Gangguan Kognitif pada Geriatri

BPSD dan Demensia

Dr. Danny Darmawan

Dr. Adhi Dhairyanto
Moderator: dr. Profitasari Sp.KJ
Introduction
• US Census Bureau projected that by 2050, people older than 65 years
will be more than double from 40 million to approximately 88.5
million people.
• There is a rapid growth in individuals 65 years or older between 1900
and 2060. Those in the oldest age group, 85 years and older, will
increase from 5.8 to 8.7 million individuals

World Health Organization. Diunduh dari

https://www.who.int/news-room/fact-sheets/detail/mental-health-of-older-adults. Pada tanggal
15 Januari 2021 pukul 18.11
Epidemiology

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie CS, et al. Hazard’s geriatric medicine and gerontology. 7 th Ed. McGraw Hill
Education. 2017
 • The later years of life may be characterized by various
losses that for many may not have been present in earlier
life stages.
• Some of these losses such as loss of function, physical
Cognitive and limitations, and decline in physical health and cognition.

Aging • Retirement is a common change and a potential burden

that arises later in life
• Complex grief infeluences up to 7% of geriatric patients.
• Symptom like a major depressive disorder (MDD) triggered
by a loss.

Harada CN. Natelson MC. Normal Cognitive Aging. Clin Geriatr Med. 2013 November ; 29(4): 737–52
 Domain of Cognitive Ability
• Processing speed  speed with which cognitive activities are performed
• Attention ability to concentrate and focus on specific stimuli.
• Memory, Language  complex cognitive domain composed of both crystallized
and fluid cognitive abilities.
• Visuospatial abilities  the ability to understand space in 2 and 3 dimensions
• Executive functioning/reasoning  capacities that allow a person to
successfully engage in independent, appropriate, purposive, and self-serving
behavior.

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie CS, et al. Hazard’s geriatric medicine and gerontology. 7 th Ed. McGraw Hill
Education. 2017
Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie CS, et al. Hazard’s geriatric medicine and gerontology. 7 th Ed. McGraw Hill
Education. 2017
 Cognitive function through ages

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie CS, et al. Hazard’s geriatric medicine and gerontology. 7 th Ed. McGraw Hill
Education. 2017
 • Cognitive tests are effective tools for
screening and diagnosis in ambulatory
clinic and inpatient settings when patients
Cognitive test are suspected to have cognitive
impairment or a neurocognitive disorder.

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie

CS, et al. Hazard’s geriatric medicine and gerontology. 7th Ed.
McGraw Hill Education. 2017
 Short questionnaires such as the
• Mental Test Score (MTS) or Six Item Cognitive Impairment Test (6 CIT)
The Clock Drawing Test,
• Mini-Cog
• Mini Mental State Examination (MMSE), Montreal Cognitive
Assessment (MoCA)
• St. Louis University Mental Status Examination (SLUMS)
• Addenbrooke’s Cognitive Examination (ACE), and Test Your Memory
(TYM)

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie

CS, et al. Hazard’s geriatric medicine and gerontology. 7th Ed.
McGraw Hill Education. 2017
Cognitive Fraility
• Cognitive frailty is a condition recently defined by operationalized
criteria describing coexisting physical frailty and mild cognitive
impairment (MCI), with two proposed subtypes:
• potentially reversible cognitive frailty (physical frailty/MCI)
• reversible cognitive frailty (physical frailty/pre-MCI subjective cognitive
decline).
 Cognitive impairment

• Cognitive impairment is a common condition, and in most instances,

primary care providers are the first point of contact for a patient and
family.
• In persons over age 70 years, 14% have sufficient cognitive
impairment to warrant a diagnosis of dementia

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie

CS, et al. Hazard’s geriatric medicine and gerontology. 7th Ed.
McGraw Hill Education. 2017
 Dementia according WHO
• Dementia is a syndrome in which there is deterioration in memory, thinking,
behaviour and the ability to perform everyday activities.
• Although dementia mainly affects older people, it is not a normal part of ageing.
• Worldwide, around 50 million people have dementia, and there are nearly 10
million new cases every year.
• Alzheimer's disease is the most common form of dementia and may contribute
to 60–70% of cases.
• Dementia is one of the major causes of disability and dependency among older
people worldwide.
• Dementia has a physical, psychological, social, and economic impact, not only on
people with dementia, but also on their carers, families and society at large

WHO. Available from.

https://www.who.int/news-room/fact-sheets/detail/dementia. Diunduh
Early stage
Early stage: the early stage of dementia is often overlooked, because
the onset is gradual.

• forgetfulness
• losing track of the time
• becoming lost in familiar places.

WHO. Available from.

https://www.who.int/news-room/fact-sheets/detail/dementia.
Diunduh tanggal 15 Januari 2021. pukul 18.20
 Middle stage

• Becoming forgetful of recent events and people's names

• Becoming lost at home
• Having increasing difficulty with communication
• Needing help with personal care
• Experiencing behaviour changes, including wandering and repeated
questioning.
WHO. Available from.
https://www.who.int/news-room/fact-sheets/detail/dementia.
Diunduh tanggal 15 Januari 2021. pukul 18.20
 Late stage
• Becoming unaware of the time and place
• having difficulty recognizing relatives and friends
• having an increasing need for assisted self-care
• having difficulty walking
• experiencing behaviour changes that may escalate and include
aggression.

WHO. Available from.

https://www.who.int/news-room/fact-sheets/detail/dementia.
Diunduh tanggal 15 Januari 2021. pukul 18.20
MCI atau Demensia?

Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Ritchie

CS, et al. Hazard’s geriatric medicine and gerontology. 7th Ed.
McGraw Hill Education. 2017
 Dementia is identified based on:
 • Medical history, including from family, friend, or caregiver, focusing on cognition and
function
 • Brief outpatient or bedside cognitive examination
 • If needed, neuropsychological testing
The etiology of dementia is determined based on:
 • Medical history
Clinical   ➢ Neurologic history
  ➢ General medical history
evaluation   ➢ Family history

of suspected  • Physical examination

  ➢ Neurologic signs (e.g., cognitive impairment, focal signs, parkinsonism, other)

dementia
Halter JB, Ouslander JG, Studenski S, High KP,
Asthana S, Ritchie CS, et al. Hazard’s geriatric
medicine and gerontology. 7th Ed. McGraw
Hill Education. 2017
  ➢ Pertinent systemic signs (e.g., for vascular and metabolic diseases)
 • Neuropsychological testing
 • Laboratory testing
  ➢ Thyroid function and vitamin B12 level
  ➢ Other tests as indicated, such as for metabolic, infectious, autoimmune, and other
etiologies*
 • Structural brain imaging with CT or MRI
  ➢ AD: generalized or focal cortical atrophy, often asymmetric (hippocampal atrophy)
  ➢ Vascular contributions to cognitive impairment and dementia: brain infarcts or white
matter lesions
 Management
• Non Pharmacologic Treatment
• Cognitive training and activities
• Music or art therapy
• Physical exercise
• Social actvivites

Poon NY. Ooi CH. Dementia management: a brief overview for

primary care clinicians. Singapore Med J 2018; 59(6): 295-299
Pharmacology Treatment

Donepezil
STAGE INDICATED All stages of dementia
DOSAGE TITRATION Tablet or orally
AND TARGET disintegrating
tablet: starting dose is 5 mg
once daily for 6 weeks; if
tolerated, increase to 10 mg
once daily (typical target
dose); if tolerated and
needed, may increase to 23
mg once daily (note: 23 mg
dose available as brand-
name tablet only).
ADVANTAGES Among drugs listed, this has
been available for the
longest time and, with
prescriber familiarity,
remains commonly used;
available as generic drug
and covered by most health
insurance plans.
Acetylcholinesterase inhibitors
Rivastigmine
Mild-to moderate***
Capsule: starting dose is 1.5 mg
twice daily for two weeks; if
tolerated, increase to 3 mg twice
daily for 2 weeks, then 4.5 mg
twice daily for 2 weeks, then 6 mg
twice daily. Maximum
recommended dose: 6 mg twice
daily.
Transdermal patch: starting dose
is 4.6 mg/24 hours patch once
daily for 4 weeks; if tolerated,
increase to 9.5 mg/24 hours for
≥4 weeks; if tolerated and
needed, increase to 13.3 mg/24
hours. Recommended effective
dose: 9.5 to 13.3 mg/24 hours
patch.
Also available as a skin patch
application, which is a good
option for when a patient has
barriers to using an oral route of
administration; also indicated for
mild-to-moderate dementia
associated with Parkinson disease.
Galantamine
Mild-to moderate
Extended-release capsule:
starting dose is 8 mg once
daily for 4 weeks; if
tolerated, increase to 16 mg
once daily for ≥4 weeks; if
tolerated and needed,
increase to 24 mg once
daily. Recommended target
dose range: 16 to 24 mg
once daily.
Immediate-release tablet
or oral solution: starting
dose is 4 mg twice daily for
4 weeks; if tolerated,
increase to 8 mg twice daily
for ≥4 weeks; if tolerated
and needed, increase to 12
mg twice daily.
Recommended target dose
range: 8 to 12 mg twice
daily.
The most recent option for
use in mild-to-moderate
stage.
NMDA** receptor antagonist
Memantine
Moderate-to-severe
Extended-release
capsule: starting dose is 7 mg
once daily for one week; if
tolerated, may increase to 14 mg
once daily, then 21mg once daily,
and then 28 mg once daily, at a
minimum of 1 week intervals.
Recommended target dose: 28
mg once daily.
Tablet or oral solution: starting
dose is 5 mg once daily for one
week; if tolerated, may increase
to 5 mg twice daily, then 5 mg in
am and 10 mg in pm, and then 10
mg twice daily, at a minimum of 1
week intervals. Recommended
target dose: 10 mg twice daily.
May be used in combination with
one of the acetylcholinesterase
inhibitors, or as monotherapy.
Combination drugs
Memantine and
donepezil
Moderate-to-severe
Capsule: target dose is
28 mg memantine
extended-release with
10 mg donepezil, once
daily in the evening.
For patients with
severe renal
impairment: maximum
dose is 14 mg
memantine extended-
release with 10 mg
donepezil once daily.
Singe pill combination
is best for patients
already exposed to one
or both of these
individual drugs in the
past, and who have not
experienced adverse
effects.
Poon NY. Ooi CH. Dementia management: a brief overview for primary care clinicians.
Singapore Med J 2018; 59(6): 295-299
 BPSD
• BPSD includes emotional, perceptual, and behavioral disturbances
that are similar to those seen in psychiatric disorders.
• It classify them into five domains:
• cognitive/perceptual (delusions, hallucinations),
• Motor (e.g., pacing, wandering, repetitive movements, physical aggression),
• verbal (e.g., yelling, calling out, repetitive speech, verbal aggression),
• emotional (e.g., euphoria, depression, apathy, anxiety, irritability), and
• vegetative (disturbances in sleep and appetite).

Tible Op. Riese F. Best practice in the management of

behavioural and psychological symptoms of dementia.Ther Adv
Neurol Disord 2017, Vol. 10(8) 297–309
• The clinical presentations of BPSD include apathy, depression, anxiety,
delusions, hallucinations, sexual or social disinhibition, sleep–wake
cycle disturbances, aggression, agitation and other behaviours
considered inappropriate.
• There are several instruments to systematically assess the presence
and severity of BPSD among which the Neuropsychiatric Inventory
(NPI) and Behavioral Pathology in Alzheimer’s Disease Rating Scale
(BEHAVE-AD)are recommended.

Tible Op. Riese F. Best practice in the management of

behavioural and psychological symptoms of dementia.Ther Adv
Neurol Disord 2017, Vol. 10(8) 297–309
Tible Op. Riese F. Best practice in the management of behavioural and psychological
symptoms of dementia.Ther Adv Neurol Disord 2017, Vol. 10(8) 297–309
Ilustrasi kasus
• Wanita usia 61 tahun datang dengan keluhan lemas sejak 1 minggu
SMRS. Lemas dirasakan seluruh tubuh. Pasien memiliki keeluhan yang
berulang sejak 6 bulan SMRS dan ditransfusi berulang. Sejak 1 bulan
SMRS, pasien mengaku nyeri tulang belakang dan kaki terasa
lemah.Pasien hanya di Kasur dan lemas
• Pasien kemudian berobat poli HOM hendak dilakukan BMP dikatakan
Multipel Mieloma
• Sejak 1 bulan SMRS, pasien mengaku kurang bertenaga. Makan hanay
setengah porsi. Pasien merasa tidak bertenaga. Pasien cenderung
mudah tersinggung dan menangis.
• Pasien merasa saat ini tidak memiliki harapan. Namun pasien tidak
ada keinginan untuk bunuh diri.
• Geriatric Depression Scale 15
• MMSE 15 dari 30
• MNA 19
• Barthel Index sebelum sakit 13, Saat sakit 5
• Saat pulang MMSE meningkat 23 / 30 sesuai KU pasien.
• Pasien dahulu seorang akuntan S1. namun 2 smp 3 tahun terakhir
sudah pensiun dan bekerja ibu rumah tangga. Akhir-akhir ini pasien
merasa kurang fokus dan susah menangkap pembicaraan.
Depresi pada Lansia
Depresi pada Lansia
• Salah satu gangguan psikiatrik tersering pada lansia
• Prevalesi : 10 – 20% (WHO)
• Umumnya tidak dikenali dan tidak terdiagnosis
• Insidensi lansia = insidensi dewasa
• Berhubungan dengan peningkatan risiko bunuh diri, perawatan
berulang di RS, dan juga dianggap beban keluarga

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
Mekanisme Depresi pada Lansia
Faktor risiko:
• Wanita
• Single
• Terisolasi
• Kondisi fisis
ataupun psikis
• Penyalahgunaan
zat
• Ciri kepribadian
• Obat-obatan

Alexopoulos GS et al. Mechanisms and

treatment of late-life depression. 2019
Klasifikasi Gangguan Depresi pada Lansia
Berdasarkan Simptomatologi:
• Gangguan depresi mayor
• Gangguan depresi minor (gangguan depresi lainnya, episode depresi
dengan gejala yang insufisien di DSM-5) / Subsyndromal or
subthreshold depression/ Depresi tanpa Kesedihan
• Gangguan Ansietas-Depresi Campuran
• Gangguan distimik
• Bereavement
• Gangguan penyesuaian dengan mood depresi
Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
Klasifikasi Gangguan Depresi pada Lansia
Berdasarkan Etiologi:
• Gangguan mood yang disebabkan oleh kondisi medis umum
(depressive disorder due to another medical condition)
• Depresi vaskular/depression-executitve dysfuncgion syndrome
• Depresi yang terinduksi zat atau pengobatan (substance-induced
depression, medication-induced depression)

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
 Depresi vs Demensia vs Delirium

Jha RN et al. Psychology of Depression in Elderly: A Review. 2019

Penilaian dan Evaluasi

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
Penyakit Fisis yang Sering Berkaitan dengan
Depresi
• HIV/SIDA • Hiperparatiroidisme
• Addison’s disease • Hipotiroidisme
• Alzheimer’s disease • Tumor intrakranial
• Keganasan : pankreas, paru, rongga mulut • Multiple Sclerosis
• Aterosklerosis otak, infark otak • Defisiensi nutrien : B12, asam folat, tiamin
• CAD (coronary artery disease) atau infark • Parkinson’s Disease
miokard • Porfiria
• Cushing’s syndrome • Pasca-Stroke
• Penyakit degeneratif otak • Penyakit ginjal : CKD (chronic kidney disease),
• DM (diabetes mellitus) pasien yang sedang menjalani dialisis
• Imbalans elektrolit (hipernatremia, • Rheumatoid arthritis
hiperkalsemia, hipokalemia, hiperkalemia)
Avasthi et al. Clinical Practice Guidelines for Management of
• Epilepsi (epilepsi lobus temporalis) Depression in Elderly. 2018
 Obat-obatan yang Diketahui
Menyebabkan Depresi

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
Penapisan Depresi pada Lansia
• Hamilton Rating Scale for Depression (Ham-D)  oleh pemeriksa
• Geriatric Depression Scale (GDS)  oleh pemeriksa
• Montgomery-Åsberg Depression Rating Scale (MADRS)  oleh
pemeriksa
• Zung Self-rating Depression Scale (SDS)  oleh pasien
• Beck Depression Inventory (BDI)  oleh pasien
 GDS (Geriatric
Depression Scale)

Njoto EN. Cermin Dunia Kedokteran-217 Volume 41 no. 6. 2014

 Kriteria Depresi berdasarkan DSM-IV & DSM-V

The Diagnostif and Statistical Manual of Mental Disorders 5th ed. (DSM-
V). 2016
 Kriteria Depresi
Berdasarkan ICD-10

The International Classification of Diseases and Related Health Problems

10th ed. (ICD-10). 2016
 Kriteria Diagnostik
Provisional untuk Depresi
pada Alzheimer’s Disease
berdasarkan NIMH
(National Institute of Mental
Health)

Teng E, et al. Diagnosing depression in Alzheimer disease with the

national institute of mental health provisional criteria. Am J Geriatr
Psychiatry. 2008 Jun;16(6):469-77
Indikasi Rawat Inap pada Lansia dengan
Depresi

Avasthi et al. Clinical Practice

Guidelines for Management of
Depression in Elderly. 2018
 Algoritme untuk Memulai
Menatalaksana Depresi

Avasthi et al. Clinical Practice Guidelines for Management of Depression in

Elderly. 2018
 Algoritme Penatalaksanaan
Depresi Ringan hingga Sedang
pada Lansia

Avasthi et al. Clinical Practice Guidelines for Management of Depression in

Elderly. 2018
 Algoritme
Penatalaksanaan Depresi
Berat pada Lansia

Avasthi et al. Clinical Practice Guidelines for Management of Depression in

Elderly. 2018
Pilihan Antidepresan

Avasthi et al.
Clinical Practice
Guidelines for
Management of
Depression in
Elderly. 2018
 Kombinasi Obat yang Memerlukan
Pemantauan atau Kontraindikasi pada Lansia
Avasthi et al. Clinical Practice
Guidelines for Management of
Depression in Elderly. 2018
 Intervensi Psikoterapeutik pada Lansia
dengan Depresi

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
 Algoritme
Penatalaksanaan Depresi
pada Lansia dengan
Depresi yang Tidak
Respon terhadap
Antidepresan Lini Pertama

Avasthi et al. Clinical Practice Guidelines for Management of Depression in

Elderly. 2018
Algoritme Penatalaksaan
Terapi Fase Lanjutan
pada Lansia dengan
Depresi

Avasthi et al. Clinical Practice Guidelines for Management of

Depression in Elderly. 2018
 Algoritme Penatalaksaan Terapi Fase
Lanjutan pada Lansia dengan Depresi (Fase
Rumatan)

Avasthi et al. Clinical Practice Guidelines for Management of Depression in Elderly. 2018
Ilustrasi kasus
• Pria usia 63 tahun datang dengan keluhan sesak memberat sejak 1 hari SMRS. Sesak
sebetulnya sudah dirasakan sejak 1 bulan SMRS. Sempat dirawat di HCU Kiara karena
terkonfirmasi COVID-19. Pasien dirawat selama 2 minggu dan kemudian pulang. 1 hari
SMRS, pasien mengeluhkan sesak napas lagi, kemudian ke IGD RSCM dan saat ini
dirawat
• Sebelum pasien sakit 1 bulan SMRS, pasien masih aktif bekerja di proyek sebagai
karyawan swasta. Pasien bekerja sejak tahun 1980. Sejak 1 bulan SMRS, pasien hanya
di tempat tidur karena masih ada keluhan sesak napas dan lemas
• Pasien hobi bermain bola voli. Namun sejakTahun 1996, pasien mengalami kecelakaan
mobil sehingga paha di panggul kanan pasien lepas. Pasien lalu ke tukang urut dan
dilakukan pengobatan. Pasien dilarang bermain voli lagi sehingga pasien sejak itu
hanya berjalan kaki 1 – 1,5 jam tiap hari (kadang tidak dilakukan). Pasien juga sebelum
sakit aktif di kegiatan Karang Taruna
• Pasien merasa saat ini merasa cukup bersemangant dan tidak pernah ada
keinginan untuk bunuh diri.
• Geriatric Depression Scale 2 (tidak depresi)  pasien mengatakan telah
meninggalkan banyak kegiatan dan minta atau kesenangan, serta sering
merasa tidak berdaya
• MMSE 27 dari 30 (mild cognitive impairment)  kekurangan di atensi dan
kalkulasi dan mengenal kembali
• MNA 10,5 (malnustrisi)
• Barthel Index sebelum sakit 20, Saat sakit 6 (hanya bisa mengendalikan
rangsang pembuangan tinja, mengendalikan rangsang berkemih secara
mandiri, dan untuk membersihkan diri serta makan perlu dibantu)
TERIMA KASIH