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.
 Intellectual
Impairment Impairment Impairment
of Hearing of Visual

Inanition
Isolation

Instability Impaction
and Falls
Geriatric
Syndromes
Impotence Incontinence

Immuno
Iatrogenesis
deficiency

Immobilization Infection
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 Apathy, depression

capabilities Poor concentration

Reduced mobility Poor Appetite

Loss of muscle
strength
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 3
Tuberculosis 10
Urinary tract infections 1
Bacteremia / sepsis 3
Cholecystitis 2-8
Appendicitis 15-20
Septic Arthritis 2-3
Bacterial meningitis 3
Infective endocarditis 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 patient’s disease
 Contributors to Polypharmacy
Patient
– Borrowing or sharing medications
– Failing to understand instructions
– Saving medication for later use
– Combining Rx’s with OTC’s and Herbals
– Visiting more than one physician
Doctor
– Failing to review the patient’s 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)
36

• ↑ morbidity : intestinal obstruction,

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
Obat

Jatuh Inkontinensia urin Infeksi

Fraktur Kesadaran 

Hipotermia Imobilisasi
Depresi Gangguan
Ulkus tidur
Trombosis vena
Pneumonia
ISK Dehidrasi konstipasi
Atrofi otot
Asupan makanan Malnutrisi
Asupan cairan 
 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