Download 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.
- Perlu penatalaksanaan segera
- Identifikasi penyebab
- Comprehensive geriatric assessment
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
Kane, Ouslander Abrass. (from
• Immune deficiency
Solomon 1988), Essentials of
• Impotence
Clinical Geriatrics.2004 . p.13-14.
Impairment
of Hearing
Intellectual
Impairment
Impairment
of Visual
Inanition
Isolation
Instability
and Falls
Impaction
Geriatric
Syndromes
Impotence
Incontinence
Immuno
deficiency
Iatrogenesis
Infection
Immobilization
Insomnia
Immobilization
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)
Imobilization
• Keadaan tidak bergerak atau tirah
baring selama 3 hari atau lebih dengan
gerak anatomik yang hilang akibat
perubahan fungsi.
Pasien Imobilisasi
Aging and Malnutrition
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
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
Malnutrition : A vicious circle
Malnutrition
Reduced feeding
capabilities
Apathy, depression
Poor concentration
Reduced mobility
Loss of muscle
strength
Poor Appetite
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)
• Eating problems
• Low-salt, low-cholesterol diet
• Shopping problems
Faktor-faktor medis (melalui anoreksia, rasa cepat kenyang,
malabsorpsi, metabolisme meningkat, pengaruh sitokin, dan
gangguan status fungsional)
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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
Faktor-faktor psikologis
• Alkoholism
• Kehilangan
• Depresi
• Demensia
• Fobia Kolesterol
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
Consequences of malnutrition
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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
Identify elderly who are at risk of
malnutrition
Validation of MNA®
• Nursing home, hospitalized & free living
elderly
• Sensitivity 96%
• Specificity 98%
• Predictive value 97%
• Inter-observer MNA- Kappa 0.51
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
Intellectual Impairment:
Dementia & Delirium
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
Depression
Infection
Infection
• Morbidity and mortality no.2 after CV
diseases:
– Comorbid of chronic diseases
– Decrease of immunity
– Communication difficulties
– Environment
• Predisposition: intrinsic, virulence,
environment
Comparative mortality rates of
infections in elderly and young adults
Infection
Ratio mortality rates
: elderly vs young
Pneumonia
Tuberculosis
Urinary tract infections
Bacteremia / sepsis
Cholecystitis
Appendicitis
Septic Arthritis
Bacterial meningitis
Infective endocarditis
3
10
1
3
2-8
15-20
2-3
3
2-3
Clinical features of infections
in elderly
• Fever
• Nonspecific symptoms :
- Anorexia
- Fatigue
- Weight loss
- Incontinence (acute)
- Falls
- Mental confusion
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.”
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
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
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
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,
36
Definition
37
Physio-pathology Chronic
Constipation
38
Risk Factors Constipation in Elderly
Medications
• Anticholinergic drugs
(trisyclic,antipsichotic,antihistamin,antiemet
ic 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)
39
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)
40
Physical Examination
All patients constipation :
Rectal Touche !!
Rectal impaction ?
Rectal dilatation ?
Hemorrhoid ?
Anorectal disease ?
Perianal fecal soiling ?
41
SITI SETIATI, Geriatri IPD FKUI/RSUPN-CM, 2003
Instabilitas
Jatuh
Obat
Inkontinensia urin
Fraktur
Hipotermia
Infeksi
Kesadaran 
Imobilisasi
Ulkus
Trombosis vena
Pneumonia
ISK
Atrofi otot
Asupan makanan
Asupan cairan 
Depresi
Gangguan
tidur
Dehidrasi
konstipasi
Malnutrisi
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