Clinical Management in the Elderly
Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACPDivision of Geriatrics
Department of Internal MedicineRSCM FMUI
Outline
• Medical case example• Surgical case example• Why do we need special approach for geriatric
patients?• What is a CGA? • How does the CGA should be applied?
Example of medical case
• Elderly woman, 78 yo– Outpatient visit, loss of appetite, epigastric pain– Frequently feeling weak, episode of fall in bathroom– History of HT, well controlled by HCT 12,5 mg– No fracture; No wound/ bruises• CM, 130/80, 80/m, 37,0°C, 20/m• Conjungtiva not pale, sclera not icteric• heart/lung wnl, H/L not palp, edema -/-
– Hb 12 ; rBG 115 ; Cholesterol (T) 155
Dx Dysepsia
• Antasida, ranitidin, multivitamin• One week complain ↓, symptoms ↓
• Remaining symptoms:– weakness, – frequent falls, instable– Outpatient consultation for 2 months no improvement– Referred to specialist still no improvement
Dx Dysepsia
• Antasida, ranitidin, multivitamin• One week complain ↓, symptoms ↓
• Remaining symptoms:– weakness– frequent falls, instable– Outpatient consultation for 2 months no improvement– Referred to specialist still no improvement
Weakness
• Vitamin deficiency• Mineral deficiency
Weakness
Deficiency
Low intake
Dehydration
Hyponatremia
Hypoglycemia
Depression
Hypoxia
Anamnesis (addition)
• Frequent urination, leakage, asshamed• Reduce drinking• Reduce food intake, to prevent blood pressure increase• Reduce salt intake, to prevent blood pressure increase• Husband, passed away a year ago– Frequently found pensive– Decrease outside house activity while previously
very active in peer group activities
Weakness
• Vitamin deficiency• Mineral deficiency
Weakness
Deficiency
Low intake
Dehydration
Hyponatremia
Hypoglycemia
Depression
Hypoxia
Frequent falls, instable• Due to old age• Due to the weakness
Frequent falls, instable• Due to old age• Due to the weakness
POSTURAL INSTABILITY
Internal Factors:Systemic diseaseOrtostatic hypotentionHypercoagulable stateIncrease platelet aggregation
Local pathologyOA knee, fasciitis, cervical SA
External Factors :Home environment
Anamnesis, PE (addition)
• Transfer process: unstable sensation• Painfull knee joints, sitting standing
• BP, sitting 110/60 (supine: 130/80)• Crepitation (+) , both knee joints
Frequent falls, instable• Due to old age• Due to the weakness
POSTURAL INSTABILITY
Internal Factors:Systemic diseaseOrtostatic hypotentionHypercoagulable stateIncrease platelet aggregation
Local pathologyOA knee, fasciitis, cervical SA
External Factors :Home environment
Current diagnosis
• Dyspepsia• Low intake• Dehydration• Hyponatremia (suspect) • Depression • Urinary incontinence• Ortostatic hypotention in hypertensive patient• OA of the knee
Current management• Antasida• Nutritional consult• Psychotherapy • Restore food patern• Oral rehydration• Nutritional supplement• Multivitamin• Urine sample; culture• HCT ACE-inh or CCB• Parasetamol (prn) ; muscle strengthening exercise
Surgical case, example
• Old lady of 82 yo– Brought to EU, fell in the bath room– Pain; right hip– She could not stand up on her own– DM ; well controlled by gliquidon– Hipertention; well controlled by lisinopril
Physical exam, Lab, Ro
• CM, vital sign: stable• Heart and lung: no significant findings• H/L not palpable; edema/ ascites were (-)• Peripheral blood: normal• rBG 134 mg/dL; ureum 25 mg/dL; creat 0,8 mg/dL• Na 138 mEq/L; K 4,0 mEq/L• OT, PT and Albumin, Globulin: normal• CXR and ECG: normal
Often overlooked......
• Patient’s functional status?• Cognitice function and psycho-affective
condition?• How does the social arrangement so far?• What about fer food and fluid intake?• Her actual kidney function?• Peri-operative condition in geriatrics?• What does the patient’s real wish actually?
Patient’s functional status?Cognitice function and psycho-affective condition?Social arrangement so far?What about fer food and fluid intake?Her actual kidney function?Peri-operative condition in geriatrics?What does the patient’s real wish actually?
Patient’s functional status?Cognitice function and psycho-affective condition?Social arrangement so far?What about fer food and fluid intake?Her actual kidney function?Peri-operative condition in geriatrics?What does the patient’s real wish actually?
Dementia; bedridden ; severely dependent
Relatives often come to visit for longer period of time; play a role as care giver
Poridge; balanced; but for the past one week: decreased food intake; very limited fluid intake
Kidney function: CCT Cockroft-Gault formula
Ask the patient/ family re AMP-operation?; is it really necessary and approved by the family?
Eventually....
• Conventional medical aspects .. +• Other aspects that should be
considered:
• Tapi masih terdapat:– Sering lemes, – Suka jatuh, jalan ‘oyong’– Berobat sampai 2 bulan kemudian masih tetap– Berobat ke spesialis sudah sebulan tak ada perubahan
Eventually....
• Conventional medical aspects .. +• Other aspects that should be
considered:
• Tapi masih terdapat:– Sering lemes, – Suka jatuh, jalan ‘oyong’– Berobat sampai 2 bulan kemudian masih tetap– Berobat ke spesialis sudah sebulan tak ada perubahan
FunctionalCognitivePsychoafectivePsichosocialNutritition
Other things should be considered
Clinical performance often non specificDecrease in reserve capacity
Presenting symptoms often:Altered consciousness; personality changesPostural instability; FallLoss of appetiteImmobility
Conclusion
• Geriatric patient, in general:– Multipathology– Decrease reserve capacity– Non specific clinical signs and symptoms– Changes in functional status– Malnutrition
Conclusion
• Geriatric patient, in general:– Multipathology– Decrease reserve capacity– Non specific clinical signs and symptoms– Changes in functional status– Malnutrition
Needs special
approach: CGA
PHYSICAL, BIOLOGICAL
PSYCHO-COGNITIVE
SOCIAL
PHYSICAL, BIOLOGICAL
PSYCHO-COGNITIVE
SOCIAL
FUNCTIONAL
ADL, IADL, MNA
NUTRITION
PHYSICAL, BIOLOGICAL
PSYCHO-COGNITIVE
SOCIAL
FUNCTIONAL
Anamnesis and PE Ax & PE SYSTEM Clinical, AMT,
MMSE, GDS
Anamnesis, home visitADL, IADL, MNA
NUTRITION
CGAI II III IV V VI
Bio/ Physical
Curative Multidisciplinary
Impairment Fluid Hospital based
Psycho/ Cognitive
Promotive Uni... X Disability Nutrition Discharge planning
Psychosoc Preventive Para...X Handicap Medication Community based
Functional Rehabilitative
Pan...X Activity
Nutrition INTERDISCIPLIN
Psychosocial care
CGAI II III IV V VI
Bio/ Physical
Curative Multidisciplinary
Impairment Fluid Hospital based
Psycho/ Cognitive
Promotive Uni... X Disability Nutrition Discharge planning
Psychosoc Preventive Para...X Handicap Medication Community based
Functional Rehabilitative
Pan...X Activity
Nutrition INTERDISCIPLIN
Psychosocial care
PHYSICAL, BIOLOGICAL
PSYCHO-COGNITIVE
SOCIAL
FUNCTIONAL
Anamnesis and PE Ax & PE SYSTEM Clinical, AMT,
MMSE, GDS
Anamnesis, home visitADL, IADL, MNA
NUTRITION
Barthel Index of ADL• Bowel control 2• Bladder control 2• Grooming 1• Bathing 1• Feeding 2• Dressing 2• Toilet Use 2• Transfers 3• Mobility 3• Stair 2• 20 : Fully independent• 12-19 : Lightly dependent• 9-11 : Moderately dependent• 5- 8 : Severely dependent• 0- 4 : Total dependent
Abbreviated Mental Test (AMT)
Age............................... Years old 1Current time/hour 1Address 1Current year 1Location right now 1Recognizing others (doctor, nurse, etc) 1National independence year 1Current president 1Patient’s or youngest child’s year of birth 1Counting down (20 to 1) 1
0-3 : Severe cognitive impairment4-7 : Moderate cognitive impairment 8-10 : Normal
MMSE
THANK YOU
Top Related