Dr.

I Nyoman Astika SpPD KGer

Instalasi UPT Geriatri RS Sanglah,

SMF/Bag. Penyakit Dalam RS Sanglah/FK UNUD
 TOPIK
PENDEKATAN KLINIK PASIEN GERIATRI

PENGKAJIAN PARIPURNA PASIEN GERIATRI

(P3G)

COMPREHENSIVE GERIATRIC ASSESSMENT

 KARAKTERISTIK PASIEN GERIATRI

• MULTIPATOLOGI DAN KOMORBID

• DISFUNGSI ORGAN MULTIPEL
• CADANGAN FAALI MENURUN
• GANGGUAN FUNGSI DISABILITY DAN HANDICAP
• GEJALA KLINIK MENYIMPANG
• KERAPUHAN DAN GAGAL PULIH
 Pain Etiology in Older Elderly

Chronic/degenerative conditions

* Bone/joint/musculoskeletal * Osteoarthritis * Osteoporosis

disorders * Back problems * Ischemia/vascular conditions
* Phantom limb pain * Neuropathy-Diabetic
* Fracture
Comorbidities
Tk. I. Pelayanan Kesehatan Lansia di Masyarakat
(Community Based Geriatric Sertvice) …Posbindu

Tk.II. Pelayanan Kesehatan Lansia di Masyarakat

Berbasis Rumah Sakit ….Posbindu plus
(Hospital Based Community Geriatric Service)

Tk.III. Pelayanan Kesehatan Lansia

Berbasis Rumah Sakit
(Hospital Based Geriatric Service) …. Rumah Sakit
1. RUMAH SAKIT
 Pelayanan sederhana : Poli ,Home Care
 Pelayanan lengkap : Poli,Home care,Rawat Akut
 Pelayanan sempurna : Tambah Day Care

 Pelayanan paripurna : Tambah Bangsal kronik,

Respite Unit

2. MASYARAKAT
* Panti Pemerintah / Swasta ( nursing home )
* Asuhan Rumah ( Home visit / care )
* Perawatan Paliatif ( hospice )
PRINCIPLE OF MEDICAL SERVICES
IN THE ELDERLY
WHOLISTIC APPROACH OF MANAGEMENT

 DIAGNOSIS = COMPREHENSIVE GERIATRIC ASSESSMENT (CGA)

= MULTIDIMENSIONAL ANALYSIS
 PATIENT’S EVALUATION
= THE GERIATRIC TEAM
= PHYSICAL, PSYCHOL, SOSEC./SOSCULT. &
ENVIRONMENTAL FACTORS
 VERTICAL AND HORIZONTAL HEALTH CARE
= REFERRAL SYSTEM ( HEALTH CENTER REFERRAL
HOSPITAL)
= SECTOR / PROGRAM CROSSING (EDUCATION,
ENVIRONMENT, SOCIO-CULT, RELIGION, Etc.)
 PROGRAME HEALTH CARE :
= PROMOTION, PREVENTION, CURATIVE, REHABILITATION
 THE GERIATRIC TEAM
 PHYSICIAN / GERIATRICIAN :CLINICAL COORDINATOR / LEADER
- Clinical Assessment & Treatment, rehabilitation etc.
- Functional assessment.
 NEURORLOGIST
 PSYCHOLOGIST, PSYCHIATRICS
 NURSE: - Patients Care
- Supporting other members of team
- Functional assessment etc.
 MED. SOCIAL WORKER : Social & environmental ass.
 Other consultants : - Rehabilitation doctors& Physiotherapist
- Nutritionist.
- Pharmacyst
 Other consultants in relevant Specialistic Med.care
TIM GERIATRI
 COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)

Definition :
As an interdisciplinary approach
to the screening and diagnosis of
physical and psychosocial impairments
and functional disabilities
in frail older patients .
 CLASSIFICATION DISEASE
( WHO - 1976)
* DISEASE
IMPAIRMENT . . . . ICD
( International Classification Disease )

* The consequences of disease

DISABILITY . . ICF

HANDICAP
( International Classification of Fungtioning )
 COMORBIDITY : DEFINISION

VALDERAS JM et al 2009 :

1. To indicate a medical condition existing simultaneously but

independently with another condition in a patient ( unralated )

2. To indicate a medical condition in a patient that causes , is caused by , or

is otherwise related to another condition in the same patient ( related )
 RELATED
PATHOLOGICAL and
DISEASE PROCESS

COMORBIDITY

UNRELATED
PATHOLOGICAL and
DISEASE PROCESS
(CONCOMITANT )
 WHO International Classification of impairments,
disabilities and handicaps .Genewa , May 1976

DISEASE

IMPAIRMENT :
Any loss or abnormality of psychological COMORBIDITY
,physiological, anatomical structur of function

DISABILITY ; ( KETERBATASAN )
Any restriction or lack resulting from an
impairment of ability to perform an activity

HANDICAP : ( KECACATAN –
SOSIAL )
A disadvantage for a given individual
resulting from an impairment or a
disability ,that limits or prevents the
fulfillment of a role that is normal
Corelation Depression and Organic Deseases
Disease Silverstone Cavanaugh
1996 1998
CAD 30 - 60 % 15 – 20 %
AMI 16 -19%
STROKE 23 - 29 % 18 – 23 %
DM 9 - 27 % 8,5 – 27,3 %
PARKINSON 2 - 51 %
HIV 4 -18 %
RA 12 - 28 %
CANCER 6 - 25 % 30 – 60%
Mudjaddid E.Depresi dan Komorbiditasnya padsa pasien geriatri.Temu Ilmiah geriatri ,Jakarta ,2003
 MENTAL DISORDERS IN OLDER Adults
( Karen WL,2006)

 Alzheimer ‘s & other memmory disorders

( 30-40% complicated by depression or
psychosis )
 Depression ,anxiety , alcohol misuse
 Suicide highest rate : age 75 +

The greater in population : Depression

PROBLEM LANSIA

* PROBLEM ORGANIK
* PROBLEM GERIATRI
( KRITERIA SOLOMON : 13-I )
* PROBLEM PSIKOSOSIAL
GERIATRIC SYNDROME
SOLOMON (13-i)
 IMMOBILITY
 INSTABILITY ( FALLS )
 INTELECTUAL IMPAIRMENT (DEMENTIA)
 ISOLATION (DEPRESSION)
 INCONTINENCE
 IMPOTENCE
 IMMUNO- DEFCIENCY
 INFECTION
 INANITION ( MALNUTRITION )
 IMPACTION (CONSTIPATION )
 IATROGENIC
 INSOMNIA
 IMPAIRMENT OF vision , hearing , taste , smell ,touch,
communication ,convlescence and skin integrity
 MODUL
COMPREHENSIVE GERIATRIC
EXAMANATION
(CGA)
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)

Patient’s Identity
Med. Rec. No. :…………………….

Name :……………………..
Age :……………………..
Sex :…………………….
Occupation :……………………..
Address :…………………….
Telephone :…………………….
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)

A. Medical History
B. Physical Examination
C. Supporting Data ( Lab )
D. Problem List
E. Therapy
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)
A. Medical History
a. Anamnesa / Major complaint
* Anamnesa System
b. History of disease for patient / family
* Hospitalization
* Health maintenance
* Allergies
* Habits ( Bad / Good )
* Current medications
c. History of Nutritional
d. History of social economic
e. History of function
* ADL, Kognitive, Mental
f. History of nurse care
g. History of rehabilitation
 COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)
B. Physical Examination
1. Vital Sign 14. Musculoskeletal
* BP Supine/Sitting/Standing * Motor
* Pulse / Resp/Temp/BH/BW * Sensation
* Test of function * Reflexes
2. Skin * Coordination test
3. Hearing
4. Vision 15. Extremities
5. Mouth * Bone & Joint
6. Neck * Deformity
7. Lymph Node * Contraction /
Contracture
9. Breast * Edema / Cyanosis
10. Cardiovascular * Pulse distal
12. Lung
13. Abdominal / Rectal
 Status Gizi ( Antropometrik )
TB
• BMI = ----- Normal 18 – 25 Kg / m²
BB ²
TB Laki : 59,01 + ( 2,08 x TL ) Cm
TB Wanita : 75,00 + (1,91 x TL ) – (0,17 x U ) Cm

• TSF( Triceps Skin Fold - Tebal Kulit Triceps )

Normal laki : > 12,5 mm
Normal Wanita : > 16,5 mm

• AMC ( Arm Muscle Circumference - Lingkar Otot Lengan atas)

AC ( Arm Circumference – Lingkar Lengan Atas )

AMC = ( AC – TSF ) x 3,14 Normal Laki : 23 – 25,50 Cm

Normal Wanita : 21 – 23 Cm
• MNA ( Mini Nutrition Assessment )
Test of function ( Aktifitas K.Seharian =AKS)
INDEKS ADL BARTHEL
FUNGSI SKOR SKOR :
BUANG AIR BESAR 0 , 1, 2
20 : MANDIRI
BERKEMIH 0,1,2 12 – 19 : TERGANTUNG RINGAN
BERSIH DIRI 0,1 9 - 11 : TEGANTUNG SEDANG
5 - 8 : TERGANTUNG BERAT
KE JAMBAN 0,1,2 0 - 4 : TERGANTUNG TOTAL
MAKAN 0,1,2
BERUBAH TIDUR KE 0,1,2,3
DUDUK
BERPINDAH 0,1,2,3
PAKAI BAJU 0,1,2
NAIK TURUN 0,1,2
TANGGA
MANDI 0,1
 Kondisi Pasien Skor
Kondisi Fisik Umum
- baik 4
RESIKO DEKUBITUS - cukup/lumayan 3
( IMOBILISASI ) - buruk 2
- sangat buruk 1
Kesadaran:
INDEX NORTON - kompos mentis
- apatis
4
3
- confused 2
- stupor 1
Skor <14  risiko tinggi Tingkat Aktivitas:
- ambulatori 4
- berjalan dengan bantuan 3
- hanya bisa duduk 2
- hanya bisa tiduran 1
Mobilitas:
- bergerak bebas 4
- sedikit terbatas 3
- sangat terbatas 2
- tak bisa bergerak/imobil 1
Inkontinensia:
- tidak ada 4
- kadang-kadang 3
- sering inkontinensia urin 2
- inkontinensia urin dan alvi 1
 Test of function ( Penapisan Kognitif )
MMSE
1. Orientasi : Tahun / Bulan / Tgl / Hari / Musim …………………...5
2. Orientasi : Negara / Propinsi / Kota / RS / Ruang ………………5
3. Pencatatan obyek 3 buah .…………………………………………3
4. Kalkulasi : hitung mundur kurang 7………………………………..5
5. Mengingat kembali ………………………………………………….3
6. Bahasa : tunjuk alat ………………………………………………..2
7. Ulang : tanpa , bila dan atau tetapi………………………………..1
8. Ikuti tiga tahap tugas ………………………………………………3
9. Baca dan tugas : Mohon pejamkan mata……………………….. 1
10. Buat kalimat sendiri …………………………………………………1
11. Contoh gambar

SKOR : < 24 ada penurunan kognitif

 Test of function ( Penapisan Depresi )
GDS - Geriatric Depression Scale
1. Apakah anda puas dgn kehidupan anda ! Ya Tidak
2. Apakah anda telah meninggalkan banyak kegiatan! Ya Tidak
3. Apakah anda merasa kehidupan anda kosong ! Ya Tidak
4. Apakah anda sering merasa bosan ! Ya Tidak
5. Apakah anda punya semangat yg baik setiap saat ! Ya Tidak
6. Apakah anda takut bahwa suatu yang buruk akan menimpa anda! Ya Tidak
7. Apakah anda merasa bahagia! Ya Tidak
8. Apakah anda sering merasa tidak berdaya ! Ya Tidak
9. Apakah anda lebih senang di rumah dari pada pergi keluar ! Ya Tidak
10. Apakah anda banyak masalah dibanding kebanyakan orang ! Ya Tidak
11. Apakah anda pikir hidup anda sekarang menyenangkan ! Ya Tidak
12. Apakah anda merasa tidak berharga saat ini ! Ya Tidak
13. Apakah anda merasa penuh semangat ! Ya Tidak
14. Apakah anda merasa bahwa keadaan anda tak ada harapan ! Ya Tidak
15. Apakah anda pikir bahwa orang lain lebih baik dari anda ! Ya Tidak
Skor : 5 – 9 Suspek depresi
> 10 Depresi
 INSOMNIA RATING SCALE ( IRS )
1. Jumlah jam tidur sehari 4. Lama waktu untuk tidur
0. > 6 ½ jam 0. < 5 menit 4. 45-60 menit
1. 5½ - 6 jam 29 menit 1. 6 -15 menit 5. > 1 jam
2. 4½ - 5 jam 29 menit 2. 16 - 29 menit
3. < 4½ jam 3. 30 - 44 menit
2. Selama tidur mengalami 5. Selama tidur terbangun
0. rasanya tak pernah mimpi 0. tak pernah bangun
1. kadang mimpi tak jelas 1. 1-2 kali terbangun
2. sering bermimpi 2. 3-4 kali terbangun
3. selalu bermimpi menakutkan 3. > 4 kali terbangun
3. Bagaimana rasa tidur 6. Bila terbangun ,tidur kembali
0. dalam sulit dibangunkan 0. < 5 menit
1. sedang sulit dibangunkan 1. 6 – 15 menit
2. sedang mudah dibangunkan 2. 16 – 60 menit
3. dangkal mudah dibangunkan 3. > 60 menit
 INSOMNIA RATING SCALE ( IRS )
7. Pada bangun pagi
0. sesuai yang dikehendaki
1. ½ jam sebelum yg dikehendaki & tak dapat tidur lagi
2. 1 jam sebelum yg dikehendaki & tak dapat tidur lagi
3. > 1 jam sebelum yg dikendaki & tak dapat tidur lagi
8. Bila bangun pagi
0. anda merasa segar
1. rasa kurang segar
2. rasa lesu

TOTASL SCORE :
0 – 6 Normal
7 – 12 Mild
13 – 18 Severe
19 – 25 Very Savere
 NEURO PSIKIATRI INVENTORI ( NPI )
NO JENIS Ada ( V ) Frekuensi Keparahan Total: Distress
Tidak ada ( 0 ) 1,2,3,4 1,2,3 FxK 1,2,3,4,5
Tidak aplikabel ( X )
1 Delusi
2 Halusinasi
3 Agitasi
4 Depresi
5 Ansietas
6 Euforia
7 Apatis
8 Disinhibisi
9 Iritabilitas
10 Perilaku motorik
Abnormal
11 Perilaku malam
hari
12 Perubahan makan
dan selera makan

Frekuensi ( F ) Keparahan ( K ): Skor distres :

1. < 1 kali / minggu 1. Ringan : sedikit tetekan 1. Tak ada 4. Sedang
2. 1 kali / minngu 2. Sedang : Mengganggu ,dapat diatasi 2. Minimal 5. Sedang berat
3. > 1 kali / minngu 3. Berat : menggangu ,sulit diatasi 3. Ringan 6. Ekstrim
4. Tiap hari
TEST FUNGSIONAL
No Perasat Skor
1 ADL < 20
2 MMSE < 24
3 GDS > 5 -15
4 IRS > 7- 25
5 NPI > 1- 6
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)
C. Supporting Data

Lab
Radiographic
EKG
Echocardiography
EEG
EMG
Nuclear Medicine
CT Scan
MRI
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)
D. Problem List

* Disease problem
* Functional problem
* Nutritional problem
* Nurse care problem
* Rehabilitation problem
* Social economic problem
COMPREHENSIVE GERIATRIC EXAMANATION
(CGA)
E. Therapy
1. Non Pharmacological
a. Psychotherapy
* Personal / family
* Behavioral
b. Physiotherapy
c. Social economic solution
2. Pharmacological
a. Medication
b. Surgery
3. Paliatif care
 Geriatrics Problem

• IMMOBILITY ,ULCUS DECUBITUS, THROMBUS , INFEKSI , HYPOPROTEINEMIA,

BMD MENURUN
• INSTABILITY ,GAIT DISORDER , FALL.
• DEMENTIA & ACUTE CONFUSIONAL STATE ,MCI
• DEPRESSION & INSOMNIA
• INCONTINENCE URINE / ALVI
• IMPOTENCE
• IMMUNO- DEFCIENCY & INFECTION
• MALNUTRITION , DEHIDRATION & ELECTROLYTE IMBALANCE
• CONSTIPATION
• POLIPHARMACY & IATROGENESIS
• IMPAIRMENT OF vision , hearing , taste , smell ,touch ,communi-
cation ,convlescence and skin integrity
Contoh Kasus :
Laki 80 thn ,sering jatuh & ggn berjalan , Tak melihat & ggn dengar,
gemuk ,kencing manis , tek.darah tinggi , sulit bicara / tidur ,
pernah stroke , mudah lupa , BAK ngompol krn sulit ke toilet

APA PERMASALAHAN
PADA PASIEN INI ?
Permasalahan :
1. Instabilitas dgn Jatuh Berulang ec Gait
Disorder
2. Osteoartritis Coxae & genu bilateral
3. Glaucome dan Blindness OD total
4. Hearing loss bilateral
5. DM tipe II , neuropatidiabetik
6. Hiperlipidemi
7. Hipertensi dalam terapi
8. Obesitas
9. Depresi dgn Insomnia
10. Inkontinensia Fungsional
11. CAD Compensated
12.Squalae Stroke dgn disartria
13.Mild Cognitive Impairment ( M C I )
 Palliative Care

• WHO definition….
….the active total care of patients whose disease is not responsive to
curative treatment.

• Goals…
…to prevent and relieve suffering and to support the best possible quality
of life for patients and their families, regardless of the stage of the disease
or the need for other therapies.
MENJADI TUA
UNTUK TETAP BERGUNA
DAN BAHAGIA DI HARI TUA