ELDERLY and DISABILITY

Sharon Gondodiputro dr., MARS.,MH

Dept. Of Public Health Faculty of
Medicine
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Fact Sheets !!!! About

Elderly

The world population is rapidly ageing

Between 2000 and 2050, the

proportion of the world's population
over 60 years will double from about
11% to 22%. The number of people
aged 60 years and over is expected to
increase from 605 million to 2 billion
over the same period.

By 2050 the world will have almost 400

million people aged 80 years or older.
Never before have the majority of
middle-aged adults had living parents.
By 2050, 80% of older people will live
in low- and middle-income countries

The main health burdens for older

people are from noncommunicable
diseases

Already, even in the poorest countries

the biggest killers are heart disease,
stroke and chronic lung disease, while
the greatest causes of disability are
visual impairment, dementia, hearing
loss and osteoarthritis.

Many of these problems can be easily

The need for long-term care is rising

The number of older people who are no
longer able to look after themselves in
developing countries is forecast to
quadruple by 2050.
Many require long-term care, including
home-based nursing, community,
residential and hospital-based care.

Effective, community-level primary

health care for older people is crucial
Good care is important for promoting
older people's health, preventing
disease and managing chronic illnesses.

Supportive, age-friendly
environments allow older people to
live fuller lives and maximize the
contribution they make
Creating age-friendly physical and
social environments can have a big
impact on improving the active
participation and independence of
older people

Healthy ageing starts with healthy

behaviours in earlier stages of life

These include what we eat, how

physically active we are and our
levels of exposure to health risks such
as those caused by smoking, harmful
consumption of alcohol, or exposure

We need to reinvent our assumptions of

old age
Society needs to break stereotypes and
develop new models of ageing for the
21st century. Everyone benefits from
communities, workplaces and societies
that encourage active and visible

Caring for older family members

is a normal, but often a stressful
situation, may be manifest
through illness in the caregivers

Human biologic aging is

characterized by the progressive
constriction of each organ
systems homeostatic reserve
(homeostenosis)

Begins in the third decade,

progressive, but varies in speed
for each individual

Pra lansia = 49 -59 tahun

Is influenced by :
genetic factor,
diet,
environment and
personal habits

Several principles from this

concept:
Individuals become more dissimilar as they
age, rejecting any stereotype of aging

Abrupt

decline in any system/function ..>

almost certain due to disease, not to normal
(or usual) aging

Normal aging can be attenuated to some

extent by modification of risk factors.
In the absence of disease, homeostenosis
should not cause symptoms or impose
restrictions on activities of daily living.

THE AGED RELATED CHANGES AND THEIR

CONSEQUENCES
ORGAN
OR
SYSTEM

AGE RELATED
PHYSIOLOGIC
CHANGE

CONSEQUENCES OF
AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUE
NCES OF
DISEASE,
NOT AGE

General

Body fat
Total body
water

vol of fat soluble

drugs
Vol of water soluble
drugs

Obesity
Anorexia

Eyes and
ears

Presbyopia
Lens
opacification
High frequency
acuity

Respirato Lung elasticity

ry
Chest wall
stiffness

Accomodation
Blindness
Suspectibility to glare Deafness
Difficulty discriminating
words if background
noise is present
Ventilation perfusion
mismatch & O2
saturation

Dyspnea,
hypoxia

ORGAN OR
SYSTEM

AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUENCES OF
AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUENCES
OF DISEASE, NOT
AGE

Endocrine

Impaired glucose
homeostatis
Thyroxine clearance,
Renin .aldosterone,
testosterone, Vit D
absorption &
activation,estrogen
ADH

Glucose level in
response to acute
illness

D.M.

Arterial compliance and

Systolic BP (LVH)

Hypotensive response
to HR, volume
depletion or loss of a
trial contraction
Cardiac output and HR
response to stress
Impaired blood pressure
to standing, volume
depletion

Cardiovas
cular

Beta adrenegic
responsiveness,
baroreceptor sensitivity
and SA node automaticity

T4 dose required in
hypothyroidism

Throid
dysfunction
Serum Na,
Serum K
Impotence
Osteomalacia,fra
ctures
Syncope
Heart failure
Heart block

ORGAN OR
SYSTEM

AGE RELATED
PHYSIOLOGIC CHANGE

Haematolo bone marrow reserve

gic and
T cell function
immune
autoanti bodies
system

Renal

GFR

urine concentrationdilution

Genitourin Vaginal or urethral

mucosal atrophy
ary

Bladder contractility
Prostate enlargement

Musculosc Lean body mass and

muscle , bone density
letal

CONSEQUENCES OF
AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUENCES
OF DISEASE, NOT
AGE

Anemia
False negative PPD
response
False positive
rheumatoid factor,
antinuclear antibody

Auto immune
disease

Impaired excretion of
some drugs
Delayed response to salt
or fluid restriction or
overload, nocturia

Serum creatinine,
renal failure
Or serum Na

Dyspareunia, Bacteriuria
Residual urine volume
BPH

Symptomatic UTI
Urinary
incontinence,
urinary retention,
Prostate cancer

Strength
Osteopenia

Functional
impairment
Hip,vertebral
fractures

ORGAN OR
SYSTEM

AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUENCES OF
AGE RELATED
PHYSIOLOGIC CHANGE

CONSEQUENCES
OF DISEASE, NOT
AGE

Gastrointe Hepatic function,

stinal
gastric acidity ,
colonic
motility,anorectal
function

Delayed metabolism
of some drugs
Ca Absorption on
empty stomach
Constipation, Fecal
incontinence

Cirrhosis
Osteoporosis
B12 def
Fecal impaction

Nervous
system

Benign senescent
forgetfulness
Stiffer gait
Body sway
Early awakening,
insomnia

Dementia
Delirium
Depression
Parkinsons
disease
Falls
Sleep apnea

Brain atrophy
Brain carechol
synthesis , brain
dopaminergic
synthesis, righting
reflexes, stage 4
sleep.

THE FRAIL ELDERLY

THE FRAIL ELDERLY

Syndrome that results from a

multisystem reduction in reserve
capacity
Increased risk of disability and death
from minor external stresses ..>
extraordinarily thin tightrope in an
attempt to balance physiologic function

FIVE CLASSIC
GERIATRIC PROBLEMS

FALLS
DEMENTIA
DEPRESSION
URINARY CONTINENCE
IRRATIONAL DRUG THERAPY
(POLYPHARMACY)

APPROACH TO THE
PATIENT

Priorities : in elderly are likely to

differ from those of younger people
> Quality of life
Caregiver issues : requires attention
as well as the patient, since the
health and well being of the two are
closely linked.

COMPREHENSIVE
GERIATRIC ASSESSMENT
1.
2.
3.
4.
5.

Physical assessment
Mental status assessment
Functional assessment
Social assessment
Home environment assessment

Physical Assessment
History taking :
1.
2.
3.
4.
5.
6.
7.
8.
9.

Auto/Allo anamnesis
visual impairment
hearing loss
Falls
Incontinence
drug ingestion
dietary patterns
sexual dysfunction
depression and anxiety

Interviewing older patients and their family

members
1.
2.
3.
4.
5.

Be prepared to spend more time with older

patients and more slowly
Always address the patient first
Involve caregivers and family members
early in the patients care
Recognize the emotional concerns
underlying any explicit requests
Do not make significant changes in a
treatment plan based solely on the familys
report without evaluating the elderly
patient directly

Physical examination: Very private, do

not mention anything, with respect
and kindness.
General examination: vital signs
Special senses : eyes and ears
Mouth and denture
Neck
Breasts
Cardiovascular system
Abdomen and urinary tract
Gait and balance : The get up and go
Neurological system

Mental status assessment

Geriatric Depression scale
Cognitive testing : dementia (intelectual
impairment)
Conversational probing: for patients
who follow the news or reading,
television
Draw a clock test: ask the patient to
draw a clock with the hands at a set
time ex 15 min before 03:00
Folsteins Mini Mental Status
Examination (MMSE)
Elderly Cognitive Assessment
Questionnaire (ECAQ)

Geriatric Depression scale

A score > 5 points is

suggestive of
depression.
A score > 10 points is
almost always indicative
of depression.
A score > 5 points should
warrant a follow-up
comprehensive
assessment.

Elderly Cognitive Assessment Questionnaire (ECAQ)

Items

Score

Memory
1

I want you to remember this number. Can

you repeat after me (4517). I shall test you
again in 15 min.

How old are you?

When is your birthday? OR in what year

were you born?

Orientation and
information
4

What is the year?

date?

day?

month?

What is this place called? Hospital/Clinic

What is his/her job?

Can you recall the number again?

Memory Recall
10
Total

Score
(correct
answer)
>7

Normal

5-6

borderlin
e

0-4

Probable
case of
cognitive
inpairme
nt

 Assessment of Decision Making

Capacity :Capacity to make decision for
medical intervention : four components:
Ability to express a choice
Ability to understand relevant information
about the risks and benefits of planned
therapy and the alternatives including no
treatment
Ability to understand the situation and its
possible consequences
Ability to reason

Functional assessment
Information about function can be used
in a number of ways:
1. As baseline information
2. As a measure of the patientss need
for support services or placement
3. As an indicator of possible caregiver
stress
4. As a potential marker of spesific
disease activity
5. To determine the need for the
therapeutic interventions

Measurement:
Activities of daily living (Katz):

Social and economic assessment

Evaluates the patients perception of
his own health status, his
environment, his family situation,
financial status and leisure activities

Home environment assessment

The main objectives :
To understand the home environment
of the elderly and home hazards
To see the interaction between the
elderlys functional abilities and the
home environment
To see how care can be optimized
taking into considerations the home
situation
To detect any potential hazards that
may predisposed the elderly to falls

Areas of assessment

Housing : accesibility, social services,

transportation, medical services,
amenities

The house/flat: type and location, number

of rooms, lift, stairs and walkway, lighting,
hazards, entry and exit

Room: flooring, ventilation, telephone

location, furniture arrangement, lighting,
hazards, bed

Living room: Furniture arrangement,

wiring, hazards, chairs and table

Bedroom: bed, lighting,flooring,hazards

Toilet/bathroom: grips,bars, railings, toilet

type, flooring, drainage, non slip

Polypharmacy
TEN STEPS TO REDUCE POLYPHARMACY
1

Keep an accurate record of all medications the

patient is on, including over the counter
medications

Get into the habit of identifying all drugs by generic

name and drug class

Make certain that each drug being prescribed has a

clinical indication

Know the side-effect profile of the drugs being

prescribed

Understand how pharmacokinetics and

pharmacodynamics of aging increase the risk of
adverse drug events