The Role of Primary

Doctors in Early
Detection of
Geriatric Syndrome
& the management Pendidikan Kedokteran
Berkelanjutan Dokter Layanan
of Hypertension in
Primer -JAMBORE
the Older Patients
in the Primary Care

dr. Lazuardhi Dwipa, SpPD-KGer

Geriatric/
Silver Tsunami
 3

Geriatric
Patients are
Unique!

An older persons are NOT only

adult with wrinkles
 What is Geriatric patients ?
4

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
5

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.
 6

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

 7

How to achieve
that goal ?
&
What is the best
approach ?
8
Rencana Aksi Nasional (RAN) Kesehatan
Lanjut Usia RI 2016
9
 Visi dan Misi
10

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 ?
11

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
12

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- 13

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)
14
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)
15

Mobilization/
Ambulation/
Pain Self Care
Transfering (Independency)

Mental
Health QoL Daily
(Depression/
Activity
Anxiety)
 Geriatric Continuum of Care
16

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 Primary Care Doctors
17

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
18

(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
 19

BANDUNG
GERIATRIC
INDEX
 Frailty Syndrome
20

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 21

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
 22

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
23
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
 24

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

Etiology of Sarcopenia
25
Sarcopenia
26
 Different kinds of weight loss
27

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
28
 Sindroma geriatri
- Immobilisasi 29
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 ?
30
Low skeletal muscle mass, low
strength, poor physical performance)

Low skeletal muscle (CT Scan, DXA, BIA)

Bioelectrical Impendance Analysis (BIA)
31
 32

Low Muscle Strength Poor Physical

Handgrip Strength test
Performance
- 6 minute walking test
 SARC-F ( Morley, JE.)
33

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
SARC-F
S = Strength (Kekuatan)
Seberapa sulit penderita mengangkat serta membawa benda seberat 5 kg? 34
0 = tidak ada kesulitan
1 = sedikit sulit
2 = sangat kesulitan atau tidak bisa
A = Assistance walking (membutuhkan bantuan untuk berjalan)
Seberapa sulit penderita berjalan melintasi ruangan dan apakah membutuhkan bantuan?
0 = tidak sulit
1 = sedikit sulit
2 = sangat sulit, membutuhkan bantuan atau tidak bisa tanpa bantuan
R= Rise from a chair (bangkit dari kursi)
Seberapa sulit penderita berpindah dari kursi atau tempat tidur dan apakah
membutuhkan bantuan?
0 = tidak sulit
1 = sedikit sulit
2 = sangat sulit, membutuhkan bantuan atau tidak bisa tanpa bantuan
C = Climb stairs (menaiki tangga)
Seberapa sulit penderita menaiki 10 anak tangga?
0 = tidak ada kesulitan
1 = sedikit sulit
2 = sangat kesulitan atau tidak bisa
F = Falls (jatuh)
Apakah terdapat riwayat jatuh dalam setahun terakhir ?
2 = untuk responden yang dilaporkan terjatuh 4 kali atau lebih dalam setahun terakhir
1 = untuk respoanden yang dilaporkan terjatuh 1-3 kali dalam setahun terakhir
0 = untuk responden yang dilaporkan tidak terjatuh dalam setahun terakhir.
Apabila Skor 4 maka dapat dikategorikan sebagai Sarkopenia.
 35

IS FRAILTY & SARCOPENIA TREATABLE?

Fried: Yes
Improve physical
Rockwood: Yes
Ameliorate deficits
function
Treat disease
Improve nutrition
Improve physiological
reserve
 TERAPI FRAILTY
36
TERBARU
Intervention that
may have efficacy Multi-
dimensional Exercise
Pharmaceutical 40%
Exercise 25%
Aerobic program
Muscle strength training
Nutrition intervention
Protein & amino acid Exercise +
Nutrition
Reduction of polypharmacy 13%
Vitamin D? Nutrition
22%
ACE inihibitor?

Unsuccessful Intervention
Pharmaceuticals: synbiotic
 FRAILTY CONSENSUS :
37
A CALL TO ACTION, 2013
Latihan fisik
aerobik dan
Asupan kalori dan
resistensi otot
protein
Meningkatkan
45 60 menit 3 massa otot dan
kali seminggu grip strength
Tatalaksana Frailty
Meningkatkan kriteria Beers
fungsi otot, dan STOPP
menurunkan and START
mortalitas
Vitamin D
Mengurangi
Polifarmasi
 38

HYPERTENSION APPROACH
IN OLDER ADULT PATIENTS
PERUBAHAN MENDASAR YANG TERJADI PADA
GUIDELINES HIPERTENSI BARU 39

JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

 USIA LANJUT
All drugs are recommended and can be used (I, A) 40

Diuretics & CCB: preferred in isolated systolic HT (I,

A).
Start drug when SBP 160 mmHg: -> aim SBP 140-
150 mmHg (I, A)
POPULASI UMUR < 80 THN: INISIASI TX FARMAKOLOGIS
DIMULAI BILA TDS 140 mmHg dan GOAL TERAPI < 140 BILA
DITOLERANSI (IIb, C)
POPULASI UMUR > 80 THN: GOAL TERAPI TDS: 140-150 mmHg
BILA KONDISI FISIK DAN MENTAL BAIK (I, B).
APABILA TD MENCAPAI <140 mmHg: TERAPI BOLEH
DILANJUTKAN BILA DITOLERANSI DG BAIK (IIa, C)
PASIEN USIA LANJUT YG RAPUH (FRAIL) DISERAHKAN
KEPADA KEPUTUSAN AHLI (TIM TERPADU GERIATRI) DAN
KONDISI KLINIS (I, C)
 REKOMENDASI 1 (BESERTA TAMBAHAN)
41

POPULASI > 60 thn

INISIASI Tx FARMAKOLOGIS : TDS> 150 mmHg
atau TDD > 90 mmHg
GOAL TERAPI : TDS< 150 mmHg
atau TDD< 90 mmHg
(Rekomendasi kuat-Grade A)
Apabila tek.drh. mencapai lebih rendah dari goal terapi
(mis: <140 mmHg) dan masih dapat ditoleransi tanpa
efek samping terhadap kesehatan maupun kualitas
hidup, maka regimen terapi tetap diteruskan tanpa
penyesuaian dosis.
(Opini Ahli-Grade E)
42
43
Possible combinations of classes of antihypertensive
drugs.
44
Thiazide + BB: increased
new-onset DM

Only DHP-CCB should

normally be combined
with beta-blockers

Green continuous lines: preferred combinations;

Green dashed line: useful combination (with some limitations);
Black dashed lines: possible but less well-tested combinations;
Red continuous line: not recommended combination.
 ARBs and DHP-CCBs are Recommended for
Complementary Indications (ESC/ESH Guidelines)
45

ARBs DHP-CCBs

Essential hypertension Isolated systolic hypertension

Heart failure CAD
Post-MI Angina pectoris
Diabetic nephropathy Hypertension in Blacks
Proteinuria/microalbuminuria (Pregnancy)
Atrial fibrillation LVH
Metabolic syndrome
ACE-I-induced cough
LVH

Mancia et al. Eur Heart J 2007;28:14621536.

45
 Treating Hypertension in Frail
Elderly 46

Lack of evidence (1 new evidence by

Sprint Trial)
Frail increases drugs adverse effects
Always measure BP in seated position,
right after standing and after 2 mins.
(Orthostatic hypotension)
Always use BP seated position in taking
decisions
LESS IS MORE
47
Results of antihipertensive
therapy in elderly patients 48
49
SPRINT TRIAL 50
51
52
 53

SAE : an event that was fatal or life threatening, resulting in significant or persistent disability, requiring or prolonging
a hospitalization, Conditions of interest : hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls,
or acute kidney injury or acute renal failure
 54

SAE : an event that was fatal or life threatening, resulting in significant or persistent disability, requiring or prolonging
a hospitalization, Conditions of interest : hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls,
or acute kidney injury or acute renal failure
 Conclusion
55

Geriatric Syndrome
Geriatric patients have distinct features & characteristics
The best approach to manage geriatric patients is by interdisciplinary
approach lead by Geriatrician.
The role of Primary Care/Family Physician Doctors is to detect and identify
Geriatric Syndromes and Refer to Geriatric Facilty (3rd healthcare facilty) using
RAPUH & SARC-F. Frail elderly must be refered to Geriatric Facility available.
Chronic Hypertensive Older adult without Geriatric Syndromes
(Frailty/Sarcopenia) nor complications can be managed in the primary Care by
Primary Doctors based on the recent JNC 8 & ESC Guidelines.
 56

Hatur Nuhun
 BMI in Older Patients
57

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)
58

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

Female
TB= (2,225xTL) + 50,25
 Instability (Risk of Falls)
59

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
60

Apakah saudara merasa kesulitan

jika menelan makanan atau
minuman ?

Apakah saudara selalu merasakan mulut

kering ?

Apakah saudara mengalami kesulitan dalam

mengunyah ?
 Cognitive Impairment (Dementia)
61

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
 deficits/ co-
morbidities/ disabilities 62
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
63
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 64

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.
 65
TERAPI TERBARU DAN MASIH
DALAM PENELITIAN
Omega-3 fatty acid Multi
Dimensional Exercise
Programs 2
Ghrelin 2

Testosterone replacement Home-Based

Services
3 Exercise + Nutritional
Bimagrumab (BYM338) Supplements
5

Allopurinol Pharmaceutical
Agents
5
Nutritional
Supplements
3
Vitamin D (and analog)
Oral nutritional supplement
containing AN777
Calorie-restricted diet
Bendayan M, et al. Prog Cardiovasc Dis.
Metformin 2014 Sep-Oct;57(2):144-51.