490.3 🩺 內科專科考前版

490.3.0.1 📌 一頁重點

22E updates:
- 5Ms framework (Tinetti et al.) — AGS 推 person-centered care 核心 framework
- Age-Friendly Health Systems (IHI initiative) — 5Ms 系統性落實
- Anti-amyloid mAbs: lecanemab (FDA 2023)、donanemab (FDA 2024)；ARIA-E/H + apoE4 篩查
- Plasma p-tau 217 as AD biomarker — 接近 PET amyloid 的準確度
- Beers Criteria 2023 update — 持續更新 PIM 清單
- TRUST trial (2017) — subclinical hypothyroidism elderly conservative
- TAME trial (metformin anti-aging) — ongoing
- Senolytics (dasatinib + quercetin) — research
- Mirabegron / Vibegron (β3-agonist) — safer OAB option in elderly
- CGM in elderly DM — 偵測 hypoglycemia
- Care transition models: Project RED、TCM、CTI、BOOST、INTERACT
- Age-Friendly Health Systems + IHI
Taiwan: 健保涵蓋 ChEI（donepezil、rivastigmine、galantamine）+ memantine（條件）；anti-amyloid mAb 未健保自費多；DPP4i + SGLT2i + GLP-1 健保；mirabegron 健保條件；CTAOH/TES + 高齡醫學會 + 台灣失智症協會指引

490.3.0.2 🌟 Pearls (20)

490.3.0.2.1 5Ms + CGA

5Ms framework（Mind/Mobility/Medications/Multicomplexity/Matters most）是 AGS + IHI Age-Friendly Health Systems 的骨幹；內專要熟到口頭可講
CGA 多 RCT 已證實: 降低 nursing home placement、improve function、reduce mortality（特別 inpatient ACE units、outpatient comprehensive program）
ePrognosis.com: 多模型 life expectancy 估算（Lee、Schonberg、Walter）— 老人 cancer screening 必查

490.3.0.2.2 Cognition + Delirium

Plasma p-tau 217 is the most promising AD biomarker — 接近 PET amyloid sensitivity；can rule in/out amyloid pathology in MCI; commercial available
Lecanemab + Donanemab: clinical decline 減緩 27-35%（CDR-SB），但未達 MCID；real-world benefit 有限；apoE4 homozygous 風險 ↑ ARIA
ARIA-E vs ARIA-H: MRI surveillance protocol（baseline + before doses 5, 7, 14）；symptomatic ARIA → hold/discontinue
CAM-ICU + 4AT: validated delirium 工具 in ICU + ED setting
HELP (Hospital Elder Life Program): bundled intervention（reorientation、therapeutic activity、early mobilization、vision/hearing aid、sleep enhancement、hydration）— 證實降 delirium incidence ~ 40%

490.3.0.2.3 Polypharmacy + Deprescribing

STOPP/START criteria (v2): STOPP 列 PIM；START 列「應該開但漏開」的藥（reverse Beers 概念）
Anticholinergic burden scale (ACB) — 累積 anticholinergic load 與 cognitive decline 相關
Deprescribing.org + AGS Deprescribing Toolkit — 系統化 protocol（特別 PPI、BZD、anticholinergic、statin in end-of-life）

490.3.0.2.4 Falls + Frailty

STEADI (CDC Stopping Elderly Accidents, Deaths & Injuries) framework — outpatient fall prevention algorithm
Fried phenotype vs Rockwood deficit accumulation — 兩種互補 frailty 模型；Clinical Frailty Scale (CFS 1-9) 臨床最實用
Sarcopenia diagnosis (EWGSOP2 2019): low grip strength + low muscle mass (DXA/BIA) ± low physical performance；新增 SARC-F 篩查

490.3.0.2.5 End-of-life + ACP

Surprise question (“Would I be surprised if this patient died in 1 year?”) sensitivity ~ 70% for 1-yr mortality
5-Day rule for hospice referral: median LOS in hospice is only 17 days — referral 多太晚；早 referral 改善 family bereavement

490.3.0.2.6 老人內分泌

Old DM CGM evidence: WISDM trial — CGM in T1DM ≥ 60 reduces hypoglycemia significantly；T2DM elderly CGM benefit emerging
Anti-osteoporosis 在 frail/dementia patient: zoledronic acid 5 mg IV q1y 比 oral 依從性好；denosumab 60 mg SC q6mo 也是 — caveat: 停藥後 rebound vertebral fracture（必 transition to bisphosphonate）
Older men hypogonadism + frailty: testosterone replacement → 部分 muscle mass + strength benefit；但無 frailty reversal evidence；CV/prostate safety 仍 caveat
Pituitary incidentaloma 老人: prevalence 高（MRI 老人 10-20% 有 incidentaloma）；功能性 evaluation + 大小 surveillance；surgery 老人 selected

490.3.0.3 📍 Taiwan + 健保

490.3.0.3.1 Drugs

中文目的：以下列出台灣可取得且健保部分覆蓋的老年常用藥物現況。

Cognition:
- Donepezil（Aricept） 健保（限早期 AD）— 5、10 mg
- Rivastigmine（Exelon） 健保 — capsule + patch
- Galantamine（Reminyl） 健保
- Memantine（Witgen, Ebixa） 健保（限 moderate-severe AD）
- Anti-amyloid mAb（lecanemab, donanemab） — 未健保，自費（lecanemab 自費約 200 萬/年）；台灣 FDA 已通過
- Vit E、ginkgo（OTC、無強 evidence）
OAB:
- Mirabegron（Betmiga） 健保（β3-agonist；老人較安全）
- Solifenacin、tolterodine、oxybutynin — 健保但老人慎用（anticholinergic）
- α-blocker：tamsulosin、silodosin（BPH-OAB）
Old DM:
- Metformin 健保完全
- DPP4i（sitagliptin、linagliptin、saxagliptin、vildagliptin）健保
- SGLT2i（empagliflozin、dapagliflozin、canagliflozin）健保條件
- GLP-1（dulaglutide、liraglutide、semaglutide）健保條件
- Glyburide（Daonil） — 健保但老人不建議
- Insulin basal（glargine、degludec）健保
骨鬆:
- Alendronate 健保
- Zoledronic acid 5 mg IV q1y 健保條件
- Denosumab 60 mg SC q6mo 健保條件
- Teriparatide / abaloparatide 健保條件（高骨折風險）
- Romosozumab 健保條件（停經後嚴重骨鬆）
疼痛:
- Acetaminophen + tramadol + duloxetine 健保
- 老人慎用 NSAID + opioid

490.3.0.3.2 Lab + Imaging

健保 TFT、anti-TPO、Vit D（條件）、PTH、Ca、P、Alb、Mg
健保 DXA（條件，骨鬆病人 q1-2 yr）
健保 brain MRI（dementia workup 條件）
健保 brain PET amyloid（自費多 — 約 5-7 萬）
健保 plasma p-tau 217（未列，研究階段）

490.3.0.3.3 學會 + 指引

台灣老年醫學會 (TGSGA) — 高齡醫學主學會
CTAOH 台灣甲狀腺醫學會
TES 內分泌學會
台灣骨鬆學會 (TOA)
台灣失智症協會 (TADA)
美國對照：AGS、ADA、ATA、AACE、Endocrine Society
跌倒指引：衛福部國健署社區跌倒預防方案

490.3.0.3.4 LTC + 長照 2.0

台灣長照 2.0 + ABC 三級服務
A 級長照旗艦店 / B 級複合服務 / C 級巷弄長照站
居家服務、日間照顧、家庭托顧、輔具、交通接送
CDR、CMS 評估等級（1-8）
失智照護資源中心

490.3.0.4 🎓 內專必懂 (20)

5Ms framework + Age-Friendly Health Systems
CGA comprehensive workup + tools (ADL/IADL/MoCA/PHQ-9/TUG/MNA/Fried)
Decision-making capacity assessment (MacArthur framework, MacCAT-T)
Falls multifactorial assessment + intervention bundle
CAM + CAM-ICU + delirium 處理（找原因 + non-pharm + 限 antipsychotic）
Dementia 4 大 + DLB 早期 parkinsonism 識別
Anti-amyloid mAb (lecanemab/donanemab) + ARIA + apoE4
Plasma p-tau 217 biomarker
Beers Criteria 2023 + STOPP/START
Deprescribing 系統化 protocol
Frailty (Fried + Rockwood + CFS) + sarcopenia (EWGSOP2)
Pressure injury staging + Braden + prevention
Incontinence DIAPPERS + 3IQ + treatment by type
Old DM HbA1c individualized, CGM 角色
Old osteoporosis secondary prevention + treatment-induced bone loss
Subclinical thyroid disease in elderly: TRUST trial conservative
Refeeding syndrome
Advance care planning + POLST + DNR
Models of geriatric care: ACE unit、PACE、CCM、care transitions
Care transition models: Project RED、TCM、CTI、BOOST、INTERACT

490.3.0.5 ⚙️ Falls Comprehensive Assessment Workflow (內專)

Step 1 — Screen (every visit):
- "Have you fallen in the past year?"
- "Are you afraid of falling?"
- "Do you have trouble climbing stairs or rising from chairs?"
- If yes to ANY → proceed

Step 2 — Multifactorial Assessment:
- History:
  - Detailed fall circumstances (preceding symptoms, position, time)
  - Rule out syncope/seizure
  - Medication review (focus on PIM, sedative, antihypertensive)
  - Comorbidities (CV, neuro, MSK, metabolic)
  - Vision/hearing assessment
- Physical exam:
  - Vital signs + postural BP (lying → sit → stand at 1 min + 3 min)
  - TUG test + gait observation (short steps, wide-based, turning)
  - Vision acuity
  - Cardiac (arrhythmia, AS, carotid bruit)
  - Neuro (cerebellar, parkinsonian, peripheral neuropathy)
  - MSK (LE strength, ROM, foot exam, footwear)
  - Cognition (Mini-Cog)
- Labs (selected):
  - CBC, BMP, glucose, Vit D, TSH
  - EKG if syncope suspected
  - Cardiac monitor if recurrent syncope
- Imaging only if indicated

Step 3 — Bundle Intervention (multifactorial):
- PT for strength + balance (Tai Chi, Otago program)
- Deprescribe high-risk drugs (BZD, anticholinergic, antihypertensive over-tx)
- Treat postural hypotension
- Vit D 800 IU/d (avoid high-dose monthly)
- Podiatry + footwear
- Vision optimization (cataract surgery if indicated)
- Home environment modification (OT home visit)
- Fall-alert device
- Address bone health (DXA + treat osteoporosis)
- Discuss anticoagulant risk/benefit (don't auto-stop)

Step 4 — Reassessment q3-6 mo

490.3.0.6 ⚙️ Delirium Workup + Management (內專)

Step 1 — Recognize:
- CAM screen daily in high-risk hospitalized 老人
- Hypoactive delirium 最常 missed → 主動 screen
- Sundowning pattern 提示 delirium

Step 2 — Identify Precipitants (systematic search):
- Infection: UA (only if symp), CXR, blood cx, source control
- Drugs:
  - New medications (opioid, anticholinergic, BZD, steroid)
  - Withdrawal (alcohol, BZD, opioid)
  - Drug interactions
- Metabolic:
  - Glucose, Na, K, Ca, Mg, P
  - Renal/liver function
  - Thyroid, B12
- Hypoxia / hypercarbia: SpO2, ABG
- Urinary retention: bladder scan
- Constipation: rectal exam
- Pain: scheduled assessment
- Sensory: glasses, hearing aids
- Sleep deprivation
- Restraint use

Step 3 — Non-Pharmacologic (FIRST LINE):
- HELP bundle (Hospital Elder Life Program):
  - Reorientation (clock, calendar, whiteboard)
  - Therapeutic activities
  - Early mobilization (out of bed, walking)
  - Vision/hearing aid use
  - Hydration protocol
  - Sleep enhancement (lights off, noise control, no awakening for routine)
- Family presence
- Familiar items from home
- 1:1 sitter if needed
- Avoid restraints

Step 4 — Pharmacologic (ONLY if danger):
- Low-dose haloperidol 0.25-0.5 mg PO/IV (avoid if QT > 500, Parkinson's, DLB)
- Risperidone 0.25-0.5 mg PO (preferred in older)
- Quetiapine 12.5-50 mg HS (DLB / Parkinson's-friendly)
- AVOID BZD (except alcohol/BZD withdrawal — then lorazepam 0.5 mg)
- Reassess + try to discontinue daily

Step 5 — Discharge Planning:
- Delirium may persist weeks-months
- Reconcile medications (remove anticholinergic + BZD)
- Geriatric / cognitive follow-up
- Family education on recovery course

490.3.0.7 ⚙️ Anti-Amyloid mAb Protocol (22E new)

Patient Selection (FDA label):
- Confirmed amyloid pathology (CSF or PET or plasma p-tau 217)
- MCI due to AD or mild AD dementia (MMSE > 22)
- 不適合：moderate-advanced AD、DLB-only、non-AD dementia

Pre-treatment Workup:
- apoE genotyping (homozygous ε4 = highest ARIA risk)
- Baseline MRI within 1 yr (exclude > 4 microbleeds, CAA, prior macrohemorrhage)
- Counsel risk/benefit:
  - Clinical decline 減緩 ~ 27-35% (CDR-SB)
  - ARIA-E ~ 10-13%, ARIA-H ~ 9-14%
  - Symptomatic ARIA ~ 3%
  - Rare severe (intracerebral hemorrhage, death)
  - Cost (US$ 26,000/yr; Taiwan 自費 200 萬+/年)

Dosing:
- Lecanemab: 10 mg/kg IV q2wk × 18 mo+ (Phase 3 CLARITY-AD)
- Donanemab: 700 mg → 1400 mg IV q4wk (until amyloid clearance on PET, then stop)

MRI Surveillance (lecanemab schedule):
- Before infusions 5, 7, 14
- More frequent if ARIA detected

ARIA Management:
- ARIA-E asymptomatic mild → continue + repeat MRI 4 wk
- ARIA-E moderate-severe or symptomatic → SUSPEND + repeat MRI
- ARIA-H microhemorrhage < 5 + asymp → continue
- ARIA-H > 10 microhemorrhage or > 1 macrohemorrhage → DISCONTINUE
- Concurrent anticoagulation → caution; reassess risk

Caveats:
- Not for use with anticoagulation (relative contraindication; case-by-case)
- apoE4 homozygous → discuss high risk before tx

490.3.0.8 ⚙️ Old DM Stepwise Deprescribing (盧醫師內專)

Step 1 — Assess Patient Profile:
- Functional status (ADL/IADL)
- Cognitive status (Mini-Cog/MoCA)
- Life expectancy estimate (ePrognosis)
- Frailty (Fried/CFS)
- Multimorbidity
- Hypoglycemia history
- Social support (caregiver capacity)

Step 2 — Set New HbA1c Target:
- Healthy + intact cognition + long LE: 7.0-7.5%
- Moderate comorbidity + limited ADL: < 8.0%
- Severe comorbidity + frailty + dementia: < 8.5% (or higher)
- End-of-life: avoid hypoglycemia; HbA1c not relevant

Step 3 — Optimize Drugs:
a. Stop high-hypoglycemia-risk drugs FIRST:
   - **Stop glyburide / chlorpropamide** (long-acting SU — Beers PIM!)
   - Switch to glipizide (shorter-acting SU) or DPP4i
   - Stop sliding-scale insulin (long-term)
b. Simplify insulin regimen:
   - Multi-dose → once-daily basal (glargine/degludec)
   - Consider stopping prandial insulin if HbA1c target relaxed
c. Continue / start where beneficial:
   - Metformin (eGFR ≥ 30) — keep unless contraindicated
   - DPP4i — low hypo, well tolerated
   - SGLT2i — if CV/renal benefit > risk (watch volume depletion, GU infection)
   - GLP-1 — if not cachectic, motor/visual skills OK
d. Consider stopping if HbA1c well below target:
   - SU, GLP-1, prandial insulin

Step 4 — Implement CGM if on insulin:
- Detects hypoglycemia + nocturnal lows
- Hypoglycemia alerts
- Useful in cognitively impaired (caregiver visibility)

Step 5 — Monitor + Family Education:
- Hypoglycemia recognition + glucagon access
- Sick-day rules
- HbA1c q3-6mo
- Reassess functional status q6-12mo

490.3.0.9 ⚙️ End-of-Life Geriatric Decision-Making (內專)

Triggers for ACP Discussion:
- New serious diagnosis (cancer, severe dementia, HF NYHA III-IV)
- Recurrent hospitalization
- Functional decline (loss of ADL)
- Surprise question: "Would I be surprised if this patient died in 1 year?" — No
- Frailty CFS ≥ 7
- Specific markers:
  - Advanced dementia (FAST 7) + recurrent aspiration
  - End-stage CHF (refractory, NYHA IV)
  - End-stage COPD (FEV1 < 30%, O2 dependent, recurrent admit)
  - Multiple comorbidities + weight loss + functional decline

Structured ACP Discussion:
1. Set the stage (private, family present, hearing aids on)
2. Assess understanding of illness
3. Explore values + goals ("What matters most to you?")
4. Discuss prognosis honestly
5. Discuss specific interventions:
   - CPR (data: hospitalized 65+ survival < 20%; nursing home ~ 0%)
   - Intubation + ventilation
   - Artificial nutrition (PEG in advanced dementia → DO NOT)
   - Antibiotics in end-stage dementia recurrent pneumonia
   - Hospital transfer vs comfort at facility
6. Document POLST/MOLST
7. Designate healthcare proxy
8. Review periodically + at care transitions

Hospice Referral Criteria (general):
- Life expectancy ≤ 6 mo (if disease runs usual course)
- Patient/family choose comfort-focused care
- Common diagnoses:
  - Cancer with metastatic disease
  - Advanced dementia (FAST 7 + complications)
  - End-stage CHF/COPD/CKD/liver
  - ALS, advanced Parkinson's

Hospice Service:
- In-home, inpatient, residential
- Interdisciplinary team (RN, MD, SW, chaplain, aide, volunteer)
- Symptom management
- Family support + bereavement
- Median LOS only 17 days (most referred too late)

490.3.0.10 ⚙️ Geriatric Care Models (內專)

Inpatient:
- ACE (Acute Care for Elderly) unit: dedicated geriatric ward; multidisciplinary; ↓ functional decline + LOS
- Co-management (geriatric-orthopedic, geriatric-trauma): ↓ complications + delirium + LOS
- HELP (Hospital Elder Life Program): bundled non-pharm delirium prevention

Outpatient:
- Comprehensive Geriatric Assessment clinic
- Memory clinic
- Falls clinic
- PACE (Program of All-Inclusive Care for the Elderly): community-based, comprehensive

Home:
- Home-based primary care (Independence at Home)
- Hospital at Home
- Care transitions:
  - Project RED (Re-Engineered Discharge): discharge advocate
  - TCM (Transitional Care Model): APN-led post-discharge
  - CTI (Care Transitions Intervention): transition coach
  - BOOST (Better Outcomes for Older Adults Safe Transitions)
  - INTERACT (long-term care quality improvement)

Long-Term Care:
- Skilled nursing facility (SNF)
- Assisted living
- Adult day care
- Hospice (home / inpatient)

Taiwan 長照 2.0:
- A-B-C 三級
- 居家服務 + 日照 + 家托 + 喘息
- 失智照護資源中心
- 預防延緩失能

490.3.0.11 ⚙️ Elder Abuse Detection + Reporting (內專)

Types:
- Physical abuse: bruising at unusual sites, restraint marks
- Psychological abuse: intimidation, isolation
- Financial abuse: unpaid bills, missing items, abrupt financial change
- Sexual abuse
- Neglect (caregiver) / self-neglect: malnutrition, dehydration, pressure ulcer, untreated condition

Screen Questions (alone with patient):
- "Do you ever feel unsafe where you live?"
- "Has anyone ever threatened or hurt you?"
- "Has anyone been taking your money without your permission?"

Red Flags:
- Discordant history vs findings
- Multiple injuries in different healing stages
- Delayed presentation
- Caregiver dominates the interview
- Patient defers to caregiver / appears intimidated
- Missing pet, missing valuables
- Repeated ED visits

Workup:
- Interview alone
- Document carefully (photograph injuries with consent)
- Assess capacity
- Cognitive + depression screen
- Labs: malnutrition, dehydration markers
- Social work consult

Reporting:
- Mandatory reporters in most jurisdictions (Taiwan: 老人福利法 — 醫師為通報義務人)
- Taiwan: 通報 1957 + 各縣市社會局
- US: Adult Protective Services
- Document refusal if competent adult declines intervention

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