (kavgac\u0131, \u00e7evresine zarar veren) aras\u0131nda s\u0131n\u0131flar. 0 puan alanlar uyan\u0131k ve sakin olan normal bilin\u00e7 durumundaki hastalar\u0131 ifade eder. mRASS y\u0131llar i\u00e7inde klinik \u00e7al\u0131\u015fmalarda s\u0131kl\u0131kla kullan\u0131larak deliryum tarama testi olarak modifiye edilmi\u015ftir. mRASS g\u00f6zlemsel bir tan\u0131 arac\u0131d\u0131r, bu sebeple klinisyenlerin kognitif becerileri de\u011ferlendirmek i\u00e7in rutin bir test kullanmas\u0131na gerek yoktur. K\u0131sa s\u00fcrede sonu\u00e7 al\u0131nmas\u0131 ve basit bir test olmas\u0131 g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda deliryumu tan\u0131ma duyarl\u0131l\u0131\u011f\u0131 (doktorlar: %82, hem\u015fireler %70) ve \u00f6zg\u00fcll\u00fc\u011f\u00fc (doktorlar %85, hem\u015fireler %93) kabul edilebilir d\u00fczeyde iyidir. Ancak en b\u00fcy\u00fck dezavantajlar\u0131ndan biri g\u00f6zlemciler aras\u0131 tutarl\u0131l\u0131k g\u00f6rece d\u00fc\u015f\u00fckt\u00fcr (\u03ba\u00a0= 0.63) ve hala acil servis hastalar\u0131 i\u00e7in k\u0131s\u0131tl\u0131 ge\u00e7erlili\u011fe sahiptir [9] (Tablo-3).<\/p>\n\n\n\n

Tablo-3:\u00a0<\/strong>Modifiye edilmi\u015f\u00a0Richmond Ajitasyon-Sedasyon Skalas\u0131.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

CAM-ICU ve bCAM: <\/strong>Konf\u00fczyon de\u011ferlendirme metodundan t\u00fcreyen CAM-ICU ve bCAM d\u00fcnya genelinde 4500\u2019den fazla orijinal \u00e7al\u0131\u015fmada kullan\u0131lm\u0131\u015f ve 20 farkl\u0131 dilde ge\u00e7erlilik kazanm\u0131\u015f acil servis ve yo\u011fun bak\u0131m \u00fcnitelerinde en \u00e7ok kullan\u0131lan deliryum tan\u0131 ara\u00e7lar\u0131d\u0131r. Deliryumun 4 temel \u00f6zelli\u011fi olan akut ba\u015flang\u0131\u00e7, dalgal\u0131 seyir, dikkati toplayamama\/da\u011f\u0131n\u0131k d\u00fc\u015f\u00fcnceleri ve bilin\u00e7 d\u00fczeyini de\u011ferlendirmeyi sa\u011flar. Deliryum tan\u0131s\u0131n\u0131n acil servis gibi kaotik hastane \u015fartlar\u0131nda %80 oranda atland\u0131\u011f\u0131 ve rutin olarak taranmad\u0131\u011f\u0131 \u00f6nermesinden yola \u00e7\u0131k\u0131larak yo\u011fun klinik \u00e7evrelerde dahi kolayl\u0131kla uygulanabilecek bir testin ihtiyac\u0131yla geli\u015ftirilmi\u015ftir. bCAM ve CAM-ICU birbirinin modifiye edilmi\u015f halidir ve her ikisi de Harvard T\u0131p Okulu \u2018Aging Brain Center\u2019 direkt\u00f6r\u00fc Inouye ve ekibi taraf\u0131ndan geli\u015ftirilmi\u015ftir. CAM-ICU ve bCAM genel itibariyle DSM-V deliryum tan\u0131 kriterlerinden k\u00f6ken alan 4 temel basamaktan olu\u015fur: (1) akut ba\u015flang\u0131\u00e7l\u0131 mental durum de\u011fi\u015fikli\u011fi veya bilin\u00e7teki akut dalgalanmalar, (2) dikkati s\u00fcrd\u00fcrebilme yetene\u011fi, (3) de\u011fi\u015fen bilin\u00e7 d\u00fczeyi ve (4) disorganize d\u00fc\u015f\u00fcnceler.<\/p>\n\n\n\n

Birinci basamaktaki zamansal sorgulamada mental durumundaki de\u011fi\u015fikli\u011fin g\u00fcnler, saatler ve hatta dakikalar i\u00e7inde de\u011fi\u015fip-de\u011fi\u015fmedi\u011fi veya 24 saat i\u00e7inde dalgalanma g\u00f6sterip- g\u00f6stermedi\u011fi sorgulan\u0131r. Akut ba\u015flang\u0131\u00e7l\u0131 bir mental durum de\u011fi\u015fikli\u011fi olmamas\u0131 halinde deliryum direkt d\u0131\u015flan\u0131r. \u0130kinci basamakta hastadan aylar\u0131 aral\u0131ktan geriye do\u011fru saymas\u0131 istenir. Bu basamakta hastan\u0131n 1 kez hata yapmas\u0131na izin verilir. Hasta aylar\u0131 geriye do\u011fru ba\u015far\u0131l\u0131 bir \u015fekilde veya tek bir hata yaparak sayabilirse direkt deliryum d\u0131\u015fan\u0131r. 3. basamak mRASS ile bilin\u00e7 d\u00fczeyini \u00f6l\u00e7er. bCAM i\u00e7erisinde di\u011fer sorulara ek olarak ayn\u0131 zamanda mRASS<\/p>\n\n\n\n

sorgulanmas\u0131 bu metodun duyarl\u0131l\u0131\u011f\u0131n\u0131 ve \u00f6zg\u00fcll\u00fc\u011f\u00fcn\u00fc de art\u0131rmaktad\u0131r. 4. basamakta hastaya daha karma\u015f\u0131k sorular sorularak y\u00fcksek bili\u015fsel becerileri test edilir. (\u00d6r; bir kaya suyun \u00fczerinde y\u00fczer mi? Bal\u0131klar denizde midir? Bir pound (a\u011f\u0131rl\u0131k birimi) mu daha a\u011f\u0131rd\u0131r yoksa 2 pound mu?) Bu basamakta yine hastalara basit emirler verilerek yapmas\u0131 istenir (\u00d6r; uygulay\u0131c\u0131 iki parma\u011f\u0131n\u0131 kald\u0131r\u0131r ve hastadan ayn\u0131s\u0131n\u0131 yapmas\u0131n\u0131 ister). Bu basamakta da hi\u00e7 hata yapmayan hastalarda deliryum d\u0131\u015flan\u0131r. bCAM \u00f6l\u00e7e\u011finin orijinal hali ve tan\u0131t\u0131m metnini payla\u015ft\u0131\u011f\u0131m linkte bulabilirsiniz. https:\/\/eddelirium.org\/wp-content\/uploads\/2016\/05\/bCAM-Training-Manual- Version-1.0-10-15-2015.pdf.<\/p>\n\n\n\n

4AT<\/strong>: 2 dakikadan k\u0131sa s\u00fcren ve \u00f6n e\u011fitim gerekmeden uygulanabilen basit ve efektif bir deliryum tarama arac\u0131d\u0131r. 2014 y\u0131l\u0131nda Belelli ve ekibi taraf\u0131ndan Age and Aging Dergisi\u2019nde tan\u0131t\u0131lan 4AT testinin ge\u00e7erlilik ve g\u00fcvenilirli\u011fi hem \u0130ngilizce hem \u0130talyanca konu\u015fan 70 ya\u015f \u00fcst\u00fc hasta pop\u00fclasyonuyla e\u015f zamanl\u0131 ve \u00e7ok merkezli olarak g\u00f6sterilmi\u015ftir. Farkl\u0131 dilleri konu\u015fan hastalarda deliryum tan\u0131s\u0131 koymak i\u00e7in %89 duyarl\u0131l\u0131\u011f\u0131 ve %84 \u00f6zg\u00fcll\u00fc\u011f\u00fcn\u00fcn olmas\u0131 bu \u00f6l\u00e7e\u011fi de\u011ferli k\u0131lar. Bug\u00fcne kadar 27\u2019nin \u00fczerinde tan\u0131sal ge\u00e7erlilik testinde 5000\u2019den fazla hastayla test edilen bu \u00f6l\u00e7ek d\u00fcnyada en fazla kullan\u0131lan deliryum tarama testlerinden biri haline gelmi\u015ftir. 4AT h\u0131zl\u0131 deliryum tarama testinde t\u0131pk\u0131 di\u011fer deliryum testleri gibi hastalar\u0131n (1) uyan\u0131kl\u0131k ve uyar\u0131labilirlik d\u00fczeyi, (2) K\u0131salt\u0131lm\u0131\u015f Mental Test-4 i\u00e7inde ya\u015f, do\u011fum tarihi, bulundu\u011fu yer, bulundu\u011fu zaman sorgulan\u0131r. Ek olarak (3) dikkati s\u00fcrd\u00fcrebilme yetene\u011finin \u00f6l\u00e7\u00fclmesi i\u00e7in hastadan aral\u0131ktan geriye do\u011fru aylar\u0131 saymas\u0131 istenir ve son olarak (4) bilin\u00e7 de\u011fi\u015fikli\u011finin ba\u015flang\u0131\u00e7 zaman\u0131 ve zaman i\u00e7inde dalgalanmas\u0131 sorulur. 4AT testi ile ilgili genel ayr\u0131nt\u0131l\u0131 bilgiler, ge\u00e7erlilik g\u00fcvenilirlik \u00e7al\u0131\u015fmalar\u0131, testin T\u00fcrk\u00e7e dahil di\u011fer dillere orijinal \u00e7evirileri https:\/\/ www.the4at.com\/ sitesinde mevcuttur, kullanmak ve payla\u015fmak i\u00e7in izin verilmi\u015ftir.<\/p>\n\n\n\n

G\u00fcncel K\u0131lavuzlar I<\/strong>\u015f<\/strong>\u0131<\/strong>\u011f<\/strong>\u0131nda Deliryum Tan\u0131 Testleri<\/strong><\/p>\n\n\n\n

Literat\u00fcrde 4AT vs CAM-ICU <\/em>yada 4AT vs bCAM <\/em>gibi \u00e7al\u0131\u015fmalar \u00e7ok say\u0131da mevcuttur. 2019 y\u0131l\u0131nda Mc Lullich ve ark. taraf\u0131ndan Birle\u015fik Krall\u0131k Ulusal Sa\u011fl\u0131k Ara\u015ft\u0131rmalar\u0131 Ensit\u00fcs\u00fc\u2019n\u00fcn de destekledi\u011fi 70 ya\u015f ve \u00fczeri 785 hastan\u0131n dahil edildi\u011fi bir \u00e7al\u0131\u015fma y\u00fcr\u00fct\u00fclm\u00fc\u015ft\u00fcr. \u00c7al\u0131\u015fmadaki hastalar acil servisler ve akut hasta servislerinden se\u00e7ilmi\u015f ve deliryum tan\u0131sal ge\u00e7erlilik \u00e7al\u0131\u015fmas\u0131 prospektif ve \u00e7ift-k\u00f6r olarak dizayn edilmi\u015ftir. Faz-2 sonu\u00e7lara g\u00f6re 4 AT testi referans metoda g\u00f6re deliryum tan\u0131s\u0131 koymak i\u00e7in %95 \u00f6zg\u00fcll\u00fck ve %76 duyarl\u0131l\u0131\u011f\u0131 sahipken (ROC e\u011frisi alt\u0131nda kalan alan: 0.90) daha uzun s\u00fcrede uygulanan ve personel maliyeti olan CAM testi %100 \u00f6zg\u00fcll\u00fc\u011fe ancak %40 duyarl\u0131l\u0131\u011fa sahip bulunmu\u015ftur. \u00c7al\u0131\u015fman\u0131n sonucu 4AT testini kabul edilebilir \u00f6zg\u00fcll\u00fck ve duyarl\u0131l\u0131\u011fa sahip daha basit, k\u0131sa ve maliyet-verimli bir \u00f6l\u00e7ek olarak tan\u0131mlamaktad\u0131r [10]. Annals of Emergency Medicine Geriatrik Acil T\u0131p K\u0131lavuzunda deliryum tarama ara\u00e7lar\u0131 i\u00e7in mRASS ve bCAM kullan\u0131lmas\u0131 \u00f6nerilirken, \u0130ngiliz Ulusal Sa\u011fl\u0131k Sistemi k\u0131lavuzlar\u0131nda (NICE ve SIGN) 4AT testine vurgu yap\u0131lmaktad\u0131r. Ocak 2024\u2019te Amerikan Geriatri Derne\u011fi\u2019nin dergisinde yay\u0131nlanan meta-analiz \u00e7al\u0131\u015fmas\u0131 sonu\u00e7lar\u0131nda deliryum tan\u0131 testlerinin klinik pratik uygulamalar\u0131n\u0131n de\u011fi\u015fkenlik g\u00f6sterdi\u011fi belirtilmi\u015ftir. Tan\u0131 testlerinin<\/p>\n\n\n\n

klinisyenler taraf\u0131ndan tamamlanmas\u0131nda ve elektronik sa\u011fl\u0131k kay\u0131t sistemine ge\u00e7irilmesinde de\u011fi\u015fkenliklerin oldu\u011funa dikkat \u00e7ekilmi\u015ftir. Ayr\u0131ca sa\u011fl\u0131k politikas\u0131 belirleyicilerinin deliryum skorlamalar\u0131ndaki beklenmedik pozitif veya negatif art\u0131\u015f\u0131 monit\u00f6rize edebilecek bir plan yapmas\u0131 vurgulanm\u0131\u015ft\u0131r [11].<\/p>\n\n\n\n

\u00d6zet<\/strong><\/p>\n\n\n\n

    \n
  • \u0130leri ya\u015f\u00a0ve klinik k\u0131r\u0131lganl\u0131k aras\u0131ndaki ili\u015fki ya\u015flanan toplumlar, ulusal sa\u011fl\u0131k sistemleri ve acil servisler i\u00e7in olduk\u00e7a \u00f6nemlidir.<\/li>\n\n\n\n
  • \u00dclkemizde ya\u015fl\u0131 hastalarda klinik k\u0131r\u0131lganl\u0131k prevalans\u0131 %41\u2019dir.<\/li>\n\n\n\n
  • Acil t\u0131p prati\u011finde Klinik K\u0131r\u0131lganl\u0131k \u00d6l\u00e7e\u011fi ya\u015fl\u0131 hastalardaki olas\u0131 advers olaylar\u0131\u00f6ng\u00f6rmek i\u00e7in kullan\u0131\u015fl\u0131 bir \u00f6l\u00e7ektir.<\/li>\n\n\n\n
  • Deliryum ve ajitasyon hospitalize edilen ya\u015fl\u0131 hastalar\u0131n yakla\u015f\u0131k %25\u2019inde g\u00f6r\u00fcl\u00fcr ve acil servis gibi kaotik hastane ortamlar\u0131nda %80 oran\u0131nda tan\u0131 atlanabilir.<\/li>\n\n\n\n
  • G\u00fcncel literat\u00fcrde, ya\u015fl\u0131 hastalarda klinik k\u0131r\u0131lganl\u0131\u011f\u0131n belirlenmesi ve hastalar\u0131n mental d\u00fczeyinin ge\u00e7erlili\u011fi ve g\u00fcvenilirli\u011fi kan\u0131tlanm\u0131\u015f\u00a0bir test ile de\u011ferlendirilip rutin olarak kaydedilmesi \u00f6nerilmektedir.<\/li>\n<\/ul>\n\n\n\n

    Referanslar<\/strong> <\/p>\n\n\n\n

    1) United Nations, Department of Economic and Social Affairs, Population Division. “World Population Ageing 2019: Highlights (ST\/ESA\/SER. A\/430).” (2019). <\/p>\n\n\n\n

    2) H\u00e4seler-Ouart, Kristin, et al. “Geriatric assessment for older adults admitted to the emergency department: A systematic review and meta-analysis.”Experimental Gerontology (2020): 111184. <\/p>\n\n\n\n

    3) Park C, Ko FC. The Science of Frailty: Sex Differences. Clin Geriatr Med. 2021;37(4): 625-638. doi:10.1016\/j.cger.2021.05.008. <\/p>\n\n\n\n

    4) Ofori-Asenso R, Chin KL, Mazidi M, et al. Global Incidence of Frailty and Prefrailty Among Community-Dwelling Older Adults: A Systematic Review and Meta- analysis. JAMA Netw Open. 2019;2(8):e198398. Published 2019 Aug 2. doi:10.1001\/ jamanetworkopen.2019.8398. <\/p>\n\n\n\n

    5) Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-495. doi:10.1503\/cmaj.050051. <\/p>\n\n\n\n

    6) European Taskforce on Geriatric Emergency Medicine (ETGEM) collaborators. Prevalence of Frailty in European Emergency Departments (FEED): an international flash mob study. Eur Geriatr Med. Published online February 10, 2024. doi:10.1007\/ s41999-023-00926-3. <\/p>\n\n\n\n

    7) Lee JH, Park YS, Kim MJ, et al. Clinical Frailty Scale as a predictor of short-term mortality: A systematic review and meta-analysis of studies on diagnostic test accuracy. Acad Emerg Med. 2022;29(11):1347-1356. doi:10.1111\/acem.14493. <\/p>\n\n\n\n

    8) Han JH, Brummel NE, Chandrasekhar R, et al. Exploring Delirium’s Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients. Am J Geriatr Psychiatry. 2017;25(3): 233-242. doi:10.1016\/j.jagp.2016.05.016. <\/p>\n\n\n\n

    9) https:\/\/gedcollaborative.com\/topic\/rass-or-mrass\/ [Eri\u015fim tarihi: 03\/04\/2024]. <\/p>\n\n\n\n

    10) MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 ‘A’s test for detecting delirium in acute medical patients: a diagnostic accuracy study.Health Technol Assess. 2019;23(40):1-194. doi:10.3310\/hta23400. <\/p>\n\n\n\n

    11) Penfold RS, Squires C, Angus A, et al. Delirium detection tools show varying completion rates and positive score rates when used at scale in routine practice in general hospital settings: A systematic review. J Am Geriatr Soc. Published online January 19, 2024. doi:10.1111\/jgs.18751.<\/p>\n","protected":false},"excerpt":{"rendered":"

    Giri\u015f Son y\u00fcz y\u0131lda modern t\u0131bb\u0131n geli\u015fmesi ve hayat standartlar\u0131n\u0131n y\u00fckselmesiyle beraber art\u0131k g\u00fcn\u00fcm\u00fczde insanlar\u0131n \u00e7o\u011fu 70\u2019li ya\u015flar\u0131 ve \u00f6tesini ya\u015famay\u0131 beklemektedir.…<\/p>\n","protected":false},"author":1185,"featured_media":577,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10042,10018,10023],"class_list":["post-573","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-acil","tag-geriatri","tag-kirilganlik"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/573","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=573"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/573\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/577"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=573"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=573"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=573"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}