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

Geriatric Giant
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
Kane, Ouslander Abrass. (from
Immune deficiency
Solomon 1988), Essentials of
Impotence
Clinical Geriatrics.2004 . p.13-14.

Impairment
of Hearing

Intellectual
Impairment

Impairment
of Visual
Inanition

Isolation

Instability
and Falls

Impaction

Geriatric
Syndromes
Impotence

Incontinence

Immuno
deficiency

Iatrogenesis

Infection

Immobilization

Insomnia

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

Malnutrition
Reduced feeding
capabilities

Apathy, depression
Poor concentration

Reduced mobility
Loss of muscle
strength

Poor Appetite

Causes of weight loss in older

persons
Causes 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

maximum score 30 points
24 :

normal/well-nourished

17 - 23.5 : border line/at risk malnutrition

< 17 :

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

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

Pneumonia
Tuberculosis
Urinary tract infections
Bacteremia / sepsis
Cholecystitis
Appendicitis
Septic Arthritis
Bacterial meningitis
Infective endocarditis

3
10
1
3
2-8
15-20
2-3
3
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 patients disease

Contributors to Polypharmacy
Patient

Borrowing or sharing medications

Failing to understand instructions
Saving medication for later use
Combining Rxs with OTCs and Herbals
Visiting more than one physician

Doctor
Failing to review the patients medications
Prescribing medications for common and non-life
threatening symptoms
Treating multiple symptoms or illnesses with several
drugs

IMPACTION
(CONSTIPATION)
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,
36

Definition

37

Physio-pathology Chronic
Constipation

38

Risk Factors Constipation in Elderly

Medications
Anticholinergic drugs
(trisyclic,antipsichotic,antihistamin,antiemet
ic 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)
39

Risk Factors Constipation in

Elderly

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 comfort
Poor toilet acces (3)

40

Physical Examination
All patients constipation :

Rectal Touche !!
Rectal impaction ?
Rectal dilatation ?
Hemorrhoid ?
Anorectal disease ?
Perianal fecal soiling ?
41

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

Instabilitas
Jatuh

Obat
Inkontinensia urin

Fraktur
Hipotermia

Infeksi

Kesadaran

Imobilisasi

Ulkus
Trombosis vena
Pneumonia
ISK
Atrofi otot
Asupan makanan
Asupan cairan

Depresi

Gangguan
tidur

Dehidrasi

konstipasi

Malnutrisi

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