運用周全性老年評估於一位高齡衰弱患者之護理經驗

Experience in caring for an elderly frail patient using comprehensive geriatric assessment

背景：本文運用周全性老年評估，盡早察覺高齡衰弱患者，因肢體活動功能障礙，致失去肢體自我掌控力，進而產生憂鬱情緒引發無力感與高齡照顧者面臨後續照護需求之護理經驗。
方法：照護期間自2024年3月8日至30日，以周全性老年評估為工具，透過會談、觀察、跨團隊會議討論等方法資料收集，藉由團隊成員中營養師、復健治療師及出院準備服務個管師等擬定照護計畫，並於照護措施執行過程中，藉由給予正向回饋，強化個案心理素質。
結果：經由老年周全性行評估，發現個案有活動功能障礙、無力感及知識缺失等護理診斷。透過跨團隊整合性照護，如復健師制定個人復健計劃、精神科醫師提供心理支持以利自我照顧能力提升，並運用急性後期整合照護居家模式，確保復健計劃的持續性和有效性。
結論：透過增強個案肢體功能的協調及穩定性，逐步恢復自立生活，並建構照護支持系統，減少照顧者照護負荷與龐大醫療成本，達長者在地老化、在家安養的期望。

This article highlights the application of Comprehensive Geriatric Assessment (CGA) in managing the complex needs of a frail older adult facing functional decline, impaired mobility, and associated psychological distress. Between March 8 and March 30, 2024, a multidisciplinary team—including dietitians, rehabilitation therapists, and discharge planners—utilized CGA data gathered through clinical observations and interdisciplinary meetings to address key health issues such as impaired physical activity, diminished empowerment, and inadequate social support. By implementing a home-based post-acute care model and leveraging electronic CGA data for precise decision-making, the intervention focused on restoring physical coordination and psychological resilience while providing essential consultative support to caregivers. This holistic approach not only gradually restored the patient's independence and ability to age in place but also established a robust support system that reduced caregiver burden and demonstrated the potential for significant long-term medical cost savings.