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 and
cheaply prevented.
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
to toxic substances.
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
participation of older people.

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
Lansia > 60 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
CONSEQUEN
CES 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
Accomodation
Suspectibility to glare
Difficulty discriminating
words if background noise is
present

Blindness
Deafness
Respiratory Lung elasticity
Chest wall stiffness
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

T4 dose required in
hypothyroidism
D.M.

Throid dysfunction
Serum Na, Serum
K
Impotence
Osteomalacia,fractur
es
Cardiovascu
lar
Arterial compliance and
Systolic BP (LVH)




Beta adrenegic
responsiveness, baroreceptor
sensitivity and SA node
automaticity
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
Syncope

Heart failure

Heart block
ORGAN OR
SYSTEM
AGE RELATED
PHYSIOLOGIC CHANGE
CONSEQUENCES OF
AGE RELATED
PHYSIOLOGIC CHANGE
CONSEQUENCES
OF DISEASE, NOT
AGE
Haematolo
gic and
immune
system
bone marrow reserve
T cell function
autoanti bodies
Anemia
False negative PPD
response
False positive
rheumatoid factor,
antinuclear antibody
Auto immune
disease
Renal
GFR
urine concentration-
dilution
Impaired excretion of
some drugs
Delayed response to salt
or fluid restriction or
overload, nocturia
Serum creatinine,
renal failure
Or serum Na

Genitourin
ary
Vaginal or urethral
mucosal atrophy
Bladder contractility
Prostate enlargement
Dyspareunia, Bacteriuria
Residual urine volume
BPH
Symptomatic UTI
Urinary
incontinence,
urinary retention,
Prostate cancer
Musculosc
letal
Lean body mass and
muscle , bone density
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
stinal
Hepatic function,
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
Brain atrophy
Brain carechol
synthesis , brain
dopaminergic
synthesis, righting
reflexes, stage 4
sleep.
Benign senescent
forgetfulness
Stiffer gait
Body sway
Early awakening,
insomnia

Dementia
Delirium
Depression
Parkinsons
disease
Falls
Sleep apnea
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
THE FRAIL ELDERLY
FALLS
DEMENTIA
DEPRESSION
URINARY CONTINENCE
IRRATIONAL DRUG THERAPY
(POLYPHARMACY)
FIVE CLASSIC
GERIATRIC PROBLEMS
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.
APPROACH TO THE PATIENT
1. Physical assessment
2. Mental status assessment
3. Functional assessment
4. Social assessment
5. Home environment assessment
COMPREHENSIVE
GERIATRIC ASSESSMENT
History taking :
1. Auto/Allo anamnesis
2. visual impairment
3. hearing loss
4. Falls
5. Incontinence
6. drug ingestion
7. dietary patterns
8. sexual dysfunction
9. depression and anxiety
Physical Assessment

1. Be prepared to spend more time with older patients
and more slowly
2. Always address the patient first
3. Involve caregivers and family members early in the
patients care
4. Recognize the emotional concerns underlying any
explicit requests
5. Do not make significant changes in a treatment plan
based solely on the familys report without evaluating
the elderly patient directly

Interviewing older patients and their family
members
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.
1
2 How old are you? 1
3 When is your birthday? OR in what year
were you born?
1
Orientation and
information
4 What is the year? 1
5 date? 1
6 day? 1
7 month? 1
8 What is this place called? Hospital/Clinic 1
9 What is his/her job? 1
Memory Recall

10 Can you recall the number again? 1
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 measures, hazards
Kitchen: storage space and accesibility, sharps, hot
water, oven, flooring and hazards.
TEN STEPS TO REDUCE POLYPHARMACY
1 Keep an accurate record of all medications the
patient is on, including over the counter
medications
2 Get into the habit of identifying all drugs by generic
name and drug class
3 Make certain that each drug being prescribed has a
clinical indication
4 Know the side-effect profile of the drugs being
prescribed
5 Understand how pharmacokinetics and
pharmacodynamics of aging increase the risk of
adverse drug events
Polypharmacy