clinical management in the elderly dr. dr. czeresna h. soejono, sppd-kger, facp division of...

Clinical Management in the Elderly

Dr. dr. Czeresna H. SOEJONO, SpPD-KGer, FACPDivision of Geriatrics

Department of Internal MedicineRSCM FMUI

Outline

• Medical case example• Surgical case example• Why do we need special approach for geriatric

patients?• What is a CGA? • How does the CGA should be applied?

Example of medical case

• Elderly woman, 78 yo– Outpatient visit, loss of appetite, epigastric pain– Frequently feeling weak, episode of fall in bathroom– History of HT, well controlled by HCT 12,5 mg– No fracture; No wound/ bruises• CM, 130/80, 80/m, 37,0°C, 20/m• Conjungtiva not pale, sclera not icteric• heart/lung wnl, H/L not palp, edema -/-

– Hb 12 ; rBG 115 ; Cholesterol (T) 155

Dx Dysepsia

• Antasida, ranitidin, multivitamin• One week complain ↓, symptoms ↓

• Remaining symptoms:– weakness, – frequent falls, instable– Outpatient consultation for 2 months no improvement– Referred to specialist still no improvement

Dx Dysepsia

• Antasida, ranitidin, multivitamin• One week complain ↓, symptoms ↓

• Remaining symptoms:– weakness– frequent falls, instable– Outpatient consultation for 2 months no improvement– Referred to specialist still no improvement

Weakness

• Vitamin deficiency• Mineral deficiency

Weakness

Deficiency

Low intake

Dehydration

Hyponatremia

Hypoglycemia

Depression

Hypoxia

Anamnesis (addition)

• Frequent urination, leakage, asshamed• Reduce drinking• Reduce food intake, to prevent blood pressure increase• Reduce salt intake, to prevent blood pressure increase• Husband, passed away a year ago– Frequently found pensive– Decrease outside house activity while previously

very active in peer group activities

Weakness

• Vitamin deficiency• Mineral deficiency

Weakness

Deficiency

Low intake

Dehydration

Hyponatremia

Hypoglycemia

Depression

Hypoxia

Frequent falls, instable• Due to old age• Due to the weakness

Frequent falls, instable• Due to old age• Due to the weakness

POSTURAL INSTABILITY

Internal Factors:Systemic diseaseOrtostatic hypotentionHypercoagulable stateIncrease platelet aggregation

Local pathologyOA knee, fasciitis, cervical SA

External Factors :Home environment

Anamnesis, PE (addition)

• Transfer process: unstable sensation• Painfull knee joints, sitting standing

• BP, sitting 110/60 (supine: 130/80)• Crepitation (+) , both knee joints

Frequent falls, instable• Due to old age• Due to the weakness

POSTURAL INSTABILITY

Internal Factors:Systemic diseaseOrtostatic hypotentionHypercoagulable stateIncrease platelet aggregation

Local pathologyOA knee, fasciitis, cervical SA

External Factors :Home environment

Current diagnosis

• Dyspepsia• Low intake• Dehydration• Hyponatremia (suspect) • Depression • Urinary incontinence• Ortostatic hypotention in hypertensive patient• OA of the knee

Current management• Antasida• Nutritional consult• Psychotherapy • Restore food patern• Oral rehydration• Nutritional supplement• Multivitamin• Urine sample; culture• HCT ACE-inh or CCB• Parasetamol (prn) ; muscle strengthening exercise

Surgical case, example

• Old lady of 82 yo– Brought to EU, fell in the bath room– Pain; right hip– She could not stand up on her own– DM ; well controlled by gliquidon– Hipertention; well controlled by lisinopril

Physical exam, Lab, Ro

• CM, vital sign: stable• Heart and lung: no significant findings• H/L not palpable; edema/ ascites were (-)• Peripheral blood: normal• rBG 134 mg/dL; ureum 25 mg/dL; creat 0,8 mg/dL• Na 138 mEq/L; K 4,0 mEq/L• OT, PT and Albumin, Globulin: normal• CXR and ECG: normal

Often overlooked......

• Patient’s functional status?• Cognitice function and psycho-affective

condition?• How does the social arrangement so far?• What about fer food and fluid intake?• Her actual kidney function?• Peri-operative condition in geriatrics?• What does the patient’s real wish actually?

Patient’s functional status?Cognitice function and psycho-affective condition?Social arrangement so far?What about fer food and fluid intake?Her actual kidney function?Peri-operative condition in geriatrics?What does the patient’s real wish actually?

Patient’s functional status?Cognitice function and psycho-affective condition?Social arrangement so far?What about fer food and fluid intake?Her actual kidney function?Peri-operative condition in geriatrics?What does the patient’s real wish actually?

Dementia; bedridden ; severely dependent

Relatives often come to visit for longer period of time; play a role as care giver

Poridge; balanced; but for the past one week: decreased food intake; very limited fluid intake

Kidney function: CCT Cockroft-Gault formula

Ask the patient/ family re AMP-operation?; is it really necessary and approved by the family?

Eventually....

• Conventional medical aspects .. +• Other aspects that should be

considered:

• Tapi masih terdapat:– Sering lemes, – Suka jatuh, jalan ‘oyong’– Berobat sampai 2 bulan kemudian masih tetap– Berobat ke spesialis sudah sebulan tak ada perubahan

Eventually....

• Conventional medical aspects .. +• Other aspects that should be

considered:

• Tapi masih terdapat:– Sering lemes, – Suka jatuh, jalan ‘oyong’– Berobat sampai 2 bulan kemudian masih tetap– Berobat ke spesialis sudah sebulan tak ada perubahan

FunctionalCognitivePsychoafectivePsichosocialNutritition

Other things should be considered

Clinical performance often non specificDecrease in reserve capacity

Presenting symptoms often:Altered consciousness; personality changesPostural instability; FallLoss of appetiteImmobility

Conclusion

• Geriatric patient, in general:– Multipathology– Decrease reserve capacity– Non specific clinical signs and symptoms– Changes in functional status– Malnutrition

Conclusion

• Geriatric patient, in general:– Multipathology– Decrease reserve capacity– Non specific clinical signs and symptoms– Changes in functional status– Malnutrition

Needs special

approach: CGA

PHYSICAL, BIOLOGICAL

PSYCHO-COGNITIVE

SOCIAL

PHYSICAL, BIOLOGICAL

PSYCHO-COGNITIVE

SOCIAL

FUNCTIONAL

ADL, IADL, MNA

NUTRITION

PHYSICAL, BIOLOGICAL

PSYCHO-COGNITIVE

SOCIAL

FUNCTIONAL

Anamnesis and PE Ax & PE SYSTEM Clinical, AMT,

MMSE, GDS

Anamnesis, home visitADL, IADL, MNA

NUTRITION

CGAI II III IV V VI

Bio/ Physical

Curative Multidisciplinary

Impairment Fluid Hospital based

Psycho/ Cognitive

Promotive Uni... X Disability Nutrition Discharge planning

Psychosoc Preventive Para...X Handicap Medication Community based

Functional Rehabilitative

Pan...X Activity

Nutrition INTERDISCIPLIN

Psychosocial care

CGAI II III IV V VI

Bio/ Physical

Curative Multidisciplinary

Impairment Fluid Hospital based

Psycho/ Cognitive

Promotive Uni... X Disability Nutrition Discharge planning

Psychosoc Preventive Para...X Handicap Medication Community based

Functional Rehabilitative

Pan...X Activity

Nutrition INTERDISCIPLIN

Psychosocial care

PHYSICAL, BIOLOGICAL

PSYCHO-COGNITIVE

SOCIAL

FUNCTIONAL

Anamnesis and PE Ax & PE SYSTEM Clinical, AMT,

MMSE, GDS

Anamnesis, home visitADL, IADL, MNA

NUTRITION

Barthel Index of ADL• Bowel control 2• Bladder control 2• Grooming 1• Bathing 1• Feeding 2• Dressing 2• Toilet Use 2• Transfers 3• Mobility 3• Stair 2• 20 : Fully independent• 12-19 : Lightly dependent• 9-11 : Moderately dependent• 5- 8 : Severely dependent• 0- 4 : Total dependent

Abbreviated Mental Test (AMT)

Age............................... Years old 1Current time/hour 1Address 1Current year 1Location right now 1Recognizing others (doctor, nurse, etc) 1National independence year 1Current president 1Patient’s or youngest child’s year of birth 1Counting down (20 to 1) 1

0-3 : Severe cognitive impairment4-7 : Moderate cognitive impairment 8-10 : Normal

MMSE

THANK YOU