ISBN 978-602-1672-60-0

9 786021 672600
 PROCEEDING UDAYANA UNIVERSITY HOSPITAL
INTERNATIONAL SYMPOSIUM GERIATRIC HEALTH SERVICE

Contents

Management Of Insomnia In Elderly 1

R A Tuty Kuswardhani

Immobilization In Elderly Patient 8

R A Tuty Kuswardhani

Falls In Elderly, Cause, Diagnostic, And Management 15

R A Tuty Kuswardhani

Fecal Incontinence In Elderly 25

R A Tuty Kuswardhani

Orthostatic Hypertension In Elderly 33

R A Tuty Kuswardhani

Healthy Life Expectancy And Food Life In The Elderly 43

Naemi Kajiwara

Evaluation Adverse Drugs Reaction Between Amitriptyline And Gabapentin On Neuropatic 51

Pain Treatment In Geriatric Type II Diabetes Mellitus
I B Maharjana, R A Tuty Kuswardhani

Determination Of Factors Influence Pain Reduction And Adverse Drug Reaction Between 61
Amitripthyline Versus Gabapentin On Neuropatic Pain Therapy In Geriatric With Type II
Diabetes Mellitus
Md Krisna Adi Jaya, R A Tuty Kuswardhani

Depression In Elderly 69
Made Wedastra, R A Tuty Kuswardhani

Research Article
Correlation Of Sepsis And Albumin Serum Among Elderly Patients In RSUP Sanglah Bali 77
Ni Made Darma Patni Sri Rejeki, R A Tuty Kuswardhani

Correlation Between Depression And Falls Among Elderly Patient Hospitalized At Geriatric 87
Ward In Sanglah Hospital
IDG Teguh Krisna Murti, Tuty Kuswardhani
Correlation Between Immobilitation With Albumin Serum Among Elderly In Sanglah Hospital 97
Putu Dhenny Wahyu Wiguna, R A Tuty Kuswardhani

Correlation Nutrition With Mini Nutritional Assesment (MNA) And Functional Status At 105
Elderly People In Sanglah Hospital
Kadek Dwi Wulandari, R A Tuty Kuswardhani
 Immobilization in Elderly Patient

RA Tuty Kuswardhani

Geriatric Division of Medical Faculty of Udayana University /

Sanglah General Hospital

Introduction

Mobilization depends on coordinated interaction between perceptive sensory

function, motoric ability, physical condition, cognitive level, premorbid health status,
and external variables like community resource, family support, environment, and
institutional policy.
Immobilization is defined as the loss of anatomic movement as the result of
physiologic alteration, which in daily practice is often addressed as inability to be
mobile on the bed, during transfer, or ambulation for more than three days.
Immobilization delineates physiologic degeneration syndrome which is caused by
decreasing activities and deconditioning.1 Immobilization is often found in evry elderly
people. Research in geriatric hospitalization service of Dr. Cipto Mangunkusumo
Hospital obtained prevalence immobilization of 33.6% and in 2001 by 31.5% in elderly
patient.
Various factors, both physical, psychological, and the environment can lead to
immobilization in elderly patients. Some of the main causes of immobilization are the
presence of pain, weakness, muscle stiffness, imbalance, and psychological problems.
Parkinson's disease, arthritis rheumatoid, gout, and antipsychotic drugs such as
haloperidol can also cause stiffness. The aches, both of the bones (osteoporosis,
osteomalacia, Paget's disease, bone cancer metastasis, trauma), joints (osteoarthritis,
rheumatoid arthritis, gout), muscle (polimialgia, pseudoclaudication) or problems in
the feet can cause immobilization. Severe cognitive impairment such as dementia and
impaired mental function such as the depression would very often cause
immobilization. Excessive worries of the family or laziness of the health workers can
also cause the elderly constantly lies in bed at home or at the hospital. The side effects
of some drugs such as hypnotics and sedatives medications can also cause
immobilization disorder. Various physical, psychological, and environmental factors
which cause immobilization in the elderly can be seen on table 1.
 There are various risk factors that contribute to immobilization in elderly
including musculoskeletal disorder (arthritis, osteoporosis, fracture, feet problems),
neurologic disorder (stroke, parkinson, cerebellar dysfunction, neuropathy),
cardiovascular disease (severe congestive heart failure, coronary heart disease,
peripheral vascular disease with frequent claudication), lung disease such as chronic
obstructive pulmonary disease, sensory factor (visual disturbance, instability and fear
of falling), environmental cause (enforced immobilization in hospital or retirement
house, inadequate mobilization assisting device), deconditioning (after long bed rest),
malnutrition, severe systemic disease (such as metastatic cancer), depression, drug’s
adverse effect (rigidity from psychotic effect) and long trip/travel which makes
mobilization impossible.
Immobilization in elderly may lead to adverse effects to various organ system.
In musculoskeletal systems, it can cause osteoporosis, bone mass reduction, loss of
muscle strength, plummeting of muscle surface area, contracture, cartilage
degeneration, ankyloses, increasing intraarticular pressure, intraarticular volume
decrease. In cardiopulmonary and vascular systems, it may cause increase of resting
heart rate, decrease of myocardial perfusion, orthostatic intolerance, decrease of
maximum oxygen uptake (VO2 max), heart deconditioning, plasma volume decrease,
changes of lung function and capacity, atelectasis, pneumonia, stasis of vein,
excessive thrombocyte aggregation, and hypercoagulation. Immobilization can
increase risks of decubitus ulcer and skin maceration (integument systems).
Meanwhile in metabolic and endocrine systems, it can cause negative nitrogen
balance, hypercalciuria, natriuresis and sodium depletion, insulin resistance and
glucose intolerance, hyperlipidemia, and mineral/vitamin absorption and metabolism
disturbance. Immobilization can also affect neurology and psychiatry systems such as
depression and psychosis, motoric and sensory cortex atrophy, balance disorder,
cognitive function deterioration, compression neuropathy, and inefficient
neuromuscular recruitment. Urinary incontinence, fecal incontinence, urinary tract
infection, calcium stone formation, incomplete bladder voiding and bladder
distention, fecal impaction, constipation, decreasing intestinal motility, esophageal
reflux, aspiration, and risks of gastrointestinal bleeding are effects of immobilization
in gastrointestinal and urinary tract systems.
Complications of immobilization
Immobilization can lead to complications in the respiratory system, including
decline in ventilation, atelectasis and pneumonia. Endocrine and kidney
complications, increased diuresis, natriuresis and extracellular fluid shifts, glucose
intolerance, hypercalcemia and loss of calcium, kidney stones and a negative nitrogen
balance.
Gastrointestinal complications that can arise are anorexia, constipation and
scibala. In the central nervous system, can occur sensory deprivation, disruption of
balance and coordination. Other complications include pressure sores (decubitus
ulcers), thrombosis (deep vein thrombosis and pulmonary emboli), muscle weakness,
muscle and joints contracture, osteoporosis, postural hypotension, urinary tract
infection and nutrition problem (hypoalbuminemia)

Assesment of Imobilization in Elderly People

Clinical approach to immobilization: Role Assessment of Geriatric Patients
Plenary (P3G)
In reviewing immobilization, anamnesis of present illness history needs to be
done, how long has the patient experienced the disability, a disease that can affect the
ability to mobilize and drugs that can cause immobilization. Complaints of pain,
depression screening and the fear of falling and the environmental assessment,
including home visits when necessary, are important to be done.
Anamnesis
1. History of disability/immobilization and its duration
2. Certain medical condition which causes or are risks of immobilization
3. Premorbid condition
4. Pain
5. Drugs consumption
6. Social service/retirement house support
7. Social interaction
8. Psychological factor
9. Environmental factor
On physical examination, it is necessary to check the status of
cardiopulmonary, a detailed musculoskeletal examination, for example muscle
strength and range of motion, neurologic status checks and the skin checks for
identification of decubitus ulcers. Immobilization status of patients should be always
assessed on an ongoing basis.

Physical Examination1
1. Cardiopulmonary status
2. Skin
3. Musculoskeletal: muscle tone and power, range of motion of joints, deformity
and lesions of the feet
4. Neurologic: focal weakness, perception and sensory evaluation
5. Gastrointestinal
6. Genitourinary
7. Functional status: Barthel’s Activity of Daily Living Index
8. Mental Status: screening using geriatric depression scale (GDS)
9. Cognitive status: screening using mini-mental state examination (MMSE),
abbreviated mental test (AMT)
10. Grade of mobility: Mobility on bed, transfer ability, mobility on wheelchair, gait,
pain while moving.

Work Ups1
Assessment of the severity of immobilization’s underlying medical causes (knee x-
ray, echocardiography, etc) and immobilization’s complications (albumin, electrolyte,
blood glucose, and hemostasis workups, etc).

Treatment
General Treatment
1. Multidiscipline medical team and active participation from patient, family, and
social service/retirement house
2. Informing the family about the fee of bed rest, the importance of gradual
exercise and early ambulation, and preparing patient to be independent in
doing daily routines based on patient’s ability
3. Complete geriatric assessment, functional target formulation, and treatment
plan which estimates time needed to achieve therapy’s goals.
 4. Identify and treat infection, malnutrition, anemia, fluid and electrolyte
imbalance, and other comorbid conditions which might be related to
immobilization
5. Evaluate all consumed drugs, all fatigue or weakness-causing drugs should be
adjusted accordingly or totally stopped
6. Supply adequate nutrition, enough fluids and high-fiber foods, vitamin, and
minerals.
7. Commence exercise and remobilization program once medical condition’s
stability is achieved. The program includes mobility on bed, joints’ range of
motions (passive, active, and active with assistance), muscles’ strength
restoration, coordination/balance exercise (ie, walking in a straightline),
transfer with assistance, and ambulation on limited extent.
8. Assist the patient to use mobilization aid device and ambulation
9. Urination and defecation training and management, including using a toilet

Specific Treatment
1. Treatment of immobilization’s risk factors
2. Treatment of immobilization’s complications
3. Consult certain medical condition to a specialist when needed
4. Remobilize early and gradually to avoid further immobilization in a hospital
or social service/retirement house setting
5. Provide environmental and social support and mobilization aid device for
elderly with permanent disability
6. Low dose heparin (LDH) and Low molecular weight heparin (LMWH),
contracture prevention, and pneumonia prevention (what movements should
be exercised, and how to prevent decubitus ulcer).

Prevention of Immobilization’s complications

Management that can be done may include pharmacological and non
pharmacologic management.

Non Pharmacological
The effort that can be done is by doing some regular physical therapy and
physical exercise. For patients who undergo complete bed rest, changing positions
regularly and exercising in bed. Besides, early mobilization in the form of getting out
of bed, moving from bed to chair and functional exercises can be done gradually.
To prevent decubitus, one thing to be performed is eliminating cause of ulcers
which is the pressure on the skin. So, changing position in the lateral 300 can be done,
with the use of anti-decubitus mattress or a hollow pillow. Patients with a wheelchair
can do repositioning every hour or rested from sitting. Training the movement by
tilting the patient to the left and to the right and preventable friction can also prevent
decubitus. Giving oil after a bath or wetting can be done to prevent maceration.
Regular blood pressure control and review the use of drugs that can causes a
decrease in blood pressure and early mobilization need to be done to prevent
hypotension.
Monitoring the intake of fluid and foods that containing fiber needs to be done
to prevent constipation. It also needs an evaluation and assessment of the patient's
bowel habits. The provision of adequate nutrition needs to be noticed to prevent
malnutrition of a immobilization patient.

Pharmacological
Pharmacological management that primarily can be given is prevention of
thrombosis occurrence. Provision of low-dose anticoagulation heparin (LDH) and low
molecular weightheparin (LMWH) is a safe and effective prophylaxis for geriatric
immobilization patients but it is a must to consider the function of the liver, kidney
and interactions with other drugs.

Prognosis
Prognosis depends on underlying disease of immobilization and its
complication. It is to be highlighted that the underlying disease will be worsened by
immobilization if not treated early, and might even cause death.
References:
1. Anderson LC, Cutter NC.Immobility. In: Hazzard WR, Blass JP, Ettinger WH,
Halter JB, Ouslander JG. Principles of geriatric medicine and gerontology. 4thed.
New York: McGraw-Hill; 1999.p.1565-75.
2. Govinda A. Setiati S. Immobilization in the Elderly. In: Alwi I, Setiati S,
Simadibrata M, eds. Textbook of Medicine. Jakarta: PIP. 2009.
3. Kane RL, Ouslander JG, Abras IB. Immobility. In: Kane RL. Editors.Essential of
clinical Geriatrics. New York: McGraw Hill; 2004.p. 245-77.
4. Setiati S. Guidelines for the management of immobilization in geriatric patients.
In: Soejono CH, Setiati S, Wiwie M, Silaswati S. Editor. Guidelines for the
management of patient health geriatrics for doctors and nurses. Jakarta: Center for
Information and Publishing Disease In - Faculty of Medicine; 2000.p. 115-22.
Preface
This book reports the proceeding of Udayana University International Symposium Hospital Based
Geriatric Service. The purpose of this symposium was to Improving knowledge about health
services based integrated geriatric hospital, especially at Udayana University Hospital. At
Udayana University Hospital are public health services, comprehensive specialist and sub-
specialist, one of which is an integrated geriatric health care. Integrated geriatric health services
at Udayana University Hospital is also supported by human resources, as well as adequate
infrastructure, qualified line with the rules of government and national or international
accreditation commission. Based on that then held a symposium and workshop activities related
to international health services based integrated geriatric hospital, health workers and medical
students at the Udayana University. End of the word, we hope this book is useful for readers.

Best Regards

Chairwoman Of Committee
R A Tuty Kuswardhani