Disease diagnosis in the elderly should include 4 levelsDiseaseImpairmentDisability Handicap

COMPREHENSIVE GERIATRIC ASSESSMENTIMPLIES :Physical HealthMental HealthFunctional StatusSocial FunctionEnvironment(Multi or Inter-disciplinary Team)

Source: Forceia (2004), Reuben (2003)

Evaluating The Elderly PatientThe factors interact in complex ways influence the health & functional status of the elderlyComprehensive evaluation will require an assessment of each of these domains.Functional abilities a central focus of the comprehensive evaluation of an elderly individual. Diagnoses-physical-laboratory findings are useful in dealing with underlying etiologies & detecting treatable conditions, in the elderly, measures of function are often essential in determining overall health.Figure 1 : Components of assessment of the elderly(David B Reuben )

PRIMORDIAL PREVENTIONPENYAKITKELAINAN/KELUHAN(INTRINSIC)PRIMARY PREVENTIONSECONDARY PREVENTIONHAMBATAN(IMPAIRMENT)(EXTERIORIZED)FUNCTIONAL LIMITATIONACTIVITY RESTRICTIONDISABILITY(OBJECTIVIED)HANDICAP(SOCIALIZED)TERTIARY PREVENTION

WHO-Community Study of the Elderly Central Java 1990 (n=1203)Boedhi-Darmojo et al., 1994Disease / Complaints :- Arthritis / Rheumatism- Hypertension + CVD- Bronchitis / dyspnea- Diabetes Mellitus- Fall- Stroke / Paralysis- TBC- Bone Fracture- Cancer- Health problems affecting ADL

49.0%15.2%7.4%3.3%2.5%2.1%1.8%1.0%0.7%29.3%

(F > M)(F > M, r < u)(F < M)(F = M, r < u)(F > M)(r < u)(F = M)(F = M)(F > M)(r < u)r = rural ; u = urban ; F = female ; M = male

14 IMPAIRMENTS (14 I)ImmobilityInstabilityIncontinenceImpairments of cognitiveImpactionImpairments of Vision, Hearing, skin integrity, tasteInfection Isolation Inanition ImpecunityIatrogenesisInsomniaImpotenceImmunodeficiency

TIPE KONSTRUKTIF CONSTRUCTIVE/PRODUCTIVE) Integritas baik, toleransi tinggi, tahu diri Luwes/humoristik TIPE KETERGANTUNGAN (DEPENDENT) Masih dapat diterima dalam masyarakat Pasif, ambisi , masih tahu diri Biasanya PANTOFFEL HELD Senang malas-malasan, dsb. TIPE DEFENSIF Selalu menolak bantuan, emosinya tak terkontrol Memegang teguh pada kebiasaanya Bersifat kompulsif aktif Takut tua dan tak senang masa pensiun TIPE BERMUSUHAN (ANGRY MAN) Tidak mengakui kegagalannya Selalu mengeluh, agresif, curigaIri hati pada yang muda TIPE MEMBENCI DIRI (SELF HATERS) Menyalahkan diri sendiri Ambisi tidak bahagia/depresif Kematian = pembebasanSTEREOTYPES OF ELDERLY(Brocklehurst & Allen, 1987)

Psycho-social status of the Elderly Population (n=1203)ForgetfulnessLonelinessInsomniaDepressionCompletely dependentChronic illness

Still prefer to workStill active at homeStill earning moneyStill active in social organizationWatching TVListen to the radio50,320,421,34,22,129,3

58,875,114,036,649,275,648,019,819,74,33,334,7

50,975,117,856,679,288,657,320,823,84,21,222,5

63,071,311,518,918,763,0U + RUrbanRuralSource : Boedhi-Darmojo et al.,1994

According to many studies,COMPREHENSIVE GERIATRIC ASSESSMENTResult in: Diagnostic accuracy Medication used Nursing facilities admission Annual Med. Care cost. Improve independence & Quality of Life Mortality (Multi or Inter-disciplinary Team)

Source: Adjusted by Boedhi-Darmojo from Forceia (2004), Reuben (2003)

ANAMNESIS Patient identity (name, address, age, job, etc.) Chief complaints (when, where, why, chronology, etc.) Complaints, associated & others. Past illness, complaints & diagnosis, Syncope, vertigo, TIA/Stroke, dyspneu, chest pain and other location of pain, Allergy, fever, diarrhoea, etc. Operation & hospitalization, falls, immunization status.

ANAMNESIS Bad habits / life style: smoking, alcohol, overeating, improper diet, physical inactivity, etc. Good habits: regular exercise, balanced diet, social participation, etc. Drug prescription / administration, including over the counters (OTC). Family history: habits, life style, genetic factors, etc. Family members. Environmental information. Social-economic information. Carers at home, institutional care. Mood & personality (changes). Sexual life

SOCIAL SUPPORT Ability of assistance from family & friends, neighbours, etc. Pensions, home supportive services. Medicare, medicaid. Other sources.

ENVIRONMENT Safety of home environment Access to needed persons for help Access to medical service Access to regular information (radio, TV, etc).

SPIRITUALITY Availability of formal religions service (in hospital as well as community setting) Respite care facilities Hospice care (dying in dignity)

Source: Forciea (2004), Hazzards (2003)

CHANGES ASSOCIATED WITH AGING ( Kane et al, 1999) Overall: - Weight, Height and Total Body water - Fat-to-lean-Body mass ratio Cardiovasculars: - Cardiac output, Heart Rate response to stress - Increased intimal thickening - Sclerosis of heart valves - Decreased compliance of periph. Vessels.Lungs: - Decreased elasticity & cilia activity, cough reflex - Vital capacity, max O2 uptake Kidney: - Increased number of abnormal glomeruli - Renal blood flow, creatinine cl., max. urine osmol. GI Tract: - Fewer taste buds, decreased saliva flow - Decreased HCl prod. and enzymes.Skeleton: - More osteoarthritis and osteoporosis.Endocrines: - T3 and free testosteron - Insuline, norepinephr. Parathormone, vasopres. Nervous syst: - Decreased brain weight, intellect. compl. Learning - Decreased hours of sleep, REM

PHYSICAL EXAMINATION Vital signs: BP, HR, Respiratory rate, Weight / Height (BMI, abdominal circ). Skin / Rash / Lesions / Pressures shore. Hearing, Vision (visual acuity), fundus exam. Mouth: oral hygiene, dentures. Neck : thyroid, motion, lymph gland. Breast: mass, lymph gland, tenderness. Lungs: rhonchi, spasm, etc.CVD: chest pain, heart sounds.

PHYSICAL EXAMINATION (contd) Extremity: a dors ped/femoris, varices, edema. Abdomen: liver, epigastrium, spleen, tenderness, mass. In women: vag. Atrophy, mass, fluor. Neurology: mental, memory, dementia ass. Extremity: tremor, involuntary movement, pathological reflexes, etc.

IMPAIRMENTS of Sensory apparatus Visual Presbiopy, cataracta lentis, retinopathy diabetic, glaucoma, macular degeneration (Increase in prevalence with age)

Hearing 1/3 of people over 65 reduced emotional, social & physical factor whispered voice exam (3 6 random item)

Taste ability Smell ability Peripheral sensory ability , vibration

Weight loss / gain can be judged by BMI examUrban comm. dwellers more obese than rural.Seneca Project (W. v Staveren et al, 1998, report 30% obesity among the elderly in Europe.Indonesian Figures mostly ideal weight 44%,overweight / obesity 15,9%)The rest of elderly: underweight/ malnourish

Incontinence (urinary common among elderly esp. females)

Balance & Gait : Strength, balance, coordination,vertigo, lower extremity strengthFalls very frequent situation fracturesUp and Go test walk 3 meters back (N: 20)

Cognitive AssessmentMini-Mental State Examination (MMSE)Recall 3 items in 1, Clock Drawing Test

Schematic 2.INTERACTING DIMENSIONS OF GERIATRIC ASSESSMENT (David B Reuben, )

Konsep Menua sehat(The Healthy Aging Concept)CellularOrganTissueAnatomicalEnvironmentLife StyleEndogenic AgingHealthy Aging(menua sehat)Exogenic FactorsGambar 2. Model Healthy aging dengan faktor-faktornya (Boedhi-Darmojo, 1994, 2001) (Promotion, Prevention, Curative & Rehabilitation)

Blood Pressure

Tobacco

Dyslipidemia

Improper food/Obesity

Glucose

Personality/ Stress

Physical inactivity

Alcohol

Environment

Oral hygiene Heart disease

Stroke

Hypertension

Dementia

Diabetes M

Cancer

Osteoporosis

Liver disease

Renal failure

Respiratory diseaseCORERISK FACTORSDEGENERATIVE DISEASESGambar 1. Faktor risiko dan penyakit degeneratif (FR harus dihindari/dihilangkan sedini mungkin supaya lebih berhasil) - Boedhi-Darmojo, Orasi, 6 Januari 2001, Sidang Konsorsium Ilmu Kesehatan (KDK) 2000.SPIDER MODELRISK FACTORS CONCEPT

Kontinum Osteoporosis75+ KifosisRisiko fraktur paha55+ PascamenopausalRisiko lebih besar fraktur tl belakang.50 MenopauseMengalami gejalavasomotor

DEVELOPMENT FROM CHILDHOOD TO OLD-AGED

Body-length becomes shorter due to esp. osteoporosis, diseases of bones and joins and body composition and postures.Prevention of abdominal bulging (android obesity).Prevention of fall and fractures.Keep exercising (keep fit) not strenuous, not to heavy but regular - non competitive, incl. intellectual and brain exercise.5. Use your intellectual capacity.6. Practice a balanced diet.Prevent degenerative diseases risk factors.Keep practicing a Healthy life-style.Source: Boedhi-Darmojo, 2004

PERAWATAN LANSIA(R. Boedhi-Darmojo, 2003)HOSPITAL BASEDAcut & Chronic Med CareHealth Assesment Facil.Day-Hospital (Day Care C)RahabilitationMemory Clinic etc.Special therapy/Rehabil.Occupational th/PhysicalSpeechPodiatryAudiologyNutritional / mealDental CareOrthopedic etc.Respite Care etc.Hospice care/Religious ServiceHOME / COMMUNITY BASEDCarers programElderly sitters (Pramu Rukti Werda)Community NursesSocial workersHome help serviceNursing homeDementia careElderly Clubs (sports, recreation, etc.)Hostels (STW)/village/POSYANDUReligious serviceBoedhi Darmojo, R P: Pertemuan Lembaga Lansia Indonesia, 2003 (Jakarta)Manpower : LSM, Kr Taruna, Darmawanita/PKK, Relawan (TOT, TOC)Funding : Govnt, LSM, Insurance, Syst, MEDICARE, MEDICAID etc.

Table 3.Multidimensional Case-Finding Instruments used, with references and Average Performance Time (David B Reuben)

THE ELDERLY HEALTH REPORT

IDENTIFICATION PATIENTNameAgeSexAddressTelephoneOccupation Care giverNo RecordDate of the first treatmentLocation wardDoctor

...........

GERIATRIC INSTALATIONSANGLAH HOSPITAL DENPASARDIPONEGORO STREET TELP/ FAX. (0361) 246663, (0361) 227911-14 EXT. 258

I. PATIENT CHARACTERISTIC

II. MEDICAL HISTORYII.05II.06Riwayat Inap rumah Sakit Tgl ......bl...th...RS..Diagnosa... Riwayat kesehatan lain :Selama 1 bulan terakhir, apakah Bapak/Ibu melakukan pemeriksaan kesehatan berikut ini : Gigi 1. Ya2. TidakMata1. Ya2. Tidak1. Ya2. Tidak

II.10

II.12 NUTRITION ASESSMENT

Recall 24 Hours

III. SYSTEM ANAMNESTIC

IV. DEPRESSION DESCRIPTIONV. BARTHEL ADL INDEKS (BAI)Mengontrol BABFungsiMengontrol BAKSkorKeteranganV.01V.020 1 2Inkontinen tak teratur kadang-kadang inkontinen kontinen teratur0 1 2Inkontinen/pakai keteter & tak terkontrol kadang-kadang inkontinen mandiri20 12 19 9 11Mandiri Ketergantungan ringan Ketergantungan sedangBAI SCORE 5 8 0 4 Ketergantungan berat Ketergantungan total

VI. PHYSICAL EXAMINATION

MMSE

VII. ENVIRONMENTAL ASSESMENT

1Apakah tersedia kamar khusus untuk penderita?Kamar tidurDipakai sendiri / bersama dengan Ya / tidakYa / tidak2Daftar keamananYaTidakApakah penderita dapat :membuka/ mengunci pintumencapai sakelar lampu3Daftar bahaya / penyebab jatuh :YaTidakDari lingkungan rumah, pastikan bahwa hal berikut ini terpasang baik :Lantai dan karpet dalam keadaan baik dan tidak menonjol di sana-sini, yang mungkin menyebabkan terpeleset/ jatuhPencahayaan cukup terang dan tidak silauKamar mandi :YaTidakTerdapat ril pegangan di daerah toilet dan bak mandi dan mudah dicapai bila diperlukanKamar tidur :YaTidakKeset tidak merupakan hambatan yang memungkinkan terpeleset atau tergelincir, terutama yang di jalan lalu ke kamar mandiDapurYaTidakLantai terbuat dari bahan yang tidak licin

GERIATRIC INSTALATION SANGLAH HOSPITAL DENPASAR

PERSONAL ASSESMENT RECAPITULATIONDate o f recapitulation assessment :

I. IDENTYTY Nama: LK / PR Umur: .Th.CM. Alamat: . Pekerjaan: .

II. DIAGNOSIS (NO. ICD) 1... 2...

III. IMPAIRMENT (NO. ICIDH) 1... 2..

IV. DISABILITY (NO.ICDH) 1.. 2..

V. HANDICAP (NO.ICDH) 1.. 2..

VI. REKOMENDATION 1.. 2 ..

Keterangan :ICD: International Classification of Disease X 1994ICIDH: International Classification of Impairment. Disability and Handicaps (WHO). 1980

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