Bimbingan Dokter Muda Topik : Geriatri

Number of Persons 65 and over from 1900 to 2030

(Administration on Aging, 2000)5Slide 2ulati on, The older population represents about 12.7% of the U.S. population, about one out of 8 Americans. The number of older Americans has increased by nearly 11% since 1900. (Compared to 9% increase in the under-65 population). (AoA, 2001)Every eight seconds a baby boomer turns 50 (U.S. Census Bureau, 1996)The older U.S. population is growing rapidly as baby boomers age, and more people are living longer:

*The first baby boomers will turn 65 in 2011, and people aged 65 and over are projected to represent 20 percent of the total U.S. population in 2030 compared with 12 percent in 2003. *Average life expectancy at birth in 2000 was 76.9 years; females could expect to live an average of 5.4 years longer than men. *About 80 percent of centenarians are women.*The United States is relatively young compared with other developed countries. Despite its aging, the United States has a lower proportion of adults aged 65 and older than that of most countries in Western Europe.

Number of Persons 85 and Over 1900 to 2050

(U.S. Census Bureau, 1996)6Slide 4(U.S. Census Bureau, in P23-190, 1996)This slide indicates the projected growth in the 85-year and older groupthe U.S. Census Bureau estimates that approximately 19 million people will be 85 or older in the U.S. by 2050.Level Kompetensi (SKDI 2012)Daftar Masalah Kesehatan dan Daftar Penyakit Individu :Penurunan Kesadaran pada Lanjut Usia = Acute confusional state = Delirium (3B)Gangguan Mental&Intelektual, pelupa = Demensia (3A)Depresi (3A)Gangguan Tidur (4A)Gangguan Makan dan Malnutrisi pada lanjut usia(4A)Kulit Melepuh (ulkus dekubitus)Gangguan berkemih (Prostatism = 3A) dan Sembelit/konstipasiGangguan gerak, berjalan dan koordinasi (Parkinson = 3A)Demam dan infeksi pada lanjut usia (Pneumonia = 4A dan pneumonia aspirasi = 3B, dan UTI = 4A)

Daftar Masalah Kesehatan Masyarakat/Kedokteran Komunitas&Pencegahan Pola Asuh = Care GiverPenganiayaan/perlukaaan = Elder AbuseKesehatan Lansia (fokus : Gaya hidup : Olah raga dan Nutrisi)Rehabilitasi Medik dan Sosial = Setting Kegiatan LansiaPengelolaan Pelayanan Kesehatan = Setting Perawatan lansia

Daftar Keterampilan Klinis :CGA (pemeriksaan fungsional/ADL, status nutrisi&fungsi menelan, MMSE, inspeksi gait&fungsi motorik/sendi, perawatan luka/dressing, colok dubur, palpasi prostat) = 4A

Percent Aged 65 and Over: 2000

(An Aging World:2001, November 2001)7Slide 34 Percent Aged 65 and Over: 2000(An Aging World:2001, November 2001)Over half (59%). of the worlds elderly now live in developing nations (Africa, Asia, Latin America, Caribbean, Oceania)Industrialized nations of Europe, North America, and Japan: higher percentages of older people.

Percent Aged 65 and Over: 2030

(An Aging World:2001, November 2001)**8Slide 35 Percent Aged 65 and Over: 2030(An Aging World:2001, November 2001)

By 2030, this proportion of elderly in developing countries is projected to increase to 71%.As noted in the report, An Aging World: 2001, these expanding numbers of very old people represent a social phenomenon without precedent. This growth is also bound to change the previously held stereotypes of older people. In addition, this growth is pertinent to public policy because individual needs and social responsibilities change with increased age. As the numbers grow their impact will be felt in the global economy. It is important that we understand the characteristics of this population, their strengths, and their needs. We face the challenge of anticipating the changing needs and desires of an aging world in a new millennium.Ilmu GeriatriCabang Ilmu yang memperhatikan kondisi fisik, mental, fungsional dan sosial yang muncul pada perawatan fase akut, penyakit kronis, rehabilitasi pencegahan, sosial dan situasi akhir hayat dari pasien lanjut usia

Kelompok pasien ini memiliki kerapuhan yang sangat dan penyakit aktif yang multipel, yang membutuhkan pendekatan yang holistik

Penyakit yang muncul sering nampak berbeda dan sulit tuk terdiagnosa, respon lambat terhadap terapi dan seringkali membutuhkan dukungan sosial

Ilmu Geriatri melampaui pengobatan yang berbasis organ dan menawarkan terapi dengan setting multidisplin dengan tujuan untuk mengoptimalisasi status fungsional para lansia dan memperbaiki kualitas hidup dan otonomi lansia

Ilmu Geriatri tidak hanya spesifik terkait usia tua, namun lebih pada morbiditas yang khas pada usia tua : Geriatric Giants

Sub TopikDelirium Demensia Depresi : Skrining dan Penilaian, Pencegahan, Pendekatan Diagnosa dan Terapi (Penilaian GCS, MMSE, GDS)Gangguan Fungsional : gangguan berjalan, stabilitas dan resiko Jatuh&Imobilitas (penilaian gaya berjalan, performan fisik, keseimbangan, dan penilaian ADL-IADL) : Parkinson, jatuh, imobilitas, ulkus dekubitus (Norton Scale), pneumonia aspirasi, kontraktur

Sub TopikGangguan Saluran Pencernaan pada Lanjut Usia: Gangguan menelan, konstipasi, resiko Malnutrisi (penilaian menelan dan MNA)Gangguan Tidur/InsomniaGangguan Berkemih (prostatism; pemeriksaan colok dubur, palpasi prostat ,inkontinensia urin) dan infeksi saluran kencingPeran Keluarga dan MasyarakatKesehatan Lansia : Olahraga dan Rehabilitasi Medik serta NutrisiRehabilitasi Sosial (Setting Kegiatan Lansia)Pengelolaan Pelayanan Kesehatan (Setting Perawatan Lansia)Pola Asuh dan Pengasuh (Care Giver)Elder Abuse (Penganiayaan/perlukaan)

Berbagai sarana yang diperlukanPelayanan berbasis komunitasPuskesmasAsuhan rumahPanti werdha ; hostelKarang werdha / PUSAKA

Pelayanan berbasis rumah sakitRRA (ruang rawat akut) ; RRK (ruang rawat kronis)Klinik asuhan siangPoliklinik terpaduKonsep sehat harus ditambah menjadi konsep MANDIRI.

Konsep status kesehatan harus ditambah dengan konsep STATUS FUNGSIONAL.

Konsep sembuh ditambah menjadi konsep PENINGKATAN KUALITAS HIDUPMelakukan pendekatan khusus apa?Lakukan Comprehensive Geriatric Assessment

Apakah C G A ?Apakah komponen CGA ?Bagaimana cara menerapkan CGA ?Ruang lingkup CGAKetentuan WHO:Physical healthMental functionFunctional capacitySocial resourcesEnvironmental resourcesEconomic resourcesInterdisciplinary approachWorld Health Organization. 2000. The World Health Report 2000; Health Systems: Improving Performance. Geneva: World Health Organization. Hal 3-17.Apakah CGA ?CGA = P3G = Pengkajian Paripurna Pasien Geriatriprosedur evaluasi multidimensimengungkapkan dan menguraikan berbagai masalah pada pasien geriatri (described and explained)menemu kenali semua aset pasien (berbagai sumber dan kekuatan yang dimiliki pasien)mengidentifikasi jenis pelayanan yang dibutuhkanmengembangkan rencana asuhan secara terkoordiniryang semua itu berorientasi kepada kepentingan pasien (dilihat tidak semata-mata dari sudut medik). Apakah CGA ?CGA = P3G = Pengkajian Paripurna Pasien Geriatriprosedur evaluasi multidimensimengungkapkan dan menguraikan berbagai masalah pada pasien geriatri (described and explained)menemu kenali semua aset pasien (berbagai sumber dan kekuatan yang dimiliki pasien)mengidentifikasi jenis pelayanan yang dibutuhkanmengembangkan rencana asuhan secara terkoordiniryang semua itu berorientasi kepada kepentingan pasien (dilihat tidak semata-mata dari sudut medik). Mempunyai karakteristik tertentuMUTIPATOLOGIDAYA CADANGAN FAALI MENURUNSTATUS FUNGSIONAL BERUBAHTAMPILAN KLINIKNYA MENYIMPANGSTATUS NUTRISI TERGANGGUPASIEN GERIATRIPASIEN GERIATRIMasalah kesehatannya kompleksMembutuhkan pendekatan yang khususTidak hanya memperhatikanMasalah medikStatus fungsionalKondisi kognitifKondisi afektif CGADukungan sosialSTATUS FUNGSIONAL BERUBAHStatus fungsional:Kemampuan untuk melakukan aktivitas hidup sehari-hari (ADL) Duduk, berdiri, berjalan, menggunakan toilet, bab, bak, membersihkan diri, mandi, berpakaian, makan, minum, naik-turun tangga ADL

Mengendalikan rangsang BAB 2Mengendalikan rangsang BAK 2Membersihkan diri (seka,sisir,skt gigi) 1 P(g)n WC[in/out,lepas/pakai celana,siram] 2Makan 2Transfer 3Mobilisasi = ambulasi 3Mengenakan pakaian 2Naik turun anak tangga 2Mandi 1

20: Mandiri12-19: Ketergantungan ringan 9-11: Ketergantungan sedang 5- 8: Ketergantungan berat 0- 4: Ketergantungan totalTampilan KlinikTampilan klinik menyimpang SINDROM GERIATRIGERIATRIC GIANTSAcute confusional state/ sindrom deliriumJatuh Instabilitas posturalImobilisasiInkontinensiaDemensiaDepresi Impairment of hearingImpairment of visionImpotenceInanitionInstabilityImmobilizationImpairment of cognitionIsolation Tampilan KlinikPendekatan klinik: Gangguan faal kognitifIdentifikasi: Delirium vs Demensia vs DepresiDelirium: Confusion Assessment Method (CAM)Diagnosis delirium jika terdapat 1 dan 2 serta 3 atau 4:(1) Awitan akut dan perjalanan kliniknya berfluktuatif(2) Inattention(3) Disorganised thinking (eg. disorientasi, gangguan persepsi)(4) Perubahan kesadaran

Dementia: adapted from DSM-IVThe development of multiple cognitive deficits manifested by both: (1) memory impairment(2) one (or more) of the following cognitive disturbances:- aphasia (language disturbance)- apraxia (impaired ability to carry out motor activities, intact motor fc.)- agnosia (failure to recognise or identify objects, intact sensory fc.)- executive dysfunction (impaired problem-solving, organizing, etc)

The cognitive deficits in criteria (1) and (2) each cause significant impairment in social or occupational functioning and represent significant decline from a previous level of functioning.Pendekatan klinik: Gangguan faal kognitifIdentifikasi: Delirium vs Demensia vs DepresiImportant causes of DELIRIUM:- Infections- Drugs: hypnotics, antidepressants, antipsychotics, antiparkinsonism, antihistamines, analgesics, antimicrobials, H2 antagonists, digoxin- Metabolic disorders: hypoxia, hypercarbia, hypo- or hyperglycaemia, renal or hepatic failure- Fluid and electrolyte disorders: dehydration, acute blood loss, hyponatremia, hypercalcaemia- Neurological: cerebrovascular event, intracranial heamorrhage- Cardiovascular: acute myocardial infarction, cardiac failure- Withdrawal states: alcohol, drug (eg benzodiazepine)- Others: urinary retention, faecal impaction, unfamiliar environmentPendekatan klinik: Gangguan faal kognitifImportant causes of dementiaNon-reversible: - Alzheimers disease (AD)- Vascular dementia (VD)- Diffuse Lewy Body Disease(DLBD)- Fronto-temporal dementia(FTD)- Parkinson's Disease (PD)

Reversible/ arrestable: - Depresi (pseudodementia)- Drug effects (termasuk alkohol, hypnotics)- Ggn metabolik: hipotiroidi, def. vitamin B12, hiperkalsemia- Neurological: space-occupying lesions, normal pressure hydrocephalus, neurosyphilisDelirium and DementiaIs it Delirium or Dementia?DeliriumDementiaOnsetRapid (hours/days); rapid decrease in MMSE score.Slow (months, years); slow decline of 2 to 3 MMSE points over a period of years.SymptomsFluctuate over the course of the day.Relatively stable.DurationDays to weeks.Years.OrientationDisorientation and disturbed thinking are intermittent.Persistent disorientation.Level of consciousnessFluctuates, with inability to concentrate.Alert, stable.Sleep/wake cycleSleep/wake cycle may be reversed.Sleep may be fragmented.28AMT

Umur ............................... Tahun1Waktu / jam sekarang1Alamat tempat tinggal1Tahun ini1Saat ini berada di mana1Mengenali orang lain (dokter, perawat, dll)1Tahun kemerdekaan RI1Nama presiden RI sekarang1Tahun kelahiran pasien atau anak terakhir1Menghitung terbalik (20 s/d 1)1

0-3 : Gangguan kognitif berat4-7 : Gangguan kognitif sedang8-10 : NormalMMSE

ORIENTASI [thn,bln,tgl,hari,musim,negara, propinsi,kota,RS,ruang apa] 10REGISTRASI [3 obyek, sebut ulang] 3ATENSI+KALKULASI [100-7/mesra] 5RECALL [sebut ulang 3 obyek] 3BAHASA Tunjuk 2 benda 2 Tanpa, bila, dan atau tetapi 1 Ambil kertas dgn tangan kanan, lipat dua, letakkan di meja. 3Read and do it: MOHON PEJAMKAN MATA IBU/BPK 1Tulis 1 kalimat 1Gambar 2 buah segi-5 1

Depression: SymptomsThree types of symptoms:MoodPhysicalCognitive

31Depression: Mood SymptomsSadness In older adults, sadness may be denied -- many complain of bodily aches and pains, rather than admitting to their true feelings of sadness.Loss of interest and pleasure in usual activities.IrritabilityThis is especially common in older adults.

32Depression: Physical SymptomsAbnormal appetite with weight loss or weight gain.Abnormal sleepDifficulty falling asleep, frequent awakenings during the night or very early morning awakening.Fatigue or loss of energy.Psychomotor retardation or agitation.

33Depression: Cognitive SymptomsAbnormal self-reproach or inappropriate guilt.Abnormal poor concentration or indecisiveness.The term abnormal here and on the previous slide means different from the individuals usual functioning. In other words, abnormal for him or her.Morbid thoughts of death (not just fear of dying or thoughts about death) or suicide.The next slide exhibits the incidence of depression by gender and age group

34Depression: EpidemiologyOf particular concern to social workers the incidence of depression is higher among older adults in clinical settings.For example, depressive symptoms occur in:15 to 20 percent of community-based elders. 37 percent of elders in primary care settings.50 percent of elders in long-term care settings.35Depression: EpidemiologyAmong older adults:Depression is associated with increased mortality and morbidity rates. The incidence of depression increases in conjunction with medical conditions (Conwell, 1994). Depression can lead to increased mortality from other diseases such as heart disease, myocardial infarction, and cancer (U.S. Dept. of Health and Human Services, 1997).36Depression: EpidemiologyAmong older adults untreated depression may also result in:Increased substance abuse.Slowed recovery from medical illness or surgery.Malnutrition.Social isolation (Katz, 1996). 37Geriatric Depression Scale1.Apakah anda sebenarnya puas dengan kehidupan anda ?YaTIDAK2.Apakah anda telah meninggalkan banyak kegiatan dan minat atau kesenangan anda ?YATidak3.Apakah anda merasa kehidupan anda kosong ?YA Tidak4.Apakah anda sering merasa bosan ? YA Tidak5. Apakah anda mempunyai semangat yang baik setiap saat ?YaTIDAK6.Apakah anda takut bahwa sesuatu yang buruk akan terjadi pada anda ?YATidak7.Apakah anda merasa bahagia untuk sebagian besar hidup anda ?YaTIDAK8.Apakah anda sering merasa tidak berdaya ? YATidak9.Apakah anda lebih senang tinggal di rumah daripada pergi ke luar dan mengerjakan sesuatu hal yang baru ?YATidakGeriatric Depression Scale10.Apakah anda merasa mempunyai banyak masalah dengan daya ingat anda dibandingkan kebanyakan orang ?YATidak11.Apakah anda pikir bahwa hidup anda sekarang ini menyenangkan ?YaTIDAK12.Apakah anda merasa tidak berharga seperti perasaan anda saat ini ?YATidak13.Apakah anda merasa penuh semangatYaTIDAK14.Apakah anda merasa bahwa keadaan anda tidak ada harapan ?YATidak15.Apakah anda pikir bahwa orang lain lebih baik keadaannya dari anda ?YATidak Setiap jawaban bercetak tebal mempunyai nilai 1 Skor antara 5-9 menunjukkan kemungkinan besar depresi Skor 10 atau lebih menunjukkan depresi Pendekatan Klinik: Instabilitas PosturalPenyebab utama:Neurological causesNon-neurological causesCerebrovascular diseaseParkinsonismCervical myelopathyOthers Cerebellar dysfunction Normal pressure hydrocephalus Peripheral neuropathyAcute medical illness Sepsis Cardiac failure/coronary artery disease Chronic obstructive airways disease (severe) Dehydration/acute blood loss Electrolyte abnormalitiesDrug effects Antipsychotics Sedatives AntihypertensivesMusculoskeletal causes Arthritis (inflammatory, degenerative) Fractures (especially hip) Foot problemsSensory causes Visual impairmentOthers Postural hypotension Fear of falling Deconditioning (after prolonged bed rest) Pain Depression Environmental (restraints, restrictions)Pendekatan Klinik: JatuhPenyebab utama:SyncopeDrop attacksAcute illness (eg sepsis, cardiac failure, cardiac arrhythmia, dehydration/acute blood loss, electrolyte abnormalities)Vestibular diseaseNeurological disease (eg cereborvascular disease, parkinsonism, cerebellar dysfunction, cervical myelopathy, normal pressure hydrocephalus, peripheral neuropathy, epilepsy)Musculoskeletal causes (eg arthritis, foot problems)Drugs effects (eg sedatives, antipsychotics, antihypertensives, diuretics)Postural hypotensionVisual impairment Accidents True accidents Environmental hazards (eg slippery floors, inadequate lighting, unstable furniture) Fall Fracture Stroke Dementia and Depression Instability Hypnotic medicine Impairment of vision Polypharmacy Fear of fall

Causes of immobilizationResnick NM, Dosa D. Geriatric Medicine. Harrisons Principles of Internal Medicine. Ed.16. 2005: 43-53

Ulcus decubitus (pressure ulcer) Muscle atrophy & joint contracture Atelectasis & Pneumonia Decrease bone density Osteoporosis ConstipationDeep vein thrombosis & Pulmonary embolism Postural hypotension

Complications of immobilizationResnick NM, Dosa D. Geriatric Medicine. Harrisons Principles of Internal Medicine. Ed.16. 2005: 43-53

Penatalaksanaan Komplikasi Akibat ImobilisasiUlkus DekubitusPencegahan Tabel 4. Skala Norton utk Mengukur Risiko Ulkus Dekubitus

Penilaian risiko terjadinya ulkus dekubitus dg skala NortonSkor