PERAN REHABILITASI MEDIK PADA

GERIATRI
 THE GERIATRIC TEAM

• PHYSICIAN / GERIATRICIAN :CLINICAL COORDINATOR / LEADER

- Clinical Assessment & Treatment, rehabilitation etc.
- Functional assessment.
• NEURORLOGIST
• PSYCHOLOGIST, PSYCHIATRICS
• NURSE : - Patients Care
- Supporting other members of team
- Functional assessment etc.
• MED. SOCIAL WORKER : Social & environmental ass.
• Other consultants : - Rehabilitation doctors& Physiotherapist
- Nutritionist.
- Pharmacyst
• Other consultants in relevant Specialistic Med.care
 Kelompok usia lanjut
cepat atau lambat memerlukan
Rehabilitasi Medis
 FALSAFAH & TUJUAN
REHABILITASI MEDIK

Falsafah rehabilitasi medik ialah

meningkatkan kemampuan fungsional
seseorang sesuai dengan potensi yang
dimiliki untuk mempertahankan dan atau
meningkatkan Kualitas hidup dengan
cara mencegah atau mengurangi
Impairment, Disability dan handicap
semaksimal mungkin
 KATA KUNCI
• Kemampuan fungsional seseorang
• Potensi yang masih dimiliki
• Kualitas Hidup
• Diagnosis Kecacatan :
• Impairment
• Disability
• Handicap
 3 STADIA FUNGSIONAL PERJALANAN
PENYAKIT / CEDERA YANG DIDERITA
SESEORANG :
“IMPAIRMENT” (tingkat organ) :
Stadia dimana penderita masih memerlukan / tergantung pada
perawatan dan terapi secara aktif, sehingga tidak mampu
melaksanakan kegiatan sehari-hari (ADL), “temporary disability”

“DISABILITY” (tingkat manusia) :

Stadia disebut juga “recovery period” dimana penderita mulai
dapat melaksanakan pekerjaan sesuai keadaan kesembuhan
penyakitnya

“HANDICAP” (tingkat sosial) :

Stadia cacat menetap, keterbatasan kemampuan dan
melaksanakan tugas pekerjaan

Prof. Soelarto Reksoprodjo

Unit Rehabilitasi Medis
Jakarta - Indonesia
 REHABILITASI MEDIS

Pendekatan medis, psikis, sosial,

kultural, spiritual untuk meningkatkan
kemampuan fungsional pasien atau
para penyandang cacat.

Rehabilitasi medis aspek yang sangat

mendasar pada perawatan geriatri
Upaya Rehabilitasi Medik

Bagian integral dari pelayanan

Kedokteran/Kesehatan yang berkaitan
langsung dengan terwujudnya kualitas
hidup seorang pasien
Proses Rehabilitasi Medik

adalah
Proses mengembalikan
Seseorang, dari perannya sebagai
pasien, menjadi seorang manusia
seutuhnya
 Konsep Upaya Pencegahan
dari Sudut Rehabilitasi Medis

I. Pencegahan Primer
Sehat  cegah jangan sakit (impairment)
II. Pencegahan Sekunder
Sakit (impairment)  cegah jangan cacat
(disable)
III. Pencegahan Tertier
Cacat (disable)  cegah jangan handicap
 THE ESSENTIAL COMPONENTS
OF A COMPREHENSIVE
REHABILITATION PROGRAM

PREVENTION PREVENTION PREVENTION

PATIENT PSYCHOSOCIAL
PATIENT ASSESMENT TRAINING EXERCISE FOLLOW UP
INTERVENTION

PREVENTION PREVENTION

Prevention Strategies
 EVALUASI REHABILITASI

DIAGNOSIS GOAL JANGKA GOAL JANGKA PROGRAM

REHAB/
EVALUASI FUNGSIONAL PENDEK PANJANG
TERAPI

REEVALUASI
REPROGRAM
 Rehabilitation
• Rehabilitation efforts for frail elders may be directed to
avoid loss of function, to help promote return or lost
function, or both.
• Rehabilitation of older adults can take place in an
acute hospital medical or rehabilitation unit, the
nursing home, an outpatient area, or at patient’s
home
• An important preventing measure in primary care is to
encourage physical activity to help patients achieve a
higher level of baseline function, so that they will
have more functional reserve during an illness.
Nusbaum NJ
primary geriatric care
a cased based approach 2007
 Early Instruments Used in
Rehabilitation

In selecting an assessment instrument to

be used in rehabilitation, choose those
that are able to measure changes over a
relatively short period of time, can detect
small changes in function, and are based
on a variety of sources of information.
 Functional Status
• Functional status has been defined as “a
person’s ability to perform tasks and fulfill
social roles associated with daily living cross
a broad range of complexity”.
• Measures of functional status are used for a
wide variety of purposes. Clinicians apply
them to establish baselines, to monitor the
course of treatment, or for prognostic
purposes. The assessment can also be used
for screening.
Gallo JJ, ADL & Instrumental ADL
Assessment in and book of
Geriatric Assessment 4th ed,
2006
Functional Status
The capacity to function independently is poorly
described by the constellation of medical diseases
alone.
Performance on mental status testing does not
necessarily predict functional status.
The severity of disease as measured by standard
laboratory tests does not necessarily imply disability.
Functional status should be assessed
directly and independently of medical and
laboratory abnormalities or cognitive
impairment.

Gallo JJ, ADL & Instrumental ADL

Assessment in and book of
Geriatric Assessment 4th ed,
2006
Functional Status

• Examinations of function divided into

three levels:
– Basic Activities of Daily Living (BADL or
ADLs)
– Instrumental Activities of Daily Living
(IADL)
– Advanced Activities of Daily Living (AADL).
 Barthel Index
• The Barthel Index (Mohaney & Barhel, 1965) was
originally devised as a means of clearly differentiating
patients who are dependent in ADL from those who
are not. It is a 10 category, weighted index, which
includes ambulation and stairs as well as self-care
and has a perfect score of 100.
• At least five versions (including the original) have
been used. These include zero to 20-point scoring
modification (Collin, Wade, Davies, & Horne, 1988).
The Index should be used as a record of what a
patient does, NOT as a record of what a patient could
do.
Barthel Index

• The Barthel Index was used to document

improvement.
Patients who did not improve their
score during rehabilitation were
believed to have poor potential for
recovery.
 INDEKS ADL BARTHEL (BAI)

NO FUNGSI SKOR KETERANGAN

1 Mengendalikan rangsang pembuangan 0 Tak terkendali/tak terukur (perlu pencahar)
tinja 1 Kadang-kadang tak terkendali (1x seminggu)
2 Tak terkendali

2 Mengendalikan rangsang berkemih 0 Tak terkendali atau pakai kateter

1 Kadang-kadang tak terkendali (hanya 1x/24 jam)
2 Mandiri

3 Membersihkan diri (seka muka, sisir 0 Butuh pertolongan orang lain

rambut, sikat gigi) 1 Mandiri

4 Penggunaan jamban, masuk dan keluar 0 Tergantung pertolongan orang lain

(melepaskan, memakai celana, 1 Perlu pertolongan pada beberapa kegiatan tetapi dapat
membersihkan, menyiram) mengerjakan sendiri beberapa kegiatan yang lain
2 Mandiri

5 Makan 0 Tidak mampu

1 Perlu pertolongan memotong makanan
2 Mandiri

6 Berubah sikap dari berbaring ke duduk 0 Tidak mampu

1 Perlu banyak bantuan untuk bisa duduk (2 orang)
2 Bantuan minimal 1 orang
3 Mandiri
INDEKS ADL BARTHEL (BAI) (lanjutan)
NO FUNGSI SKOR KETERANGAN

7 Berpindah/berjalan 0 Tidak mampu

1 Bisa (pindah) dengan kursi roda
2 Berjalan dengan bantuan 1 orang
3 Mandiri

8 Memakai baju 0 Tergantung orang lain

1 Sebagian dibantu (mis mengancing baju)
2 Mandiri

9 Naik turun tangga 0 Tidak mampu

1 Butuh pertolongan
2 Mandiri

10 Mandi 0 Tergantung orang lain

1 Mandiri

TOTAL SKOR 19

Skor BAI
20 : Mandiri 5-8 : Ketergantungan berat
12-19 : Ketergantungan ringan
0-4 : Ketergantungan total
9-11 : Ketergantungan sedang
Lawton IADL Scale

No
1 Dapatkah menggunakan telephone
2 Mampukah pergi kesuatu tempat
3 Dapatkah berbelanja
4 Dapatkah menyiapkan makanan
5 Dapatkah melakukan pekerjaan rumah tangga
6 Dapatkah melakukan pekerjaan tangan
7 Dapatkah mencuci pakaian
8 Dapatkah mengatur obat-obatan
9 Dapatkah mengatur keuangan
Keterangan :
1 = mandiri
2 = butuh bantuan
3 = ketergantungan
Nilai maksimal = 27
A HIERARCHICAL MODEL OF
PHYSICAL FUNCTION

When selecting a performance-based

measure of function, rules that are used
to choose any functional status measure
apply
 Hierarchy of physical function

Integration level III Role function

Task or
Integration level II goal-oriented
function
(e.g., ADL, IADL)

Specific physical
Integration level I Movements
(e.g., 8-foot walk)
Basic component

Coordination
Balance Strength Flexibility Endurance
Line motor
 Hierarchy of Physical Function and Disability

ADL = activities of
Physically daily living
elite
• Sports competition,
BADL = basic ADL
Physically
Physical function

Senior Olympics
fit Physically
• High-risk and power independent
• Moderate physical
sports (e.g., hang-
work
gliding, weight • Very light physical Physically
lifting
• All endurance work frail
sports and games Physically
• Hobbies (e.g., • Ligtht
• Most hobbies walking, housekeeping dependent
and games
• Food preparation • Cannot pass
• Low physical some
demand • Grocery shopping or all BADLs :
activities (e.g., golf, • waling
social dance, hand • Can pass some • bathing
crafts, traveling, IADLs, all BADLs • dressing
auto- • eating
mobile driving) • May be • transferring
homebound
• Can pass all IADLs • Needs home or
institutional care

Disability

Adapted from Spicduso WW. Physical Dimensions of Aging. Champaign, IL; Human Kinetics; 1995
 PROSES REHABILITASI

Langkah 1

• Atasi masalah medis utama

• Kondisi stabil, menjadi landasan untuk
mengawali program Rehabilitasi Medis
 PROSES REHABILITASI
Langkah 2

Cegah Komplikasi Sekunder

Malnutrisi Inkontinensia
Gangguan kognisi Pneumonia
Kontraktur Dekubitus
Sindroma dekondisi Ketergantungan Psikologis
Depresi Trombosis Vena
 PROSES REHABILITASI
Langkah 3
Mengembalikan fungsi yang hilang

• Nilai kemampuan fungsional yang masih

tersisa, dan maksimalkan
• Bila perlu, gunakan alat bantu agar mandiri,
bersosialisasi

Walau penyebab gangguan fungsi tak dapat

dihilangkan, pasien tetap mampu beraktifitas
 PROSES REHABILITASI
Langkah 4

Ciptakan kemampuan
adaptasi bagi pasien

Adaptasi Fisik
Adaptasi Psikis
Adaptasi Sosial
 PROSES REHABILITASI

Langkah 5

Adaptasi Lingkungan

Ciptakan lingkungan yang bersahabat,

baik dirumah sakit, dirumah, dilingkungan,
untuk kemudahan pasien beraktifitas
 PROSES REHABILITASI
Langkah 6

Adaptasi Keluarga

• 85% aktifitas usia lanjut, dirumah

• Para usia lanjut butuh waktu untuk ‘menerima’
kondisinya
• Keluarga, makna hidup bagi para usia lanjut
• Keluarga, mitra kerja tenaga medis/paramedis
PENGAWASAN & EVALUASI

• Lakukan Reevaluasi dan Reprogram

• Setiap kali, tentukan target baru, agar
motivasi terjaga
• Target pencapaian merupakan
kesepakatan dokter dan pasien
 PEMILIHAN PROGRAM
TERAPI REHABILITASI MEDIK

• Tujuan Rasional
• Dosis latihan tepat & jelas
• Latihan bertahap
• Jenis latihan mudah dan aman
 Basic Consideration

If we are to rehabilitate our elderly

patient successfully we need:

1. Timing of treatment
2. The team
3. Techniques
 Basic Consideration
Timing of treatment
• When does rehabilitation begin
• Frequency and intensity of therapy
• When to stop

The team
• Involvement of patient and family
• Team coordinator
• Involvement of nurse in rehabilitation (enablement)
• Focusing on goals
• Concern with the well-being of the team
 Basic Consideration
Techniques
• Accurate assessment and recognition of
all problems
• Prevention of complications
• Physical agents
• Physical techniques
• Compensating for disability
• Rating scales
• Morale and motivation
Age-related factors that may
affect rehabilitation

Biologic
Muscle strength Psychologic
Cardiac function Slow learning pace
Pulmonary function More repetitions
Aerobic capacity Belief about rehab
Vital capacity Belief about recovery
Minute volume Belief about self
Orthostatic changes
Peripheral resistance

Social
Negative views of aging
Less frequent referrals
Self-ageism
Financial barriers
Disease-related factors that
may affect rehabilitation

Biologic
Multiple diseases
Deconditioning Psychologic
Contractures Cognitive deficits
Disease-disease Depression
interactions Atypical presentations
Polypharmacy motivation
Subclinical organ
dyfunction

Social
Societal prejudice
(“Disabilityism”)
Lack of services
Inaccessible buildings
Reimbursement regulations
Rehabilitation Problem List

– Primary rehabilitation diagnosis or anatomic injury

– Other associated diagnoses with severity measures
– Impairments (e.g., neurogenic, bladder, bowel,
sexual function)
– Activity limitations (e.g., mobility, ADLs,
communication)
– Education
– Participation barriers
– Psychological adaptation
– Social role function
– Architectural accessibility
– Community reintegration
– Vocational adaptation
– Spiritual practice
Quality of Life Paradigm has
meaning for both patient and
physician
Geriatric Giant
Geriatric Giant adalah problem-problem raksasa/ luar biasa
besar pada pasien geriatri yaitu :
1. Imobilisasi
2. Instabilitas dan jatuh .
3. Inkontinensia urin dan alvi
4. Gangguan Intelektual (demensia)
5. Infeksi
6. Gangguan penglihatan & pendengaran
7. Impaksi (konstipasi)
8. Isolasi (depresi)
9. Inanisi (malnutrisi)
10. Impecunity (kemiskinan)
11. Latrogenesis (sering karena terlalu banyak obat)
12. Insomnia
13. Defisiensi imunitas
14. Impotensi
MENGENAL ISTILAH GERIATRIC

Pasien Geriatri adalah : Pasien berusia lanjut (untuk Indonesia saat ini
adalah mereka yang berusia 60 tahun ke atas) dengan beberapa masalah
kesehatan (multipatologi) akibat gangguan fungsi jasmani dan rohani,
dan atau kondisi social yang bermasalah

Ciri Pasien Geriatri adalah :

- Memiliki beberapa penyakit kronis
- Gejala penyakit tidak khas
- Fungsi organ menurun
- Tingkat kemandirian berkurang
- Sering disertai masalah nutrisi
- Karena alasan-alasan tersebut di atas maka:

"Perawatan usia lanjut berbeda dari pasien dewasa muda”.