CASE REPORT

GERIATRIC PROBLEM

PRECEPTOR:
dr. Hj. Ihsanil Husna, Sp.PD

ARRANGED BY:
Siti Halimah Intan P
(2013730101)

DEPARTMENT OF INTERNIST

JAKARTA ISLAMIC HOSPITAL CEMPAKA PUTIH

FACULTY OF MEDICINE

MUHAMMADIYAH JAKARTA UNIVERSITY

2017

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 KATA PENGANTAR

AssalamualaikumWr. Wb.

Alhamdulillah, Puji syukur penyusun panjatkan kehadiran ALLAH SWT atas

terselesaikannya tugas Laporan Kasus “Geriatric Problem”.

Makalah refreshing ini disusun dalam rangka untuk dapat lebih mendalami dan
memahami mengenai “Geriatric Problem”. Tujuan khususnya adalah sebagai pemenuhan tugas
kepaniteraan Stase Ilmu Penyakit Dalam.

Semoga dengan adanya laporan kasus ini dapat menambah khasanah ilmu pengetahuan
dan berguna bagi penyusun maupun peserta didik lainnya.

Penyusun menyadari bahwa laporan kasus ini masih jauh dari kesempurnaan, oleh karena
itu penyusun sangat membutuhkan saran dan kritik untuk membangun laporan kasus yang lebih
baik di masa yang akan datang.

Terimakasih.

WassalamualaikumWr. Wb

Jakarta, November 2017

Penulis

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 CHAPTER I

PATIENT’S IDENTITY

A. PATIENT’S IDENTITY

Name : Mr. S

Age : 84th years old

Education : Senior High school

Marital Status : Married

Occupation : Retaired

Religion : Moslem

Date of Admission : October 23rd 2017

MR Number : 00 39 43 29

Doctor : dr. Ihsanil Husna, Sp.PD

B. ANAMNESIS (ALLOANAMNESIS WITH HIS SON)

a. Chief Complaint :

Limp since ± a week ago before entering the hospital

Another Complaint :

Anorexic, Cough, and Bitter Tounge

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b. History of Present Illness

A Patient came to emergency unit of Jakarta Islamic Hospital of Cempaka Putih

Complained of limping since a week ago. The patient is also complained having no

appetite and tounge taste bitter. The Patient refuses any meals and drinks then ended up

puke. Patient only consume sweetened drinks (ex: water mixed with sugar). In the other

hand, the patient is also complained cough with sputum since one month ago, but

difficulty of spitting out and just can swallowing the sputum. This time, the patient lived

with his children, lying down on the bed, can’t sit or get up from the bed properly. Patient

had difficulty of doing activity by himself. Using diaper to monitoring urine and faeces

about two until three times per day. Beforehand, the patient had been treated in Jakarta

International Hospital of Cempaka Putih with trauma caused by fall accidentally at home.

c. History of Past Illness

No history of same problem

No history of Hypertension

No history of Diabetes Mellitus

No history of urinary or kidney disease

No history of cardiovascular disease

History of falling accidentally at home on march 2017

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 d. History of Family

None of his family has same problem

No history of Hypertension
No history of DM
No history of cardiovascular disease

e. History of Allergy

Patient has no allergy to food, drugs and weather.

f. History of Treatment

The patient never consumed any kind of medication before

g. Habits

Smoking Habits : Denied

Drinking Alcohol : Denied
Doing Exercise : Denied

C. PHYSICAL EXAMINATION

- Generalis Status : Mild ill

- Conciusness : Composmentis

Vital Sign

- Blood Pressure : 140/80 mmHg

- Heart Rate : 84x/minute

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 - Respiratory Rate : 20x/minute

- Temperature : 37.0 ° C

Anthropometric Status

- Body weight :-

- Body high :-

- BMI :-

It’s been a long time since his condition worsen (lying down on the bed) to measure

weight and height. The patient looked lean.

D. GENERAL PHYSICAL EXAMINATION

Head : Normocephal, Deformity (-)

Eyes : Anemic Conjungtiva (-/-), Icteric Sclera (-/-)

Nose : Epistaksis (-/-), Secret (-/-), Deviasi Septum (-/-),

Mouth : The Oral Mucosa Moist, Edentulous

Neck : Palpable Mass (-), Lymphadenopathy (-)

Thorax

Inspection : The movement of the chest symmetrical

Palpation : Same vocal fremitus in dextra and sinistra

Percussion : Sonor

Auscultacion : Vesicular breath sounds + / +, Ronkhi + / +, Wheezing - / -

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Heart

Inspection : Ictus cordis not seen

Palpation : Ictus cordis not palpable

Percussion : Right heart margin : Sternalis line sinistra ICS-V

Left heart margin : Midclavicula line sinistra ICS-V.

Auscultation : Regular 1st & 2nd heart sounds, Murmur (-), Gallop (-)

Abdomen

Inspection : Looked flat

Auscultation : Bowel sounds (+) normal

Palpation : Pressure pain (-), Ascites (-)

Percussion : Timpani (+)

Extremities

Superior : Edema (- / -), Warm akral (+ / +), RCT <2 seconds (+ / +)

Inferior : Edema (-/ -), Warm akral (+ / +), RCT <2 seconds (+ / +)

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E. LABORATORY EXAMINATION
October 23rd 2017

Examination Value Units Normal

Hemoglobin 11.3 g/dL 11.7 – 15.5
Leukosit 8.40 103/µL 3.60 – 11.00

Hematokrit 34 % 35 – 47
Trombosit 466 103/µL 150 - 440
Eritrosit 3.72 106/µL 3.80 – 5.20

MCV 92 fL 80 – 100
MCH 30 Pg 26 – 34
MCHC 33 g/dL 32 – 36
Chemical Clinic
Blood Creatinin 0.6 mg/dl <1.4
Natrium Blood 149 mEq/L 135-147
Kalium Blood 2.6 mEq/L 3.5-5.0
Chloride Blood 106 mEq/L 94-111
Diabetes
GDS 116 mg/dl 70-200
F. RESUME

Mr. S, 84th years old came to emergency unit of Jakarta Islamic Hospital of Cempaka

Putih Complained of limping since a week ago. The patient is also complained having no

appetite and tounge taste bitter. The Patient refuses any meals and drinks then ended up

puke. In the other hand, the patient is also complained cough with sputum since one

month ago, but difficulty of spitting out and just can swallowing the sputum. This time,

the patient lived with his children, lying down on the bed, can’t sit or get up from the bed

8
 properly. Patient had difficulty of doing activity by himself. Using diaper to monitoring

urine and faeces about two until three times per day. History of falling accidentally at

home on march 2017

Physical examination : Blood pressure: 140/80 mmHg, Heart rate: 84x/minute,

Respiratory rate: 20x/minute, Temperature : 37.0 ° C.

Laboratory examination : (October, 23rd 2017)

Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466 (H), Eritrosit : 3.72

(L), Na Blood : 149 (H), K Blood : 2.6 (L)

G. PROBLEM LIST

 Immobilitation

 Low Intake

 Pulmonary Infection

 Imbalance electrolit

 Falls

 Pneumonia

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H. ASSESSMENT :

1. Geriatric Problem

S : Limping since a week ago. The patient is also complained having no appetite

and tounge taste bitter. The Patient refuses any meals and drinks then ended up puke.

This time, the patient lived with his children, lying down on the bed, can’t sit or get up

from the bed properly. Patient had difficulty of doing activity by himself. History of

falling accidentally at home on march 2017

O : Blood pressure: 140/80 mmHg, Heart rate: 84x/minute, Respiratory rate:

20x/minute, Temperature : 37.0 ° C.

Lab examination: October, 23rd 2017

Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466 (H),

Eritrosit: 3.72 (L), Na Darah : 149 (H), K Darah : 2.6 (L)

A : Geriatric Problem

P :

- Bedrest

- Asering IVFD 20 tpm

- Inj. Ceftriaxone IV 1x2 gr

- KCl 25 mg/kolf

- Paracetamol tab 3x500 mg

- NGT insertion

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2. Pneumonia

S : Cough since a month ago. Cough continuously with sputum. Difficulty of

spitting out, ended up swallowing the sputum.

O : Blood pressure: 140/80 mmHg, Heart rate: 84x/minute, Respiratory rate:

20x/minute, Temperature : 37.0 ° C.

Lab examination: October, 23rd 2017

Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466 (H),

Eritrosit: 3.72 (L), Na Darah : 149 (H), K Darah : 2.6 (L)

A : Bronchitis dd 1. Suspect unspecific infection : Pneumonia

2. Suspect specific infection : Tuberculosis

P :

- Bedrest

- Asering IVFD 20 tpm

- Microbiologic test: rapid molecular testing

- Tuberculin test

- Rontgent Thorax

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 I. Follow Up

Date Subjektif Objektif Assesment Planning

25/10/2017 Malaise (+)  Generalis Status : Geriatric - IVFD Asering 20 tpm
anorexic (+) Problem with - Paracetamol tab 3x500
insomnia since Mild ill suspect mg
last night pneumonia - Ceftriaxone Inj. 1 x 2
 Conciusness : gr

Composmentis

 BP:130/80 mmHg
 HR : 60x/mnt
 RR : 22x/mnt
 T : 36,5oC
Physical Examination :
- Pulmo : rhonchi +/+
- Abd : Bowel sounds
(+) normal

26/10/2017 Malaise (+)  Generalis Status : Geriatric - IVFD Aminofluid 14

anorexic (+) Problem with tpm
but have an Mild ill suspect - Ceftriaxone Inj. 1x2gr
appetite to pneumonia - Paracetamol tab 3x500
drink water.  Conciusness : mg
Insomnia (+)
cough (+) Composmentis

 BP:130/80 mmHg
 HR : 60x/mnt
 RR : 22x/mnt
Physical Examination :
- Pulmo : rhonchi +/+
- Abd : bowel sounds
(+) normal

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27/10/2017 Malaise (+)  Generalis Status : Geriatric - IVFD Aminofluid 14
anorexic (+) Problem with tpm
but have an Mild ill Pneumonia - Ceftriaxone Inj. 1x2gr
appetite to - Paracetamol tab 3x500
drink water.  Conciusness : mg
Insomnia (+) - plan : countermarch
cough (+) Composmentis (tomorrow) :
1. Ciprofloxacin tab
 BP:130/90 mmHg 2x500 mg
2. Ranitidine tab 2x1
 HR : 80x/mnt 3. Neurolex tab 1x1
 RR : 22x/mnt
Physical Examination :
- Pulmo : rhonchi +/+
- Abd : bowel sounds
(+) normal
Rontgent available.
Interpretation:
Broncopneumonia Dextra

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 CHAPTER II

LITERATURE REVIEW

GERIATRIC PROBLEM

A. Definition
The term “geriatric syndrome” is used to capture those clinical conditions in older
persons that do not fit into discrete disease categories. Many of the most common conditions
cared for by geriatricians, including delirium, falls, frailty, dizziness, syncope and urinary
incontinence, are classified as geriatric syndromes. Nevertheless, the concept of the geriatric
syndrome remains poorly defined.
Geriatric syndrome is a set of clinical conditions in the elderly that can affect the patient's
quality of life and is associated with disability. Uncommon clinical appearance often makes
geriatric syndrome undiagnosed.

Geriatric syndrome includes cognitive impairment, depression, incontinence, functional

dependence, and falls. This syndrome can cause significant morbidity and poor state in old
age. This syndrome usually involves several organ systems. Geriatric syndrome may have a
similar pathophysiology even with different presentation of the sign, and require
interventions and strategies that focus on etiologic factors.

B. Epidemiology

The prevalence of advanced age over 60 years increases faster than other age group
populations due to an increase in life expectancy and reduced birth rate. World demographic
data show an increase in the elderly population of 60 years or more triples in 50 years; from
600 million in 2000 to more than 2 billion by 2050.

The number of elderly people in Indonesia reaches the top five in the world, which is
18.1 million in 2010 and will double to 36 million by 2025. The life expectancy of
Indonesians is 67.8 years in 2000-2005 and became 73.6 years in 2020-2025. The proportion
of elderly increased 6% in 1950-1990 and to 8% today. The estimated proportion rise to 13%

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by 2025 and 25% by 2050. By 2050 a quarter of Indonesia's population is elderly population,
compared to the current one-twelveth of Indonesia's population.

C. Classification

In assessing the health of the elderly need to be distinguished between the

changes caused by aging with changes due to pathological processes. Some clinical
problems of elderly diseases are common. Geriatric syndrome include:
 “the O complex” :fall, confusion, incontinence, iatrogenic disorders, impaired
homeostasis
 “the big three” :intelectual failure, instability, incontinence
 “the 14 I” :Immobility, Impaction, Instability, Iatrogenic, Intelectual
Impairment, Insomnia, Incontinence, Isolation, Impotence,
Immunodefficiency, Infection, Inanition, Impairment of
Vision, smelling, hearing, Impecunity

Immobility

Mobility limitation is common in older adults and is associated with increased

rates of morbidity, hospitalization, disability, and mortality. Structured physical activity
programs may help reduce mobility-related disability among community-dwelling elders.
Hospital-associated bed rest is a common precipitant of immobility and functional
decline. Among hospitalized medical patients over age 70, about 1 0 % experience a
decline in function, and those who experience critical illness are at particularly high risk.
The hazards of bed rest in older adults are multiple, serious, quick to develop, and
slow to reverse. Within days after being confined to bed, deconditioning of the
cardiovascular system occurs and involves fluid shifts, decreased cardiac output,
decreased peak oxygen uptake, increased resting heart rate, and postural hypotension.
More striking changes occur in skeletal muscle, with loss of strength. Pressure ulcers,
deep venous thrombosis, pulmonary embolism, and falls are additional serious risks.
Recovery from these changes usually takes weeks to months.

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 Physical activity should be encouraged for all elders, particularly sedentary elders.
Protocols for hospitalized elders that promote walking two to three times daily and sitting
upright for much of the day can minimize unnecessary immobility. When immobilization
cannot be avoided, several measures can be used to minimize its consequences. To
reduce the risks of contracture and weakness, range-of-motion and strengthening
exercises should be started immediately and continued as long as the patient is in bed.
Avoiding restraints and discontinuing intravenous lines and urinary catheters will
increase opportunities for early mobility. Graduated ambulation should begin as soon as
it is feasible. Prior to discharge, physical therapists can recommend appropriate exercises
and assistive devices; after discharge, they can recommend safety modifications and
maintenance exercises.

Instability

About one-third of people over age 65 fall each year, and the frequency of falls
increases markedly with advancing age. About 10% of falls result in serious injuries,
such as fractures, soft-tissue injuries, and traumatic brain injuries. Complications from
falls are the leading cause of death from injury in persons over age 65. Hip fractures are
common precursors to functional impairment, nursing home placement, and death.
Balance and ambulation require a complex interplay of cognitive, neuromuscular,
and cardiovascular function. With age, balance mechanisms can become compromised
and postural sway increases. These changes predispose the older person to a fall when
challenged by an additional insult to any of these systems.
A fall may be the clinical manifestation of an occult problem, such as pneumonia
or myocardial infarction, but much more commonly, falls are due to the interaction
between an impaired patient and an environmental risk factor. Falls in older people are
rarely due to a single cause, and effective intervention entails a comprehensive
assessment of the patient's intrinsic deficits (eg, diseases and medications), the activity
engaged in at the time of the fall, and environmental obstacles.

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Incontinence

Urinary incontinence is defined as uncontrolled release of urine at an

undesirable time regardless of frequency and number, resulting in social and
hygienic problems. Incontinence is unconscious expenditure of urine (or
feces), in sufficient quantities and frequencies causing health or social
problems. This is not a normal consequence of aging. The causes of
incontinence are derived from urological disorders (inflammation, stones,
tumors), neurologic disorders (stroke, spinal cord injury, dementia), or other
(immobilization, environment). Incontinence may be acute in the event of a
disease or a chronic / prolonged period.

A. Acute Urinary Incontinence Reversible

causes of acute reversible urinary incontinence:
D -> Delirium
R -> Mobility restriction, urinary retention

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 I -> Infection, Inflammation, Impaction
P -> Polyuria, pharmacy
B. Persistent Urinary incontinence
Clinical categories include:
1) Urinary incontinence stress
Uncontrolled urine flow due to increased intraabdominal pressure, such as when
coughing, sneezing or exercising. Generally caused by weakening pelvic floor muscles,
is the most common cause of urinary incontinence in elderly under 75 years. It is more
common in women but may occur in men due to damage to the urethral sphincter after
transurethral surgery and radiation. Patients complain of urinating when laughing,
coughing, or standing up. The amount of urine that comes out can be few or many.
2) Urgency urinary incontinence
The uncontrolled release of urine is associated with the sensation of urination desire.
This type of urinary incontinence is commonly associated with uncontrolled detrusor
contractions (detrusor overactivity). Neurologic problems are often associated with
urinary urgency incontinence, including stroke, Parkinson's disease, dementia and
spinal cord injury. Patients complain of not enough time to get to the toilet after the
urge to urinate arise so that urinary incontinence events arise. This type of urgency
incontinence is the most common cause of incontinence in the elderly over 75 years.
One variation of urge incontinence is detrusor hyperactivity with impaired
contractility. The patient had an involuntary contraction but was unable to empty the
bladder completely. They have symptoms such as urinary stress incontinence, overflow
and obstruction. Therefore it is necessary to recognize the condition because it can
resemble other types of urinary incontinence will not treated properly.
3) Increased urinary incontinence / overflow
Unbridled urinary expenditure is associated with excessive bladder distention. This is
caused by anatomical obstruction, such as prostate enlargement, neurogenic factors in
diabetes mellitus or multiple sclerosis, which causes reduced or no bladder contraction,
and drug factors. Patients generally complain of a slight urine release without the
sensation that the bladder is full.
4) Functional urinary incontinence

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Functional incontinence is the state of a person who has unconscious and
unpredictable expenditure of urine. This state of incontinence is characterized by the
lack of urge to urinate, feeling that the bladder is full, the contraction of the bladder is
strong enough to release urine.
Functional incontinence is an incontinence with intact lower urinary tract function but
there are other factors, such as severe cognitive impairment which makes it difficult
for patients to identify the need for urination (eg, Alzheimer's dementia) or physical
disorders that make it difficult or impossible for the patient to reach the toilet for
urination
5) Incontinence Reflex
Incontinence reflex is a condition in which a person experiences an unhealthy urine
release, occurring at predictable intervals when the volume of the bladder reaches a
certain amount. This type of incontinence is probably caused by neurological damage
(spinal cord lesions). Reflex incontinence is characterized by a lack of urge to urinate,
feeling that the bladder is full, and bladder contraction or spasm is not inhibited at
regular intervals
6) Total incontinence
Total incontinence is a condition in which a person experiences a continuous and
unpredictable expenditure of urine. Possible causes of total incontinence include:
neurological dysfunction, independent contractions and detrusor reflexes due to
surgery, trauma or disease affecting the spinal cord, fistula, neuropathy. Management
of urinary incontinence includes behavioral training (bladder training, pelvic floor
exercise), pharmacological, surgery. Drugs used include anticholinergic
antispasmodic (imipramine) for urgency / stress type, α-adrenergic agonist
(pseudoephedrine, phenylpropanolamine) for type of stress or urgency, estrogen
agonist (oral / topical) for type of stress or urgency, cholinergic agonist (betanecol) α-
arendergic antagonist (patiozine) for overflow type or urgency due to prostate
enlargement. Surgery includes temporary catheterization (2-4 times daily) or
sedentary.

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Impecunity

Impecunity (poverty), the age of the elderly where a person becomes less productive (not
unproductive) due to decreased physical ability to move. The retirement age in which
some elderly people only rely on life from their old age benefits. Basically an elderly
person can still work, only the intensity and workload that must be reduced according to
his ability, it is evident that someone who keeps his brain up to old age by working,
reading, etc., is not easy to be "senile". In addition to financial problems, retirement also
means loss of peers, means that social interaction decreases allowing an elderly person to
experience depression.

Infection

Infection is closely related to decreased immune system function in elderly. Common

infections are urinary tract infections, pneumonia, sepsis, and meningitis. Other conditions
such as malnutrition, multipatology, and environmental factors make it easier for the
elderly to get infected.
Infection in the elderly (elderly) is the cause of morbidity and death no 2 after
cardiovascular disease in the world. This occurs due to several things, among others: the
presence of chronic comorbid disease is quite a lot, decreased resistance / immunity to
infection, decreased communication power of the elderly so difficult / rarely complain, the
difficulty of recognizing early signs of infection. The main characteristic of all infectious
diseases is usually characterized by increased body temperature, and this is often not seen
in old age, 30-65% of infected elderly are often not accompanied by an increase in body
temperature, even under 360C temperatures are more common. Complaints and symptoms
of infection are increasingly not typical, among others, in the form of confusion / delirium
to coma, a sudden decrease in appetite, the body becomes weak, and the change in
behavior occurs in elderly patients.

Isolation

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 Major depressive disorder occurs in up to 5% of community-dwelling older
adults, whereas clinically significant depressive symptoms-often related to loss, disease,
and life changes-are present in up to 16% of older adults. Depression rates rise as illness
burden increases. Depression is particularly common among hospitalized and
institutionalized elders. Older single men have the highest suicide rate of any
demographic group.
Older patients with depression are more likely to have somatic complaints, less
likely to report depressed mood, and more likely to experience psychotic features than
younger patients. In addition, depression may be an early symptom of dementia.
Depressed patients who have comorbid conditions ( eg, heart failure) are at higher risk
for hospitalization, tend to have longer hospital stays, and have worse outcomes than
their nondepressed counterparts.
Depression disorders in the elderly are poorly understood so that many cases are
not recognized. Symptoms of depression in the elderly are often regarded as part of the
aging process.
• Isolate or feel isolated in old age: late life depression
• Symptoms or signs of other illnesses
• Causes include: chronic diseases (such as cancer, diabetes mellitus, stroke),
drugs, loss of ability to perform living or activity functions, socio-economic problems
(such as financial and family), etc.
• Symptoms include: weakness, lack of excitement, sleep disturbance, unwilling to
eat, do not want to move, including immobility, guilt, suicidal, etc.
Treatment may involve psychosocial interventions, increased physical activity,
problem-solving therapy, cognitive-behavioral therapy, reduction of alcohol or medication
intake, antidepressant medications, or a combination approach. In older patients with
depressive symptoms who do not meet criteria for major depressive disorder,
nonpharmacologic treatment approaches should be used. Choice of antidepressant agent is
usually based on side-effect profile, cost, and patient -specific factors, such as presenting
symptoms and comorbidities. Selective serotonin reuptake inhibitors ( SSRis), particularly
sertraline, are often used as first -line agents because of their relatively benign side-effect
profile. Mirtazapine is often used for patients with weight loss, anorexia, or insomnia.

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Duloxetine is useful in patients who also have neuropathic pain and is better tolerated than
venlafaxine among older adults. Adding methylphenidate to an SSRI appears to enhance
clinical response rates. Regardless of the medication chosen, many experts recommend
starting elders at a relatively low dose, titrating to full dose slowly, and continuing for a
longer trial (at least 8 weeks) before trying a different medication. For patients
experiencing their first episode of depression, pharmacologic treatment should continue
for at least 6 months after remission of the depression. Recurrence of major depression is
common enough among elders that long-term maintenance medication therapy should be
considered.

Intelectual Impairment

Dementia is an acquired, persistent, and progressive impairment in intellectual

function, with compromise of memory and at least one other cognitive domain, most
commonly aphasia (typically, word-finding difficulty), apraxia (inability to perform
motor tasks, such as cutting a loaf of bread, despite intact motor function), agnosia
(inability to recognize obj ects), and impaired executive function (poor abstraction,
mental flexibility, planning, and judgment). The diagnosis of dementia requires a
significant decline in function that is severe enough to interfere with work or social life.
Causes include: Urinary tract infections, diabetes mellitus, spinal disorders such as
fractures, strokes, the effects of medications such as septicidiuretic, prostatic hypertrophy,
acute delirium syndrome, dementia, severe illness, immobility, overeating, large numbers
of children, false impaction, and others
The diagnosis of dementia is confirmed by anamnesis, examination of Mini Mental State
Examination and the exact cause with pathology examination. Dementia is divided into 4
groups: primary dementia degeneratif / Alzheimer (50-60%), multi-infarction dementia
(10-20%), reversible / partial reversible (20-30%) dementia, and other disorders (5-10%).
The causes of reversible dementia are as follows:
D : drugs
E : emotional
M : metabolic

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 E : eye and ear
N : nutrition
T : tumor/ trauma
I : infection
A : arteriosklerosis

The principle of dementia management is the optimization of patient function,

recognizing and addressing complications, ongoing care, family information, and family
advice.

Impairment of Vision and Hearing

Visual impairment due to age-related refractive error ("presbyopia"), macular

degeneration, cataracts, glaucoma, and diabetic retinopathy is associated with significant
physical and mental health comorbidities, falls, mobility impairment, and reduced quality
of life. The prevalence of serious and correctable visual disorders in elders is sufficient to
warrant a complete eye examination by an ophthalmologist or optometrist annually or
biannually for most elders. Many patients with visual loss benefit from a referral to a
low-vision program.
Hearing loss is very common in geriatrics. The prevalence of moderate or severe
hearing loss increased from 21% in the age group 70 years to 39% in the 85-year-old age
group. Basically, the etiology of hearing loss is the same for all ages, except for
presbycers for the geriatric group. Otosclerosis is commonly encountered in young
adulthood, characterized by bone remodeling in the autistic capsule causing conductive
hearing loss, and if the disease spreads to the inner ear, it can also cause sensorineural
disturbance. Ménière's disease is an inner ear disease that causes hearing loss to fluctuate,
tinnitus and dizziness. Hearing loss due to noise caused by excessive acoustic energy that
causes permanent trauma to the hair cells. Sensory presbycusis often found in geriatrics is
caused by degeneration of the cortic organ, and is characterized by high frequency
hearing loss. In patients also encountered a hearing loss so difficult to be invited to
communicate. Management for hearing loss in geriatrics is by pairing hearing aids or by
surgical action in the form of cochlear implantation.

23
Inanition

Nutritional deficiency refers to the hendaya that occurs in the elderly due to
unintentional physiological and pathological weight loss. Anorexia in the elderly is a
physiological decrease of appetite and dietary intake that causes unwanted weight loss. In
patients, nutritional deficiency is caused by the state of the patient with swallowing
disorders, thus decreasing the patient's appetite.
Weight loss affects substantial numbers of elders. The degree of unintended
weight loss that deserves evaluation is not agreed upon, although a reasonable threshold
is loss of 5% of body weight in 1 month or 10% of body weight in 6 months.
Useful laboratory and radiologic studies for the patient with weight loss include
complete blood count, serum chemistries (including glucose, TSH, creatinine, calcium,
and in men, testosterone), urinalysis, and chest radiograph. These studies are intended to
uncover an occult metabolic or neoplastic cause but are not exhaustive. Exploring the
patient's social situation, cognition, mood, and dental health are at least as important as
looking for a purely medical cause of weight loss.
Oral nutritional supplements of 200- 1000 kcal/day can increase weight and
improve outcomes in malnourished hospitalized elders. Sodium-containing flavor
enhancers (eg, iodized salt) can improve food intake without adverse health effects when
there is no contraindication to their use. Megestrol acetate as an appetite stimulant has not
been shown to increase body mass or lengthen life among elders and has significant side
effects. For those who have lost the ability to feed themselves, assiduous hand feeding
may allow maintenance of weight. Although liquid artificial nutrition and hydration
("tube feeding") may seem a more convenient alternative, it deprives the patient of the
enjoyment associated with eating as well as the social milieu typically associated with
mealtime; before this option is chosen, the patient or his or her surrogate should be
offered the opportunity to review the benefits and burdens of the treatment in light of
overall goals of care. If liquid artificial nutrition is initiated and the patient makes
repeated attempts to pull out the tube, its utility should be reconsidered. Liquid artificial
nutrition is not recommended for patients with end-stage dementia.

24
Iatrogenic
There are several reasons for the greater incidence of iatrogenic drug reactions in
the elderly population, the most important of which is the large number of medications
that elders take. Drug metabolism is often impaired in elders due to a decrease in
glomerular filtration rate as well as reduced hepatic clearance. Older individuals often
have varying responses to a given serum drug level. Thus, they are more sensitive to
some medications (eg, opioids) and less sensitive to others (eg, beta-blocking agents).
Most emergency hospitalizations for recognized adverse drug events among older
persons result from only a few medications used alone or in combination; examples
include antianxiety medications, sedative/hypnotics, warfarin, antiplatelet agents,
insulins, oral hypoglycemics, opioids, and digoxin.
Immunodefficiency
Immunodefficiency affects much of the immune system's decline in old age, such
as thymus atrophy (a gland that produces T lymphocytes), although not very significant
(appears to be significant in T lymphocytes CD8) because T lymphocytes persist in other
lymphoid tissues. The same as first barrier of infection in the body such as skin and
mucosa are thinning, cough and sneeze reflex - which serves to remove foreign
substances into the airway. The same thing happens to the immune response to the
antigen, the decrease in the number of antibodies. All of these mechanisms result in
susceptibility to infectious agents, so that infectious diseases occupy large portions in
elderly patients.
Insomnia
Insomnia, can occur because of problems in life that causes an elderly person to
become depressed. In addition, some diseases can also cause insomnia such as diabetes
mellitus and thyroid gland hyperactivity, neurotransmitter disorders in the brain can also
cause insomnia. Changed sleep hours can also be the cause.
Impotence
Impotency (Impotence), inability to engage in sexual activity at an advanced age
mainly caused by organic disorders such as hormonal disorders, nerves, and blood
vessels. Erection occurs because the penis is enlarged with blood so enlarged, in vascular

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 disorders such as blockage of plaque atherosclerosis (also occurs in smokers) can clog the
blood flow so that the penis can not erect. Another cause is depression.

Irritable Bowel
Irritable bowel (causing sensitive-easily stimulated) to cause diarrhea or
constipation / impaction (constipation). The cause is unclear, but in some cases there are
disorders of the intestinal smooth muscle, other possible disorders are intestinal sensory
nerve disorders, central nervous system disorders, psychological disorders, stress, nerve-
stimulating gas fermentation, colitis.

D. Diagnostic Examination

A comprehensive Geriatric Assessment includes: physical, mental, functional,

social, and environmental health. The purpose of the assessment is to know the holistic
health of the patient in order to empower the patient's independence for as long as
possible and prevent handicap disabilities in the future. This assessment is not only multi-
disciplinary but interdisciplinary with harmonious coordination across disciplines and
across health services.

Anamnesis is equipped with various disorders that are: swallowing, dental

problems, dentures, communication / speech disturbances, pain / movement is limited to
limbs and others.

• Assessment system: Assessment system implemented in sequence, starting from

the central nervous system, upper and lower respiratory tract, cardiovascular,
gastrointestinal (such as alvi incontinence, constipation), urogenital (such as urinary
incontinence). It can be said that the appearance of the illness and the patient's complaints
are not necessarily tangible as the appearance of disturbed organs.

• Anamnesis about habits that harm health (smoking, drinking alcohol).

• Anamnesis Environment needs to include the envirenment of living area
(neigbourhood).

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 • Review of medications that have been and are being used need to be asked, if
necessary, the sufferer or his or her family.
• Whether or not there is a change of behavior.

a) In nutrition need to be considered:

 Balance (both calorie and macronutrient)
 Having enough micronutrients (vitamins and minerals)
 Excessive or reduced caloric adjusted for its AHS activity, with the aim of
achieving ideal body weight.
 Tenderness, mastication and gastro-intestinal function.
 Whether there is a decrease or weight gain.

b). Nutrition Assessment Nutrition assessment is done by examining body mass

index.

Body Mass Index Formula (BMI) : Weight (kg)

[Height (m)] 2

IMT: 18 - 23 (normal)
Geriatric Population's High Formula:
Male : TB = 59.01 + (2.08 X Knee Height)
Female : TB = 75.00 + (1.91 X Knee Height) - (0.17 X Age).

Treatment

In treating and managing geriatric patients, there are two important components,
namely team and P3G approach which is part of comprehensive geriatric management
(CGM). The geriatric patient's plenary approach differs from standard medical review in
three ways, focusing on elderly patients with complex problems; including functional
status and quality of life; requires an interdisciplinary team. Here are some general
management of geriatric syndrome, including:

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1. Adequate dietary intake of protein, vitamin C, D, E, & minerals.
Older people generally consume less protein than nutritional adequacy (AKG). A
multicenter study in 15 provinces in Indonesia found that 47% of elderly people
consumed less than 80% of the AKG protein. Adequate protein proportions are an
important factor; not in large quantities at one meal. Another important thing is good
protein quality, that protein should contain essential amino acids. Leucine is an essential
amino acid with the highest protein anabolic ability that can prevent sarcopenia. Leucine
is converted to hydroxy-methyl-butyrate (HMB). HMB supplementation increases
protein synthesis and prevents proteolysis.
2. Regular exercise arrangements. It needs regular monitoring of basic skills such as
walking, balance, cognitive function. Physical activity can inhibit the decrease in
mass and muscle function by triggering the increase in mass and metabolic capacity
of the muscle, affecting the energy expenditure, metabolise of glucose, and reserve of
body proteins. Resistance training is the most effective form of exercise to prevent
sarcopenia and can be well tolerated in the elderly. The resistance training program is
conducted for 30 minutes per session, 2 times a week. Physical activity without
adequate nutritional intake causes a negative protein balance and causes muscle
degradation.
3. Prevention of infection with vaccine
4. Anticipate events that can cause stress such as elective surgery and rapid
reconditioning after experiencing stress with individual renutrition and physiotherapy.
5. Treatment therapy in elderly patients is significantly different from patients at a
young age, due to changes in body condition caused by age, and the impact arising
from the use of drugs used before. It is therefore suggested that the principle of
correct administration of medication in geriatric patients by knowing a complete
medical history, do not give the drug prematurely, do not take medication too long,
identify the drugs used, start with low doses, slowly rise, treat according to the
standard, give the urge to be docile and careful to use new drugs.

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E. Preventive

Types of health services to the elderly include five health efforts: promotive,
preventive, early diagnosis and treatment, disability restriction and recovery.

1. Promotion

The promotive effort is an action directly and indirectly to improve health status
and prevent disease. The promotive effort is also a process of health advocacy to increase
the support of clients, provident and community workers on positive health practices into
social norms. Promotional efforts are being undertaken to help people change their
lifestyles and move toward optimal health conditions and support one's empowerment to
make healthy choices about their behavior.

2. Prevention

a. Perform primary prevention, including prevention of healthy elderly, there are risk
factors, no disease, and health promotion. Primary types of preventive services are:
immunization programs, counseling, quitting smoking and quitting alcoholic drinking,
nutritional support, security in and around the home, stress management, proper
medication use.

b. Perform secondary prevention, including examination of patients without symptoms

from the beginning of the disease until the symptoms of the disease have not been seen
clinically and as seen in risk factors. The types of secondary prevention services include
the following: hypertension control, cancer detection and treatment, screening: rectal
examination, papsmear, mouth teeth and others.

c. Prevent tertiary prevention, done before symptoms of disease and disability, mecegah
increased defects and dependence, as well as treatment with hospital care, rehabilitation
of outpatients and long-term care.

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