Geriatric Syndrome

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Geriatric Syndrome

• Dr. Rose Dinda Martini, SpPD

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

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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.
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Immobilization
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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)
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Imobilization

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

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Pasien Imobilisasi
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• Aging and Malnutrition

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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

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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

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Malnutrition A vicious circle
Malnutrition

Apathy, depression Poor concentration
Reduced feeding capabilities
Poor Appetite
Reduced mobility
Loss of muscle strength
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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

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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

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

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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

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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

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Identify elderly who are at risk of malnutrition
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Validation of MNA

• Nursing home, hospitalized free living elderly
• Sensitivity 96
• Specificity 98
• Predictive value 97
• Inter-observer MNA- Kappa 0.51

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MNA score interpretation

• maximum score 30 points
• ? 24 normal/well-nourished
• 17 - 23.5 border line/at risk malnutrition
• lt 17 undernutrition

Guigoz et al., Facts Res. Gerontol. 1994
(suppl.2)15-70
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Intellectual Impairment Dementia Delirium
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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

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Depression
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Frail Elderly

• Characteristics
• Poor mental and physical health
• Low socioeconomic status
• Predominantly female
• Possibly isolated living conditions
• More and longer hospital stays, and
• More money spent on health care and drugs

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Infection
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Infection

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

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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
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Clinical features of infections in elderly

• Fever
• Nonspecific symptoms
• - Anorexia
• - Fatigue
• - Weight loss
• - Incontinence (acute)
• - Falls
• - Mental confusion

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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.

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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

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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 patients disease

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Contributors to Polypharmacy

• Patient
• Borrowing or sharing medications
• Failing to understand instructions
• Saving medication for later use
• Combining Rxs with OTCs and Herbals
• Visiting more than one physician
• Doctor
• Failing to review the patients medications
• Prescribing medications for common and non-life
  threatening symptoms
• Treating multiple symptoms or illnesses with
  several drugs

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A stepwise approach to prescribing

• Discontinue unnecessary therapy
• Consider adverse drug events for any new symptoms
• Consider non-pharmacologic approaches
• Substitute with safer alternatives
• Reduce the dose
• Prescribe beneficial therapy

Ladden MD. Brief Guide to Geriatric Assessment.
www.uptodate.com
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IMPACTION (CONSTIPATION)

• Constipation ? in older people gt 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

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Definition
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Physio-pathology Chronic Constipation
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Risk Factors Constipation in Elderly

• Medications
• Anticholinergic drugs (trisyclic,antipsichotic,ant
  ihistamin,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)

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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)

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Physical Examination

• All patients constipation
• Rectal Touche !!
• Rectal impaction ?
• Rectal dilatation ?
• Hemorrhoid ?
• Anorectal disease ?
• Perianal fecal soiling ?

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SITI SETIATI, Geriatri IPD FKUI/RSUPN-CM, 2003

• Instabilitas
  
• Jatuh
  Inkontinensia urin Infeksi
• Fraktur
  Kesadaran ?
• Hipotermia Imobilisasi
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  Depresi Gangguan
• Ulkus
  tidur
• Trombosis vena
• Pneumonia
• ISK
  Dehidrasi konstipasi
• Atrofi otot
• Asupan makanan?
  Malnutrisi

Obat
Asupan cairan ?
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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