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Geriatric Syndrome

Geriatric Syndrome. Dr. Rose Dinda Martini, SpPD. The Guinness Book of World Records  the fastest 100-year-old to run 100 meters . . SINDROM GERIATRI. Kumpulan gejala dan atau tanda klinis , dari satu atau lebih penyakit , yang sering dijumpai pada pasien geriatri . .

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Geriatric Syndrome

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  1. Geriatric Syndrome Dr. Rose Dinda Martini, SpPD

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

  3. SINDROM GERIATRI Kumpulan gejaladanatautandaklinis, darisatuataulebihpenyakit, yang seringdijumpaipadapasiengeriatri. • - Perlupenatalaksanaansegera • Identifikasipenyebab • 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.2004 .p.13-14.

  5. Immobilization

  6. 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)

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

  8. Pasien Imobilisasi

  9. Aging and Malnutrition

  10. Malnutrition in the Elderly:More common than you would think • 2 - 10% free-living elderly populations 1 • 30 - 60% institutionalized elderly 1 • 40 - 85% nursing home residents 2 • 20 - 60 % home care patients 2 (1) Vellas, B. et al, NNWS, 1999, Volume 1; (2) Nutr Screening Initiative

  11. 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 2 - 10 times more likely to die if malnourished Diminished muscle strength Poor healing Malnutrition is a greater threat than obesity

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

  13. Causes of weight loss in older persons 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) •Eatingproblems •Low-salt, low-cholesterol diet •Shoppingproblems

  14. 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

  15. Faktor-faktor psikologis • Alkoholism • Kehilangan • Depresi • Demensia • Fobia Kolesterol

  16. 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

  17. 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

  18. Identify elderly who are at risk of malnutrition

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

  20. MNA® score interpretation maximum score 30 points •  24 : normal/well-nourished • 17 - 23.5 : border line/at risk malnutrition • < 17 : undernutrition Guigoz et al., Facts & Res. Gerontol. 1994 (suppl.2):15-70

  21. Intellectual Impairment: Dementia & Delirium

  22. 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

  23. Depression

  24. Infection

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

  26. Comparative mortality rates of infections in elderly and young adults

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

  28. 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.”

  29. 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

  30. 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

  31. 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

  32. IMPACTION (CONSTIPATION) • 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

  33. Definition

  34. Physio-pathology Chronic Constipation

  35. 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)

  36. 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)

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

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

  39. 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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