Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clinical Management in the Elderly Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACP Division of Geriatrics Department of Internal Medicine RSCM FMUI.

Similar presentations


Presentation on theme: "Clinical Management in the Elderly Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACP Division of Geriatrics Department of Internal Medicine RSCM FMUI."— Presentation transcript:

1 Clinical Management in the Elderly Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACP Division of Geriatrics Department of Internal Medicine RSCM FMUI

2 Outline Medical case example Surgical case example Why do we need special approach for geriatric patients? What is a CGA? How does the CGA should be applied?

3 Example of medical case Elderly woman, 78 yo – Outpatient visit, loss of appetite, epigastric pain – Frequently feeling weak, episode of fall in bathroom – History of HT, well controlled by HCT 12,5 mg – No fracture; No wound/ bruises CM, 130/80, 80/m, 37,0°C, 20/m Conjungtiva not pale, sclera not icteric heart/lung wnl, H/L not palp, edema -/- – Hb 12 ; rBG 115 ; Cholesterol (T) 155

4 Dx  Dysepsia Antasida, ranitidin, multivitamin One week  complain ↓, symptoms ↓ Remaining symptoms: – weakness, – frequent falls, instable – Outpatient consultation for 2 months  no improvement – Referred to specialist  still no improvement

5 Dx  Dysepsia Antasida, ranitidin, multivitamin One week  complain ↓, symptoms ↓ Remaining symptoms: – weakness – frequent falls, instable – Outpatient consultation for 2 months  no improvement – Referred to specialist  still no improvement

6 Weakness Vitamin deficiency Mineral deficiency Weakness Deficiency Low intake Dehydration Hyponatremia Hypoglycemia Depression Hypoxia

7 Anamnesis (addition) Frequent urination, leakage, asshamed Reduce drinking Reduce food intake, to prevent blood pressure increase Reduce salt intake, to prevent blood pressure increase Husband, passed away a year ago – Frequently found pensive – Decrease outside house activity while previously very active in peer group activities

8 Weakness Vitamin deficiency Mineral deficiency Weakness Deficiency Low intake Dehydration Hyponatremia Hypoglycemia Depression Hypoxia

9 Frequent falls, instable Due to old age Due to the weakness

10 Frequent falls, instable Due to old age Due to the weakness POSTURAL INSTABILITY Internal Factors: Systemic disease Ortostatic hypotention Hypercoagulable state Increase platelet aggregation Local pathology OA knee, fasciitis, cervical SA External Factors : Home environment

11 Anamnesis, PE (addition) Transfer process: unstable sensation Painfull knee joints, sitting  standing BP, sitting 110/60 (supine: 130/80) Crepitation (+), both knee joints

12 Frequent falls, instable Due to old age Due to the weakness POSTURAL INSTABILITY Internal Factors: Systemic disease Ortostatic hypotention Hypercoagulable state Increase platelet aggregation Local pathology OA knee, fasciitis, cervical SA External Factors : Home environment

13 Current diagnosis Dyspepsia Low intake Dehydration Hyponatremia (suspect) Depression Urinary incontinence Ortostatic hypotention in hypertensive patient OA of the knee

14 Current management Antasida Nutritional consult Psychotherapy Restore food patern Oral rehydration Nutritional supplement Multivitamin Urine sample; culture HCT  ACE-inh or CCB Parasetamol (prn) ; muscle strengthening exercise

15 Surgical case, example Old lady of 82 yo – Brought to EU, fell in the bath room – Pain; right hip – She could not stand up on her own – DM ; well controlled by gliquidon – Hipertention; well controlled by lisinopril Old lady of 82 yo – Brought to EU, fell in the bath room – Pain; right hip – She could not stand up on her own – DM ; well controlled by gliquidon – Hipertention; well controlled by lisinopril

16

17 Physical exam, Lab, Ro CM, vital sign: stable Heart and lung: no significant findings H/L not palpable; edema/ ascites were (-) Peripheral blood: normal rBG 134 mg/dL; ureum 25 mg/dL; creat 0,8 mg/dL Na 138 mEq/L; K 4,0 mEq/L OT, PT and Albumin, Globulin: normal CXR and ECG:normal CM, vital sign: stable Heart and lung: no significant findings H/L not palpable; edema/ ascites were (-) Peripheral blood: normal rBG 134 mg/dL; ureum 25 mg/dL; creat 0,8 mg/dL Na 138 mEq/L; K 4,0 mEq/L OT, PT and Albumin, Globulin: normal CXR and ECG:normal

18 Often overlooked Patient’s functional status? Cognitice function and psycho-affective condition? How does the social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually? Patient’s functional status? Cognitice function and psycho-affective condition? How does the social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually?

19 Patient’s functional status? Cognitice function and psycho- affective condition? Social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually? Patient’s functional status? Cognitice function and psycho- affective condition? Social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually?

20 Patient’s functional status? Cognitice function and psycho- affective condition? Social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually? Patient’s functional status? Cognitice function and psycho- affective condition? Social arrangement so far? What about fer food and fluid intake? Her actual kidney function? Peri-operative condition in geriatrics? What does the patient’s real wish actually? Dementia; bedridden ; severely dependent Relatives often come to visit for longer period of time; play a role as care giver Poridge; balanced; but for the past one week: decreased food intake; very limited fluid intake Kidney function: CCT Cockroft-Gault formula Ask the patient/ family re AMP-operation?; is it really necessary and approved by the family?

21 Eventually.... Conventional medical aspects.. + Other aspects that should be considered: Tapi masih terdapat: – Sering lemes, – Suka jatuh, jalan ‘oyong’ – Berobat sampai 2 bulan kemudian masih tetap – Berobat ke spesialis sudah sebulan tak ada perubahan

22 Eventually.... Conventional medical aspects.. + Other aspects that should be considered: Tapi masih terdapat: – Sering lemes, – Suka jatuh, jalan ‘oyong’ – Berobat sampai 2 bulan kemudian masih tetap – Berobat ke spesialis sudah sebulan tak ada perubahan Functional Cognitive Psychoafective Psichosocial Nutritition Functional Cognitive Psychoafective Psichosocial Nutritition

23 Other things should be considered Clinical performance often non specific Decrease in reserve capacity Clinical performance often non specific Decrease in reserve capacity Presenting symptoms often: Altered consciousness; personality changes Postural instability; Fall Loss of appetite Immobility Presenting symptoms often: Altered consciousness; personality changes Postural instability; Fall Loss of appetite Immobility

24 Conclusion Geriatric patient, in general: – Multipathology – Decrease reserve capacity – Non specific clinical signs and symptoms – Changes in functional status – Malnutrition

25 Conclusion Geriatric patient, in general: – Multipathology – Decrease reserve capacity – Non specific clinical signs and symptoms – Changes in functional status – Malnutrition Needs special approach : CGA

26 PHYSICAL, BIOLOGICAL PSYCHO- COGNITIVE SOCIAL

27 PHYSICAL, BIOLOGICAL PSYCHO- COGNITIVE SOCIAL FUNCTIONAL ADL, IADL, MNA NUTRITION

28 PHYSICAL, BIOLOGICAL PSYCHO- COGNITIVE SOCIAL FUNCTIONAL Anamnesis and PE Ax & PE SYSTEM Clinical, AMT, MMSE, GDS Anamnesis, home visit ADL, IADL, MNA NUTRITION

29 CGA I IIIIIIVVVI Bio/ Physical CurativeMultidisci plinary Impairment FluidHospital based Psycho/ Cognitive Promotive Uni... XDisabilityNutritionDischarge planning PsychosocPreventive Para...XHandicap Medication Community based Functional Rehabilita tive Pan...XActivity NutritionINTERDIS CIPLIN Psychoso cial care

30 CGA I IIIIIIVVVI Bio/ Physical CurativeMultidisci plinary Impairment FluidHospital based Psycho/ Cognitive Promotive Uni... XDisabilityNutritionDischarge planning PsychosocPreventive Para...XHandicap Medication Community based Functional Rehabilita tive Pan...XActivity NutritionINTERDIS CIPLIN Psychoso cial care

31 PHYSICAL, BIOLOGICAL PSYCHO- COGNITIVE SOCIAL FUNCTIONAL Anamnesis and PE Ax & PE SYSTEM Clinical, AMT, MMSE, GDS Anamnesis, home visit ADL, IADL, MNA NUTRITION

32 Barthel Index of ADL Bowel control2 Bladder control2 Grooming1 Bathing1 Feeding2 Dressing2 Toilet Use2 Transfers3 Mobility3 Stair2 20: Fully independent 12-19: Lightly dependent 9-11: Moderately dependent 5- 8: Severely dependent 0- 4: Total dependent

33 Abbreviated Mental Test (AMT) Age Years old1 Current time/hour1 Address1 Current year1 Location right now1 Recognizing others (doctor, nurse, etc)1 National independence year1 Current president1 Patient’s or youngest child’s year of birth 1 Counting down (20 to 1)1 0-3 : Severe cognitive impairment 4-7 : Moderate cognitive impairment 8-10 : Normal

34 MMSEMMSE

35 THANK YOU


Download ppt "Clinical Management in the Elderly Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACP Division of Geriatrics Department of Internal Medicine RSCM FMUI."

Similar presentations


Ads by Google