1. ELDERLY and DISABILITY
Sharon Gondodiputro dr., MARS.,MH
Dept. Of Public Health Faculty of Medicine
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2. Fact Sheets !!!! About Elderly
The world population is rapidly ageing
Between 2000 and 2050, the proportion of the world's population over 60 years will double from about 11% to 22%. The number of people aged 60 years and over is expected to increase from 605 million to 2 billion over the same period.

3. By 2050 the world will have almost 400 million people aged 80 years or older. Never before have the majority of middle-aged adults had living parents.
By 2050, 80% of older people will live in low- and middle-income countries

4. The main health burdens for older people are from noncommunicable diseases
Already, even in the poorest countries the biggest killers are heart disease, stroke and chronic lung disease, while the greatest causes of disability are visual impairment, dementia, hearing loss and osteoarthritis.
Many of these problems can be easily and cheaply prevented.

5. The need for long-term care is rising
The number of older people who are no longer able to look after themselves in developing countries is forecast to quadruple by 2050.
Many require long-term care, including home-based nursing, community, residential and hospital-based care.

6. Effective, community-level primary health care for older people is crucial
Good care is important for promoting older people's health, preventing disease and managing chronic illnesses.

7. Supportive, “age-friendly” environments allow older people to live fuller lives and maximize the contribution they make
Creating “age-friendly” physical and social environments can have a big impact on improving the active participation and independence of older people

8. Healthy ageing starts with healthy behaviours in earlier stages of life
These include what we eat, how physically active we are and our levels of exposure to health risks such as those caused by smoking, harmful consumption of alcohol, or exposure to toxic substances.

9. We need to reinvent our assumptions of old age
Society needs to break stereotypes and develop new models of ageing for the 21st century. Everyone benefits from communities, workplaces and societies that encourage active and visible participation of older people.

10. Caring for older family members is a normal, but often a stressful situation, may be manifest through illness in the caregivers
Human biologic aging is characterized by the progressive constriction of each organ system’s homeostatic reserve (homeostenosis)
Begins in the third decade, progressive, but varies in speed for each individual
Pra lansia = tahun
Lansia > 60 tahun

11. Is influenced by : genetic factor, diet, environment and
personal habits

12. Several principles from this concept:
Individuals become more dissimilar as they age, rejecting any stereotype of aging
Abrupt decline in any system/function …..> almost certain due to disease, not to normal (or usual) aging
“ Normal aging” can be attenuated to some extent by modification of risk factors.
In the absence of disease, homeostenosis should not cause symptoms or impose restrictions on activities of daily living.

13. THE AGED RELATED CHANGES AND THEIR CONSEQUENCES
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
General
⇑ Body fat
 Total body water
⇑ vol of fat soluble drugs
 Vol of water soluble drugs
Obesity
Anorexia
Eyes and ears
Presbyopia
Lens opacification
 High frequency acuity
Accomodation
⇑Suspectibility to glare
Difficulty discriminating words if background noise is present
Blindness
Deafness
Respiratory
Lung elasticity
⇑Chest wall stiffness
Ventilation perfusion mismatch &  O2 saturation
Dyspnea, hypoxia

14. Endocrine Cardiovascular ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Endocrine
Impaired glucose homeostatis
Thyroxine clearance, Renin .aldosterone, testosterone, Vit D absorption & activation,estrogen
⇑ ADH
⇑ Glucose level in response to acute illness
 T4 dose required in hypothyroidism
D.M.
Throid dysfunction
Serum Na, ⇑ Serum K
Impotence
Osteomalacia,fractures
Cardiovascular
Arterial compliance and ⇑Systolic BP (LVH)
Beta adrenegic responsiveness, baroreceptor sensitivity and SA node automaticity
Hypotensive response to ⇑ HR, volume depletion or loss of a trial contraction
Cardiac output and HR response to stress
Impaired blood pressure to standing, volume depletion
Syncope
Heart failure
Heart block

15. Haematologic and immune system
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Haematologic and immune system
 bone marrow reserve
 T cell function
⇑ autoanti bodies
Anemia
False negative PPD response
False positive rheumatoid factor, antinuclear antibody
Auto immune disease
Renal
GFR
 urine concentration-dilution
Impaired excretion of some drugs
Delayed response to salt or fluid restriction or overload, nocturia
⇑ Serum creatinine, renal failure
 Or ⇑ serum Na
Genitourinary
Vaginal or urethral mucosal atrophy
Bladder contractility
Prostate enlargement
Dyspareunia, Bacteriuria
⇑ Residual urine volume
BPH
Symptomatic UTI
Urinary incontinence, urinary retention, Prostate cancer
Musculoscletal
 Lean body mass and muscle , bone density
Strength
Osteopenia
Functional impairment
Hip,vertebral fractures

16. THE FRAIL ELDERLY Gastrointestinal
ORGAN OR SYSTEM
AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF AGE RELATED PHYSIOLOGIC CHANGE
CONSEQUENCES OF DISEASE, NOT AGE
Gastrointestinal
 Hepatic function, gastric acidity , colonic motility,anorectal function
Delayed metabolism of some drugs
 Ca Absorption on empty stomach
Constipation, Fecal incontinence
Cirrhosis
Osteoporosis
B12 def
Fecal impaction
Nervous system
Brain atrophy
 Brain carechol synthesis , brain dopaminergic synthesis, righting reflexes, stage 4 sleep.
Benign senescent forgetfulness
Stiffer gait
⇑Body sway
Early awakening, insomnia
Dementia
Delirium
Depression
Parkinson’s disease
Falls
Sleep apnea
THE FRAIL ELDERLY

17. THE FRAIL ELDERLY
Syndrome that results from a multisystem reduction in reserve capacity
Increased risk of disability and death from minor external stresses …..> extraordinarily thin tightrope in an attempt to balance physiologic function

18. FIVE CLASSIC GERIATRIC PROBLEMS
FALLS
DEMENTIA
DEPRESSION
URINARY CONTINENCE
IRRATIONAL DRUG THERAPY (POLYPHARMACY)

19. APPROACH TO THE PATIENT
Priorities : in elderly are likely to differ from those of younger people ……> Quality of life
Caregiver issues : requires attention as well as the patient, since the health and well being of the two are closely linked.

20. COMPREHENSIVE GERIATRIC ASSESSMENT
Physical assessment
Mental status assessment
Functional assessment
Social assessment
Home environment assessment

21. Physical Assessment History taking : Auto/Allo anamnesis
visual impairment
hearing loss
Falls
Incontinence
drug ingestion
dietary patterns
sexual dysfunction
depression and anxiety

22. Interviewing older patients and their family members
Be prepared to spend more time with older patients and more slowly
Always address the patient first
Involve caregivers and family members early in the patient’s care
Recognize the emotional concerns underlying any explicit requests
Do not make significant changes in a treatment plan based solely on the family’s report without evaluating the elderly patient directly

23. Physical examination: Very private, do not mention anything, with respect and kindness.
General examination: vital signs
Special senses : eyes and ears
Mouth and denture
Neck
Breasts
Cardiovascular system
Abdomen and urinary tract
Gait and balance : “The get up and go”
Neurological system

24. Mental status assessment
Geriatric Depression scale
Cognitive testing : dementia (intelectual impairment)
Conversational probing: for patients who follow the news or reading, television
Draw a clock test: ask the patient to draw a clock with the hands at a set time ex 15 min before 03:00
Folstein’s Mini Mental Status Examination (MMSE)
Elderly Cognitive Assessment Questionnaire (ECAQ)

25. Geriatric Depression scale
A score > 5 points is suggestive of depression.
A score > 10 points is almost always indicative of depression.
A score > 5 points should warrant a follow-up comprehensive assessment.

28. Elderly Cognitive Assessment Questionnaire (ECAQ)
Items
Score
Memory 1
I want you to remember this number. Can you repeat after me (4517). I shall test you again in 15 min. 2
How old are you? 3
When is your birthday? OR in what year were you born?
Orientation and information 4
What is the year? 5
date? 6
day? 7
month? 8
What is this place called? Hospital/Clinic 9
What is his/her job?
Memory Recall 10
Can you recall the number again?
Total
Score (correct answer)
>7
Normal
5-6
borderline
0-4
Probable case of cognitive inpairment

29. Assessment of Decision Making Capacity :Capacity to make decision for medical intervention : four components:
Ability to express a choice
Ability to understand relevant information about the risks and benefits of planned therapy and the alternatives including no treatment
Ability to understand the situation and its possible consequences
Ability to reason

30. Functional assessment
Information about function can be used in a number of ways:
As baseline information
As a measure of the patients’s need for support services or placement
As an indicator of possible caregiver stress
As a potential marker of spesific disease activity
To determine the need for the therapeutic interventions

31. Measurement:
Activities of daily living (Katz):

32. Social and economic assessment
Evaluates the patient’s perception of his own health status, his environment, his family situation, financial status and leisure activities

33. Home environment assessment
The main objectives :
To understand the home environment of the elderly and home hazards
To see the interaction between the elderly’s functional abilities and the home environment
To see how care can be optimized taking into considerations the home situation
To detect any potential hazards that may predisposed the elderly to falls

34. Areas of assessment
Housing : accesibility, social services, transportation, medical services, amenities
The house/flat: type and location, number of rooms, lift, stairs and walkway, lighting, hazards, entry and exit
Room: flooring, ventilation, telephone location, furniture arrangement, lighting, hazards, bed
Living room: Furniture arrangement, wiring, hazards, chairs and table
Bedroom: bed, lighting,flooring,hazards
Toilet/bathroom: grips,bars, railings, toilet type, flooring, drainage, non slip measures, hazards
Kitchen: storage space and accesibility, sharps, hot water, oven, flooring and hazards.

35. TEN STEPS TO REDUCE POLYPHARMACY1
Keep an accurate record of all medications the patient is on, including over the counter medications 2
Get into the habit of identifying all drugs by generic name and drug class 3
Make certain that each drug being prescribed has a clinical indication 4
Know the side-effect profile of the drugs being prescribed 5
Understand how pharmacokinetics and pharmacodynamics of aging increase the risk of adverse drug events