Curriculum Vitae

Lazuardhi Dwipa, dr.,SpPD.,KGer

Bandung, 13 Maret 1979
Edelweis Raya no 33, Surapati Core, Bandung
Pendidikan
– Pendidikan Dokter Umum, FK UNPAD (2004)
– Spesialis Penyakit Dalam, FK Unpad RSUP HASAN SADIKIN (2010)
– Pendidikan Konsultan Geriatri, FKUI RSUPN CIPTO MANGUNKUSUMO (2011-2016)
Institusi/Tempat Bekerja
- Staf Divisi Geriatri (Khusus Lansia) Departemen Ilmu Penyakit Dalam RS Umum Pusat Hasan
Sadikin Bandung-Fakultas Kedokteran Universitas Padjadjaran Bandung
Organisasi
– PERGEMI (Pengurus Pusat-Bag Hub Kerjasama)
– PAPDI (anggota)
Penelitian
– Cardiometabolic risk factors and acute kidney injury based on urinary neutrophil gelatinase
associated lipocalin (NGALu) in acute coronary syndrome patients. Acta Med Indonesia. 2012
Jan;44(1):3-9.
– Profile of Food and Nutrient Intake Among Indonesian Elderly Population and Factors Associated
with Energy Intake : a Multi-centre Study Acta Med Indonesia, 2013 Oct; 265-274
– The Effect of AFA toward the clinical improvement of Knee Osteoarthritis of Older Adult patients
based on WOMAC Index : A Randomized Controlled Trial (2016)
PEMBICARA/NARASUMBER ACARA PURNABAKTI
- Telkom (tetap)
- Pelindo
- dll
Pelatihan dan Simposium
– IAGG Master Class of Ageing – Kyoto Japan (2013)
– IAGG, Korea (2013)
– IAGG Chiang May Thailand (2016)
Comprehensive
and Integrative
Approach in Deteksi Sindroma Geriatri
Older (Geriatric) Frailty Syndrome & Sarcopenia di
Patients FKTP

dr. Lazuardhi Dwipa, SpPD-KGer

Geriatric/
Silver Tsunami
 4

Geriatric
Patients are
Unique!

“An older persons are NOT only

adult with wrinkles”
 What is Geriatric patients ?
5

• Older Adults/Older patients

used to be known as “Elderly patients”

≥ 60 y.o (WHO & UU

RI no.13 thn 1998)

• Geriatric Patients :
– Older patients with complex
health problems
 Characteristics of Geriatric Patients
6

Multiple Co-morbidities (≥ 2
diseases) Decreased physiological
reserve
Impaired Functional Status
(Geriatric Syndrome) Polypharmacy (≥ 5 medications)
Frailty syndrome, Sarcopenia,
Immobilization, Instability/High Risk of
Falls, Inaniation/Malnutrition, Infection,
Impaction, Incontinence, Atypical symptoms and
Immunocompromised, etc.) laboratoric/imaging values

Mental and Social/family

support problems.
 7

The Goal in
Treating Older Good Quality of Life (QoL)
Adult Patients/
Geriatric Patients Healthy (physical,
mental, social, Independent
spiritual)
Active & Productive
(Useful &
Resourceful)

Good role model in the society

 8

How to achieve
that goal ?
&
What is the best
approach ?
 Sejarah pelayanan Geriatri 9

• Pencanangan hari lansia oleh Presiden Soeharto (29

Mei 1996)
• Pendidikan Sub-Spesialis Geriatri Ilmu Penyakit Dalam
di Padang oleh Prof. Budi Darmojo (FKUI, FK UNDIP,
FK Unpad, dll)
• UU no.13 1998 Kesejahteraan Lansia
• Yogyakarta Declaration : Aging & Health 2012
• Permenkes no.79 thn 2014 : Pelayanan Geriatri di RS
• Rencana Aksi Nasional 1 Juni 2016
• Sasaran Nasional Akreditasi Rumah Sakit (SNARS)
(KARS) tahun 2018
10
Rencana Aksi Nasional (RAN) Kesehatan
Lanjut Usia RI 2016
11
 Visi dan Misi
12

RAN-Kesehatan Lansia 2016-19

Visi Misi
lansia sehat
dan • Mewujudkan upaya pelayanan kesehatan santun
produktif lanjut usia dengan pendekatan siklus hidup,
tahun 2019 holistik, komprehensif dan terpadu, mulai dari
keluarga, masyarakat, fasilitas kesehatan tingkat
pertama dan fasilitas kesehatan rujukan tingkat
lanjutan.
• Meningkatkan pemberdayaan lanjut usia,
keluarga, dan masyarakat untuk mewujudkan
lanjut usia yang sehat, mandiri, aktif dan
produktif selama mungkin
 What is the best approach in Geriatric patients ?
13

Not only free of diseases but

also good Quality of Life 1
Assessment of
(QoL) 2 functional status is
mandatory

3
Concept of Comprehensive Geriatric
Assessment & Getriatric Continuum of
Care
Medical Approaches for Comprehensive Geriatric
Assessment/Care
14

Pan-discipline
• Lack of
collaborations
• Not
appropriate in
Indonesia
setting Multi-discipline
• Conventional (Consultation)
• Lack of integration in the real life settings.
• Each discipline has Different goal/targets  unaware of the importance of
the assessment and goals of functional status
• Lack of communications between doctors
• Increases the risk of polypharmacies, high cost, and failure of treatments
• Lack of integrative/comprehensive approach in out-patient care setting
 Inter- 15

discipline
(Comprehensive
and integrative
approach)

Not just “sitting together”

Each discipline working as each
discipline but working and
communicating in the “same language”
in Harmony
Same frame of minds, vision, same
understanding, same goal
 Interdiscipline approach
(Hospital Setting-In & Out patients)
16
Permenkes no.72 thn 2014
Internal Medicine
(Geriatrician)

Pharmacyst/Phar Consultative (Neurologist,

macolog Psychogeriatric, Dental
etc.)

Patient

Rehabilitative Gerontic nurse

medicine

Dietician
 5 Dimensions of Elderly Quality of Life (EQ-5D)
17

Mobilization/
Ambulation/
Pain Self Care
Transfering (Independency)

Mental
Health QoL Daily
(Depression/
Activity
Anxiety)
 Geriatric Continuum of Care
18

Community based
• Primary Health Care (Family
Doctors)  screening
• Nursing Home
• Long Term Care (LTC)

Post Acute Care/ Geriatric

2nd Level Hospital
Intermediate Care Syndromes

3rd Level Hospital

(Geritaric Facility)
 The Role of Family Physician
19

Family/Primarey Care
RECOGNIZE & IDENTIFY
Physician as Partner of 1
Geriatric Patient
Geriatric Team 2
• Based on Geriatric Syndromes
• Activate Posbindu lansia in
Puskesmas

3
4
REFER to higher
facility if Treat if the patient 5
available  is not geriatric HOME CARE
Comprehensive patient With close
& Integrative collaboration
Geriatric Patient with
Geriatrician
Approach
 Geriatric Syndromes
20

(Bandung Geriatric Index)

Simple & easy to use tools to screen & identify for
any health workers

Frailty syndrome & Sarcopenia 1

2 Instability/High risk of falls

Malnutrition 3

Dietary problems (mastication,

4
dysfagia, xerostomia)
Cognitif Impairment (Dementia) 5
 21

BANDUNG
GERIATRIC
INDEX
 Frailty Syndrome
22

What is frailty?

Frailty is a state of increased vulnerability to adverse

outcomes.

Frailty is an aggregate of subthreshold decrements that

affect multiple physiological systems, causing vulnerability.

A multidimensional concept that considers the complex interplay

of physical, psychological, social and environmental factors.
 Aging process
Frailty 23

Lifestyles • Age-related
• Accumulation of ↓ physiologic
reserved capacity
Diseases
• Susceptible to worsening
clinical outcome
Genetics
• mobility GERIATRIC SYNDROME
• functional status (disability)
IMPACT • hospitalization &
institutionalization
• mortality
• ↓ health-related QoL
Fried LP, et al. J Gerontol Med Sci.2001;56(3):M146-56.
Rockwood K, et al. Drugs Aging.2000;17:295-302.
Strandberg TE, et al. European Geriatric
Medicine.2011;2:344-55.
Song X, et al. J Am Geriatr Soc.2010;58:681-7
 deficits/ co-
morbidities/ disabilities 24
accumulation
•Fit/ Robust
Frailty • Pre-frail
• Frail
clinical syndrome
(phenotype)

Physical Psychological Social

• nutritional status
• physical activity • cognitive • contact/ interaction
• mobility • social support
• mood
• muscle strength
• energy
Fried LP, et al. J Gerontol Med Sci.2001;56(3):M146-56.
Rockwood K, et al. Drugs Aging.2000;17:295-302.
Strandberg TE, et al. European Geriatric Medicine.2011;2:344-55.
Song X, et al. J Am Geriatr Soc.2010;58:681-7.
 TOOLS TO DETECT
• Frailty Index 40 item (FI-40
25
item)
Deficits • Frailty Index-Comprehensive
accumulation Geriatric Assessment (FI-CGA)
• Clinical Frailty Scale (CFS)
• Groningen Frailty Indicator (GFI)
Frailty
FRAIL QUESTIONAIRRE

Phenotype • Cardiovascular Health Study

(CHS)
• The Study of Osteoporotic
Fracture (SOF)
Fried LP, et al. J Gerontol Med Sci.2001;56(3):M146-56.
• Survey of Health, Ageing, and
Song X, et al. J Am Geriatr Soc.2010;58:681-7. Retirement in Europe (SHARE)
Ensrud KE, et al. Arch Intern Med.2008;168(4):382-9. • Fatigue, Resistance,
Ensrud KE, et al. J Am Geriatr Soc.2009;57(3):492-8.
Romero-Ortuno R, et al. BMC Geriatrics.2010;10:57-68. Ambulation, Illness, Loss of
Morley JE, et al. The Journal of Nutrition, Health & Aging.2012;16(7):601-8. Weight (FRAIL)
Jones DM, et al. J Am Geriatr Soc.2004;52:1929-33.
Jones D, et al. Aging Clin Exp Res.2005;17:465-71.
Rockwood K, et al. CMAJ.2005;173(5):489-95.
Bielderman A, et al. BMC Geriatrics.2013;13:86-94.
Peters LL, et al. JAMDA.2012;13:546-51.
Operationalizing 26

phenotype of
physical frailty

Compared to
those with no
frailty criteria,
pre-frailty status
has OR 2.63 (CI
1.94;3.56) of
becoming frail

Fried LP, et al.. J Gerontol Med Sci.

2001;56(3):M146-56.
 27

Intepretasi :
• Not Frail = 0
• PRE FRAIL = 1-2
• FRAIL ≥ 3

Sensitivitas 58,62% dan

Spesifisitas 83,8%.
nilai akurasi nilai akurasi
76,24 %. Likelihood ratio
+3,52 dan LR -0,49.
Receiver Operating
Characteristic (ROC) 70,98
% (CI 95% 60,88 ; 81,08)
Priyo et.al 2016
 Kuesioner RAPUH
28
• R= Resistensi,
– Dengan diri sendiri atau tanpa bantuan alat, apakah anda mengalami kesulitan untuk
naik 10 anak tangga dan tanpa istirahat diantaranya ? Skor 1 = Ya, 0 = Tidak
• A= Aktifitas (Fatigue/Depresi),
– Seberapa sering dalam 4 minggu ada merasa kelelahan ? 1: Sepanjang waktu, 2:
Sebagian besar waktu 3: Kadang – kadang, 4: Jarang. Bila jawab 1 atau 2 skor =1
dan selain itu skor = 0
• P= penyakit lebih dari 4.
– Partisipan ditanya, apakah dokter pernah mengatakan kepada anda tentang penyakit
anda (11 penyakit utama: Hipertensi, diabets, kanker (selain kanker kulit kecil),
penyakit paru kronis, serangan jantung, gagal jantung kongestif, nyeri dada, asma
nyeri sendiri, stroke dan penyakit ginjal )?
– Bila jawaban jumlah total penyakit skor yang tercatat 0-4 penyakit = 0 dan 5-11
penyakit =1
• U= Usaha berjalan :
– Dengan diri sendiri dan tanpa bantuan, apakah anda mengalami kesulitan berjalan
kira – kira sejauh 100 sampai 200 meter ? Skor Ya = 1, dan Tidak =0
• H = Hilangnya berat badan : Berapa berat badan saudara dengan
mengenakan baju tanpa alas kaki saat ini ? Satu tahun yang lalu,
berapa berat badan anda dengan mengenakan baju tanpa alas kaki ?
– Keterangan perhitungan berat badan dalam persen : [(berat badan 1 tahun yang lalu
– berat badan sekarang)/Berat badan satu tahun lalu)]x 100%. Bila hasil >5%
(mewakili kehilangan berat badan 5%) diberi skor 1 dan <5 % skor = 0
 29

2010
European
definition of
SARCOPENIA Syndrome characterised by progressive
and generalised
LOSS of SKELETAL MUSCLE
MASS and STRENGTH or FUNCTION with a
risk of adverse outcomes, such as physical
disability,
poor quality of life, and death

A CRUZ JENTOFT et al Age Ageing. 2010:3 9.412-23

 30

Aging and skeletal muscle

• 40% loss in muscle mass from 20-70 years of age.*

• 6% decline in muscle mass per decade from age 30-
70.**
• 1.4 –2.5% decline in muscle mass per year after age
of 60.***

*Rogers & Evans. Exerc Sport Sci Rev 1 993;21:65-102

** Fleg& Lakatta. J Appl Physiol 1988;65:47-51
*** Frontera,et al. J Appl Physiol 2000;88:1321-6
Etiology of Sarcopenia
31
Sarcopenia
32
 Different kinds of weight loss
33

Malab Hyper
Cachexia Anorexia Sarcopenia
sorption metabolism
Weight loss ↘↘ ↘± ↘± →↘ ↘±
Lean tissue ↘ ↘ ↘ ↘ ↘
Fat tissue ↘ ↘ ↘ ↗ ↘

Appetite ↘ ↘ ↗ = ↗

Anemia yes ± ± No NO
Proteolysis Yes No NO Yes Yes
CRP ↗↗ = = →↗ =
Vitamin A = = = = =
Albumin ↘ ↘± ↘± = =

MORLEY JE et al Nutririon 2008;24:815-9

Relationship between Frailty & Sarcopenia
34
 Sindroma geriatri
- Immobilisasi 35
Penyakit - Ulkus dekubitus
- Instabilitas
Kronis
- Gangguan
keseimbangan
- jatuh
- Dementia
- Delirium
Faktor risiko - Depresi
Frailty
- Inkontinensia
- Impoten
- Immunodefisiensi
- Infeksi
Komorbid - Inaniasi Disabilitas
Multipel - Impaksi
- Istrogenik  Kualitas
- Insomia
hidup
- Gg pendengan/
penglihatan
Mortalitas
 How to detect Sarcopenia ?
36
Low skeletal muscle mass, low
strength, poor physical performance)

Low skeletal muscle (CT Scan, DXA, BIA)

Bioelectrical Impendance Analysis (BIA)
37
38
39
 40

Low Muscle Strength Poor Physical

• Handgrip Strength test
Performance
- 6 minute walking test
41
42
43
Kuesioner Bahasa Indonesia 44
Intepretasi
S = STRENGTH ; Kekuatan: Seberapa sulit Anda dalam mengangkat dan membawa beban
Sarkopenia
seberat 5kg?
Skor ≥ 3
0 = Tidak ada kesulitan
1 = Cukup sulit
2 = Sangat sulit atau tidak mampu
Valid : r korelasi >
A = ASSISTANCE; Bantuan untuk berjalan: Seberapa sulit Anda berjalan melintasi ruangan? 0,361
0 = Tidak ada kesulitan Croncbach Alpha
1 = Cukup sulit 0,851 &
2 = Sangat sulit, perlu bantuan atau tidak mampu Kappa>0,81
R = RISE ;Bangkit dari kursi: Seberapa sulit Anda bangkit dan berpindah dari kursi/tempat tidur? AUC 87,5
Sensitifitas 80% &
0 = Tidak ada kesulitan
Spesifitas 83,05%
1 = Cukup sulit Mira et al (2017)
2 = Sangat sulit atau tidak mampu jika tanpa bantuan
C = CLIMB; Menaiki tangga: Seberapa sulit Anda menaiki sepuluh anak tangga?
0 = Tidak ada kesulitan
1 = Cukup sulit
2 = Sangat sulit atau tidak mampu
F = FALL ; Jatuh: Berapa kali Anda jatuh dalam satu tahun terakhir?
0 = Tidak pernah
1 = 1-3 kali
2 = 4 atau lebih Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines
for the process of cross-cultural adaptation of self-report
measures. Spine. 2000;25(24):3186-91.
 SARC-F ( Morley, JE.)
45

• S = Strength
• How much difficulty do you have in lifting and carriying 10 pounds?
– 0 = None
– 1 = Some
– = A lot or unable
• A = Assistance in walking
• How much difficulty do you have walking across a room? Intepretation
– 0 = None
– 1= Some
Score ≥ 4 :
– 2 = A lot, use aid or unable Sarcopenia
• R= Rise from a chair
• How much difficulty do you have transferring from a chair or bed?
– 0 = None
– 1 = Some
• = A lot or unable without help
• C = Climb stairs
• How much difficulty do you have climbing a flight of ten stairs?
– 0 = None
– 1 = Some
– 2 = A lot or unable
• F = Falls
• How many times have you fallen in the past year?
– 0 = None
– 1 = 1-3 falls
– 2 = 4 or more falls
 Gangguan Fungsi 46

• Pendengaran (Auto / Alloanamnesis)

– Apakah ada gangguan pendengaran pada pasien
– Whisper test

• Gangguan penglihatan (visus)

– Apakah ada gangguan penglihatan ?
– Katarak senilis, Myopia/Presbiop, Retinopati (DM/HT) dll.
 POSBINDU

Pemeriksaan Study of Osteoporotic Frailty

(SOF) Score

Pre-frail / 47
Fit
Frail
Kontrol di
Posbindu

PUSKESMAS/PPK-1

Pemeriksaan FRAIL Scale

Fit Pre-frail /
Frail
Kontrol di Draft PNPK
Puskesmas
Rancangan Alur Tatalaksana dan
PPK-2
Rujukan Frailty Syndrome di
Pemeriksaan FRAIL Scale, Comprehensive
Fasilitas Kesehatan
Geriatric Assessment (CGA), dan Gait Speed

Fit dan Pre-

frail Frail atau Gait Speed dibawah
0,8 m/detik sesuai batas Asian
Working Group on Sarcopenia
Kontrol di PPK-2 (AWGS)

PPK-2 dengan dokter spesialis penyakit dalam konsultan geriatri atau

PPK – 3

Pemeriksaan Frailty Index 40 Item (FI40), Cardiovascular Health Study

(CHS) Scale, dan Comprehensive Geriatric Assessment (CGA)
 POSBINDU
DETEKSI DINI DENGAN KUESIONER SARC-F
48
Fit Sarkopenia

Kontrol di Posbindu

FKTP
Pemeriksaan SARC-F

Fit
Sarkopenia
Kontrol di Puskesmas

PPK-2/FKTRL
Pemeriksaan SARC-F, Comprehensive Geriatric Assessment (CGA), pemeriksaan massa otot
apendikular dengan DXA/BIA, Uji Kekuatan Genggam Tangan, Uji kecepatanjalan 6 menit

Fit danPre-sarkopenia
Sarkopenia sesuai kriteria Asian Working
Group on Sarcopenia (AWGS)
Kontrol di PPK-2 *

PPK – 3/FKTRL dengan dokter spesialis IlmuPenyakit Dalam/ konsultanGeriatri

Pemeriksaan SARC-F,Kriteria AGWS, dan Comprehensive Geriatric Assessment (CGA)
Keterangan : *Bilat erdapat fasilitas pelayanan khusus Geriatri dan pemeriksaan penunjang
yang diperlukan
 Management of
Frailty & Sarcopenia 49

Adequate Protein
Intake &
Nutritional Resistance
Supplementation Exercise &
• Protein 1-2 gr/day Prevention of
(Whey Protein, HMB) Falls Programs
• Creatine Monohydrate

INTERDISCIPLINARY APPROACH
Vitamin D
supplementation
Treat underlying
• D3 (Cholecalciferol) comorbidities with
• Analog/Vit D-active
(Calsitriol, alpha- cautious and
calcidol manage
Polypharmacy
 BMI in Older Patients
50

Never calculate BMI

in older patients
using actual height !
 spine problems
resulting shorter Instead measure Knee Height
height false
measurement
Formula to estimate Height from Knee Height (cm)
51

Male
TB= (1,924xTL) + 69,38

Female
TB= (2,225xTL) + 50,25
 Instability (Risk of Falls)
52

• Apakah ada Riwayat Jatuh dalam 1 tahun terakhir ?

• Apakah anda merasa tidak stabil ketika berdiri/ berjalan?
• Apakah anda takut jatuh?
• Apakah anda memerlukan bantuan saat berubah posisi dan/atau
pindah tempat?

• Jika salah satu atau dijawab ‘ya’  meningkatnya risiko jatuh

 (Mastication,
Dysphagia, Xerostomy) Inanation
53

Apakah saudara merasa kesulitan

jika menelan makanan atau
minuman ?

Apakah saudara selalu merasakan mulut

kering ?

Apakah saudara mengalami kesulitan dalam

mengunyah ?
 Cognitive Impairment (Dementia)
54

Apakah keluarga
anda • Lupa nama, bulan atau
mengalami: Ya tahun ?
nilai • Kesulitan mengatur
1, Tidak/tidak keuangan seperti
membayar rekening
tahu: nilai 0
air/listrik atau mengambil
uang pensiun di bank?
• Mengingat janji terhadap
orang lain?
Jika skor ≥ 1
 Terdapat
gangguan
kognitif
 Conclusion
55

Geriatric Syndrome

• Emphasizing in the functional status to maintain good quality of

life (QoL) in the older adult population
• Treatable and Reversible by Interdiscipline approach
• The role of Primary Care/Family Physician Doctors is to detect
and identify Geriatric Syndromes and Refer to Geriatric Facilty
(3rd healthcare facilty) using Bandung Geriatric Index
 56

Terima kasih