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Dr. Rose Dinda Martini, SpPD

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1 Dr. Rose Dinda Martini, SpPD
Geriatric Syndrome Dr. Rose Dinda Martini, SpPD

2 The Guinness Book of World Records  the fastest 100-year-old to run 100 meters.

3 Identifikasi penyebab Comprehensive geriatric assessment
SINDROM GERIATRI Kumpulan gejala dan atau tanda klinis, dari satu atau lebih penyakit, yang sering dijumpai pada pasien geriatri. - Perlu penatalaksanaan segera Identifikasi penyebab Comprehensive geriatric assessment

4 Geriatric Giant Immobility Instability Incontinence (urinary & alvi)
Intellectual impairment (MCI, Dementia) Infection (Pneumonia, etc) Impairment of hearing & vision Impaction (constipation) Isolation (depression) Inanition (malnutrition) Impecunity (poverty) Iatrogenesis Insomnia Immune deficiency Impotence Kane, Ouslander Abrass. (from Solomon 1988), Essentials of Clinical Geriatrics p

5 Intellectual Impairment
Geriatric Syndromes Intellectual Impairment Impairment of Visual Inanition Impaction Incontinence Immuno deficiency Infection Insomnia Immobilization Iatrogenesis Impotence Instability and Falls Isolation Impairment of Hearing

6 Immobilization

7 The Bed Look at a patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder, and the spirit evaporating from his soul. (R Asher: The Dangers of Going to Bed: BMJ 1947)

8 Imobilization Keadaan tidak bergerak atau tirah baring selama 3 hari atau lebih dengan gerak anatomik yang hilang akibat perubahan fungsi.

9 Pasien Imobilisasi


11 Aging and Malnutrition

12 Malnutrition in the Elderly: More common than you would think
2 - 10% free-living elderly populations 1 % institutionalized elderly 1 % nursing home residents 2 % home care patients 2 (1) Vellas, B. et al, NNWS, 1999, Volume 1; (2) Nutr Screening Initiative

13 Why the concern? Malnourished elderly are:
2 times more likely to visit the doctor 3 times more likely to be hospitalized Infection is the most common disorder times more likely to die if malnourished Diminished muscle strength Poor healing Malnutrition is a greater threat than obesity stay 2 times longer in the hospital 13

14 Malnutrition : A vicious circle
Apathy, depression Poor concentration Reduced feeding capabilities Reduced mobility Poor Appetite Loss of muscle strength

15 Causes of weight loss in older persons
• Medications • Emotions (depression) • Alcoholism, anorexia • Late-life paranoia • Swallowing problems • Oral problems • No money (poverty) • Wandering (dementia) • Hyperthyroidism, Hyperparathyroidism • Entry problems (malabsorption) • Eating problems • Low-salt, low-cholesterol diet • Shopping problems

16 Faktor-faktor medis (melalui anoreksia, rasa cepat kenyang, malabsorpsi, metabolisme meningkat, pengaruh sitokin, dan gangguan status fungsional) Kanker Alkoholism Gagal jantung PPOK Infeksi Disfagia Rematoid Artritis Parkinson Hipertiroid Sindrom malabsorpsi Gejala-gejala GI: dispepsia, gastritis atrofi, muntah, diare Konstipasi Gigi geligi yang buruk

17 Faktor-faktor psikologis
Alkoholism Kehilangan Depresi Demensia Fobia Kolesterol

18 Obat-obatan Mual/muntah: antibiotik, opiat, digoksin, teofilin, NSAIDs
Anoreksia: antibiotik, digoksin Berkurangnya cita rasa: metronidazol, calcium channel blockers, ACE inhibitor, metformin Mudah kenyang: antikolinergik, simpatomimetik Berkurangnya kemampuan makan: sedatif, opiat, psikotropik Disfagia: suplemen potasium, NSAIDs, bifosfonat, prednisolon Konstipasi: opiat, suplemen besi, diuretik Diare: laksans, antibiotik Hipermetabolisme: tiroksin, efedrin

19 Consequences of malnutrition
Diminished functional ability Compromised immune function Impaired wound healing Constipation, diarrhoea, pain Reduced renal function Respiratory failure Skeletal muscle atrophy Increased length of stay Surgery stress, increased metabolic rate Reddish hair, atrophy of tongue papillae Morbidity & mortality

20 Identify elderly who are at risk of malnutrition

21 Validation of MNA® Nursing home, hospitalized & free living elderly
Sensitivity 96% Specificity 98% Predictive value 97% Inter-observer MNA- Kappa 0.51

22 MNA® score interpretation
maximum score 30 points  24 : normal/well-nourished : border line/at risk malnutrition < 17 : undernutrition Guigoz et al., Facts & Res. Gerontol (suppl.2):15-70

23 Intellectual Impairment: Dementia & Delirium

24 ALZHEIMER'S DISEASE A progressive neurologic disorder that results in memory loss, personality changes, global cognitive dysfunction, and functional impairments. Loss of short-term memory is most prominent early. In the late stages of disease, patients are totally dependent upon others for basic activities of daily living such as feeding and toileting

25 Depression

26 Frail Elderly Characteristics: Poor mental and physical health
Low socioeconomic status Predominantly female Possibly isolated living conditions More and longer hospital stays, and More money spent on health care and drugs

27 Infection

28 Infection Morbidity and mortality no.2 after CV diseases:
Comorbid of chronic diseases Decrease of immunity Communication difficulties Environment Predisposition: intrinsic, virulence, environment

29 Comparative mortality rates of infections in elderly and young adults
Ratio mortality rates : elderly vs young Pneumonia Tuberculosis Urinary tract infections Bacteremia / sepsis Cholecystitis Appendicitis Septic Arthritis Bacterial meningitis Infective endocarditis 3 10 1 2-8 15-20 2-3

30 Clinical features of infections in elderly
Fever Nonspecific symptoms : - Anorexia - Fatigue - Weight loss - Incontinence (acute) - Falls - Mental confusion

31 Sir William Osler : “In old age, pneumonia may be latent, coming on without chill, the cough and expectoration are slight, and the physical sign changeable.”

32 Geriatric assessment is needed to:
Identify geriatric syndromes/functional decline Evaluate and manage these geriatric syndromes/functional decline - address reversible causes - apply general measures Determine the type/extent of follow-up needed to sustain gains achieved

33 Iatrogenesis: A Definition
Any illness that results from a diagnostic/therapeutic intervention or the omission of such intervention that is not a natural consequence of the patient’s disease

34 Contributors to Polypharmacy
Patient Borrowing or sharing medications Failing to understand instructions Saving medication for later use Combining Rx’s with OTC’s and Herbals Visiting more than one physician Doctor Failing to review the patient’s medications Prescribing medications for common and non-life threatening symptoms Treating multiple symptoms or illnesses with several drugs

35 A stepwise approach to prescribing
Discontinue unnecessary therapy Consider adverse drug events for any new symptoms Consider non-pharmacologic approaches Substitute with safer alternatives Reduce the dose Prescribe beneficial therapy Ladden MD. Brief Guide to Geriatric Assessment.

Constipation ↟ in older people > 60 y Regular use of laxatives Associated : anxiety, depression poor health perception Complication : fecal impaction (1) fecal incontinence (1) urinary retention (2) sigmoid volvulus (2) ↑ morbidity : intestinal obstruction, ulceration

37 Definition

38 Physio-pathology Chronic Constipation

39 Risk Factors Constipation in Elderly
Medications Anticholinergic drugs (trisyclic,antipsichotic,antihistamin,antiemetic drug for detrusor hyperactivity) (1) Polypharmacy (≥ 5 medications) (1) Opiates, calcium supplement (2) NSAID, CCB (nifedipin, verapamil) (2) Iron suplement (2) Impaired mobility (2) Depression (3)

40 Risk Factors Constipation in Elderly
Neurological conditions Parkinson, DM, spinal cord injury (1) Dementia (2), strok (3) Dehydration (2) Low dietary fiber (3) Metabolic disturbances Hypothyroidism, hypercalcemia, hypokalemia Patients receiving renal dialysis (3) Lack of privacy or comfort Poor toilet acces (3)

41 Rectal Touche !! Physical Examination All patients constipation :
Rectal impaction ? Rectal dilatation ? Hemorrhoid ? Anorectal disease ? Perianal fecal soiling ?

42 Jatuh Inkontinensia urin Infeksi Fraktur Kesadaran 
SITI SETIATI, Geriatri IPD FKUI/RSUPN-CM, 2003 Instabilitas Jatuh Inkontinensia urin Infeksi Fraktur Kesadaran  Hipotermia Imobilisasi Depresi Gangguan Ulkus tidur Trombosis vena Pneumonia ISK Dehidrasi konstipasi Atrofi otot Asupan makanan Malnutrisi Obat Asupan cairan 

43 Summary Geriatric population is rising worldwide, esp. in developing countries, including Indonesia Geriatric patients have special characteristics that need to be considered Syndromes in geriatric  geriatric giants (13 i) All the syndromes are inter-correlated and should be evaluated in all geriatric patients The assessment and management of geriatric patients holistic comprehensive

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