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 lowand 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 homebased 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
system’s 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 AGE RELATED
SYSTEM
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
D.M.
Cardiovascu  Arterial compliance and
⇑Systolic BP (LVH)
lar
Beta adrenegic
responsiveness, baroreceptor
sensitivity and SA node
automaticity

 T4 dose required in
hypothyroidism
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
Throid dysfunction
Serum Na, ⇑ Serum
K
Impotence
Osteomalacia,fractur
es
Syncope
Heart failure
Heart block
ORGAN OR
SYSTEM
AGE RELATED
PHYSIOLOGIC CHANGE
Haematolo  bone marrow reserve
 T cell function
gic and
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
Parkinson’s
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
patient’s care
Recognize the emotional concerns underlying any
explicit requests
Do not make significant changes in a treatment plan
based solely on the family’s 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
 Folstein’s 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)
Score
Items
Memory
1
I want you to remember this number. Can
you repeat after me (4517). I shall test you
again in 15 min.
1
Score
(correct
answer)
2
How old are you?
1
>7
Normal
3
When is your birthday? OR in what year
were you born?
1
5-6
borderlin
e
0-4
Probable
case of
cognitive
inpairme
nt
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
Can you recall the number again?
1
Memory Recall
10
Total
– 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 patients’s 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 patient’s 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 elderly’s
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.
Polypharmacy
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