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

• 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

Geriatric Giant

Kane, Ouslander Abrass. (from Solomon 1988), Essentials of Clinical Geriatrics.2004 . p.13-14.

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

MalnutritionApathy, depressionPoor concentration

Poor Appetite

Loss of musclestrength

Reduced mobility

Reduced feeding capabilities

Causes of weight loss in older personsCauses 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)

• 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

• 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

Guigoz et al., Facts & Res. Gerontol. 1994 (suppl.2):15-70

maximum score 30 points

24 : normal/well-nourished

• 17 - 23.5 : border line/at risk malnutrition

• < 17 : undernutrition

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

PneumoniaTuberculosisUrinary tract infectionsBacteremia / sepsisCholecystitisAppendicitisSeptic ArthritisBacterial meningitisInfective endocarditis

31013

2-815-20

2-33

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 PolypharmacyPatient– 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 physicianDoctor– Failing to review the patient’s medications– Prescribing medications for common and non-life

threatening symptoms– Treating multiple symptoms or illnesses with several

drugs

• 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

IMPACTION (CONSTIPATION)

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Definition

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Physio-pathology Chronic Constipation

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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)

Risk Factors Constipation in Elderly

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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 comfortPoor toilet acces (3)

Risk Factors Constipation in Elderly

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All patients constipation :

Rectal Touche !!Rectal impaction ?Rectal dilatation ?

Hemorrhoid ?Anorectal disease ?

Perianal fecal soiling ?

Physical Examination

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Instabilitas

Jatuh Inkontinensia urin Infeksi

Fraktur Kesadaran

Hipotermia Imobilisasi Depresi Gangguan Ulkus tidur Trombosis vena Pneumonia ISK Dehidrasi konstipasi

Atrofi otot Asupan makanan Malnutrisi

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

Asupan cairan

Obat

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