5. psikogeroB11

8/12/2019 5. psikogeroB11

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Retno Lestari



• Latin demens (without mind),

• Sindrom klinis o/k ggn organik

– karakteristik onset lambat

– Pe fs. kognitif

– Disfs. ADL

• 10% > 65th,• > 50 % > 85th





Non-Reversible Types of Dementia

Alzheimer’s disease

Vascular Dementia

Dementia with Lewy bodies

Fronto-Temporal Dementia

Others:

Parkinson’s Disease

Huntington’s Disease

Creutzfeldt JakobDisease

ProgressiveSupranuclear Palsy

Korsakoff’sSyndrome

Infection-RelatedDementia (HIV,

Syphilis)



Reversible Dementia

Malnutrisi

Dehidrasi

Disfungsi Metabolik

Defisiensi Vitamin B12

Depresi

Delirium



Perubahan Otak Saat lahir, otak > 100 trilliun sel syaraf/neurons

Dementia neurons pd bbrp bagian mati o/kpeny.ttt

Massa otak dpt ber< s.d 50%

Beberapa tipe: Alzheimer‟s (~55%),

vascular dementia (~20%), dementia with Lewybodies

(~15%), and frontotemporal dementia (~5%).

Parkinson‟s with dementia, Creutzfeldt-Jakob and

Huntington‟s disease.









Dementia- defined

Memory problems AND at least one

additional cognitive deficit:

– Aphasia

– Apraxia

– Agnosia

– Problems with “executive functioning”





Apraxia

“impaired ability to pantomime the use of

known objects or to execute known motor

acts”



Agnosia

Trouble recognizing or identifying things

despite intact sensations (ex. You can see

fine, but you can’t recognize a stop sign)

May include difficulty recognizing family

members or even themselves in the mirror



Disturbances in Executive

FunctioningAbstract thinking

Planning, initiating, sequencing, and

stopping behaviors

May manifest as trouble with novel tasks or

new situations



Masalah psikiatri

Agitation

Wandering

Insomnia

Catastrophic

reactions

Psychosis

Depression

Anxiety

Agnosia

Aphasia

Apraxia

Deficits in abstractthinking



Psychometric tests „Mini-Mental State Examination‟ Sensitif thd kultur dan sosial

dpt berubah, harus dikaji lg

Brain-imaging Structural imaging (CT and MRI scans)

functional imaging (PET and SPET scans)

Cairan tubuh CSF



TREATMENT Agitasi

Perilaku

Lingk. Nyaman dan

aman

Stimulus fs. kognitif

Music

Terapi cahaya

Siang hari exercise,<i istirahat siang

Medications

Typical antipsychotics

(Haldol)

Atypical antipsychotics

(Risperdal)

Antidepressants -- watch

for agitated depression,

harus dikaji

benzodiazepines



Intervensi

DemensiaOrientasi

Tujuan membantu klien berfungsi di lingk

Tulis nama petugas pd kamar klien yg jelas,

besar dan terbaca Orientasikan barang pribadi, waktu, tempat,

orang

Penerangan di malam hari

Jam besar, kalender harian

Kontak personal dan fisik

Aktifitas kelompok



Komunikasi

Komunikasi verbal: jelas, ringkas, tdk buru2

Topik percakapan dipilih klien Pertanyaan tertutup

Pelan dan diplomatis dlm menghadapi persepsi ygsalah

Empati, hangat, perhatianPenguatan koping

Kaji sumber kecemasan, koping masa lalu

Kurangi agitasi

Beri penjelasan, pilihan

Jadual harian

Penyaluran energi

Saat agitasi: senyum, sikap bersahabat



Keluarga dan Masyarakat

Siapkan kelg dan fasilitas di masy Perlu bantuan dlm merawat 24 jam di rumah

Home care



CHARACTERISTICS DEMENTIA DELIRIUM DEPRESSION



CHARACTERISTICS DEMENTIA DELIRIUM DEPRESSION

Onset Tdk terlihat, lambatdan tdk dikenali

Tiba2, mendadak Baru2 ini, b.d perub.hidup

Course over 24 hours Cukup stabil, berubah jika ada stres

Fluctuasi, gelisahmalam hari

Cukup stabil, mgknburuk saat pagi hari

Consciousness Sadar berkurang kesadaran sadar

Alertness Normal Meningkat, menurun,variasi

Normal

Psychomotor activity Normal, apraxia Meningkat, menurun,kombinasi

Variasi, agitasi/retardasi

Duration Berbulan2 s.dbertahun2

Ebrjam2 s.dberminggu2

Variasi (min 6 mgg),dpt berbulan2 s.dbertahun2

Attention umumnya normal Berubah, fluktuasi Sedikit ggn, mudahterdistraksi

Orientation Sering ggn (answermay be close to right)

Biasanya terganggu,variasi

biasanya normal, jawaban “saya tdktahu”

Speech Sulit mencari kata Sering incoherent,slow or rapid

Mungkin lambat

Affect Labile Variable Flat



Pseudo Dementia

( Depression )

Dementia

More acute onsetInsidious onset

Emphasizes failureDelights in accomplishments

UncommonSun downing Common

(increase confusion at night)

Often answer “Don‟t Know”Guess at answer ( confabulate )

Pt is aware of problemPt unaware of problem



Case 1

Ny. E, 80 th

keluhan: < tidur, nafsu makan <, BB turun

sedikit.

riwayat incontinence, cardiovascular disease,diabetes.

Bagaimanakah pendekatan intervensi yg

akan dilakukan o/ perawat?



Case 2

Tn. G, 74 th

Keluhan: otot nyeri, dizziness, constipation.

Uncooperative, marah >>.

Istri meninggal 2 th lalu; jatuh





Kriteria Diagnostik DSM-IV

5 > gejala yg berlangsung >2 mgg, terjadi

perubahan:

Depressed mood dan atau kehilangan

perhatian/ketertarikan

<< tidur, << energi, tdk nafsu makan/BB <<,

rasa tidak berdaya/bersalah, perubahan

psikomotor, << konsentrasi dan fokus, pikiranbunuh diri



SIG E CAPS

Sleep

Interest

Guilt (“Are you a burden to others?”)

Energy

Concentration

Appetite

Psychomotor changes

Suicidality (“Do you wish you could die?”)



Epidemiology

Men: 5-12%

Women: 10-25%

Prevalence 1-2% in elderly 6-10% in Primary Care setting

12-20% in Nursing home setting

11-45% in Inpatient setting

>40% of outpt. Psychiatry clinic and inpt.

psychiatry



Diagnosis is Difficult

Coexistence of manyother problems

medical

physical social

economic

“normal” aging May “mask”

depression



TRUE FALSE





Indirect Suicide

Starvation, refusingto eat

Refusing needed

medicationsMixing medications

Alcohol abuse

Loss of “will to live”



Poor Outcomes

Comorbid Conditions Anxiety

Medical problems

Cognitive impairmentConcurrent Problems & Issues

Psychotic depression

Impaired social supportStressful life events

Multiple previous episodes



Major Depression

Depressed mood most of the day,

everyday

ORLoss of interest or pleasure nearly every

day

and at least 4 additional symptoms . . .



Major Depression, cont.

Significant weight lossor gain

Insomnia orhypersomnia

Psychomotoragitation orretardation

Fatigue or loss ofenergy

Feelings ofworthlessness,inappropriate guilt

Loss of ability to think,concentrate, makedecisions

Recurrent thoughts ofdeath, suicidalideation

FOUR ADDITIONAL SYMPTOMS



MINOR Depression

Also known as subsyndromal

depression

subclinical

depression mild depression

2 - 4 times more

common than major

depression

Associated with: subsequent major

depression

greater use of health

services reduced physical,

social functioning

loss of quality of life

Responds to sametreatments!



Common Causes of Depression

CHAIN OF EVENTS

Stress & loss

Biological depressionPhysical illness and

its treatment interact

with depression in older adults



Stress and Loss in Late Life

Decreased sensorycapacity

vision

hearing

Changes in socialstatus, responsibility

to others

Loss of family,friends

Relocation due tochanging abilities

Declining social

contacts due to

health limitations

Reduced functional

status

Dwindling financialresources



Stress and Loss in Late LifeLoss of meaningful

roles

productivity

purpose in living

Loss of self-esteem helplessness

powerlessness

Decreased coping

options



Biological Depression

Genetic cause vs. “reaction” to stress

seems to come out of “nowhere”

family, personal history more common

increased risk of severity, reoccurrence

Effects of environment and physicalillness are still important to

address!!





Physical Illness & Depression

Physical illness can cause a reaction ofdepression by causing

chronic pain,

fear of pain

disability, loss of

function

loss of self esteem

increased dependence fear of death

2



Physical Illness & Depression

Depressed elderly may present withsomatic (physical) complaints

aches, pains

appetite, weight fatigue, loss of energy

constipation

tachycardia insomnia

3







AssessmentDepression symptoms

Suicidal thoughts

Psychiatric history

personal

family

Physical health/illness

Medications

Recent loss/stressResources/abilities



Geriatric Depression Scale

Score “0” or “1”

Add up points (0-30)

Further assessment if

> 10Remember!

Screening tool;

assess symptoms

further!!

http://localhost/var/www/apps/conversion/tmp/scratch_1/Geriatric_Depression_Scale.pdf



Suicide AssessmentAlways ASK!!!

“Have you thought that life isn’t worth living?”

If YES, then . . .

“Have you thought about harming yourself?

If YES, then . . .

“Do you have a plan?”

If YES, examine lethality. . .

Is the plan viable? Can they execute it?

Are means deadly, available?



Look

carefully!!

Psychiatric HistoryPrevious episodes of

depression Check chart/record

Undiagnosed

Bad nerves; nervous

breakdown; went to

bed sick

After childbirth, (post-

partum), children leave

(empty nest), death ofloved one, retirement



Physical Health/Illness

Consider factors that increase isolation,loneliness, fear, orworthlessness!! Loss of mobility

Level of disability

Worry about decliningabilities

Pain resulting fromhealth conditions

Look for factors that directly increasedepression symptoms Medications

New?

Change in dose?

New onset of physicalillness

Influenza? Change in status of

chronic diseases



Recent Loss

___ recent relocation? ___ change in relationships?

___ change in health?

___ change in functional abilities? ___ change in sensory status?

___ change in financial status?

___ death of loved one? (even a pet)

___ loss of control over daily routines?

___ loss of significant role?



Resources & Abilities

___ family support? ___ community support?

___ social network?

___ physical abilities? ___ functional abilities?

___ cognitive abilities?

___ financial resources?

___ personality traits? personal history?

___ experiences, beliefs, convictions?



Person-Centered

Appreciate the older person‟sperspective and experience:

control, power loss

unwanted dependency

meaning of functional

losses, relationship

to activity, meaningand purpose in living

Facility,

Staff





Interventions

Every interaction has“Therapeutic Potential”

Social environment

or “milieu” is powerful Support, encouragement

Safety, security

Interaction, involvement

Validate worth by the way we treat them!



Interventions

First-Line Interventions

Communicate caring

Help see they are

unusually sad or blue

Provide accurate

information about depression

Create a healthy physical and socialenvironment.





Interventions

Help to realize they are

UNUSUALLY sad, blue

Suggest: more than "down in the dumps"

Help: identify the things that are troubling

Recall: past positive events things haven't

always been this bad

Note: Positive attributes, characteristics they do still have worth!!



Interventions

Provide informationabout DEPRESSION

An ILLNESS, like physical illness

Symptoms are part of depression Common in people of all ages

Has a treatment AND treatment worksMedications

Talking therapies

Increased involvement in activities



Promote Mental Health

Reduce “depressing effects” of the environment

Adjust factors in the social

environment Promote health & well-being

Alter approaches to care

Offer different activities/experiences

Promote positive health outcomes!!



Monitor Physical Health

Nutrition

Elimination

Sleep/rest patterns

Physical comfort

Pain management

relaxation methods

medication alternative therapies



Encourage Physical ActivityExercise program

Referrals

physical therapy

occupational therapy

recreational therapyDevelop daily

activity schedule

Involve in

meaningful activity





Focus on PositiveCurrent abilities

knowledge, wisdom

experiences

attitudes, beliefs

attributes

Reminiscence

promotes self worth

strengthens tie to

identify, “former self” stimulates interests,

conversation



Employ Alternative Therapies

Pet therapy unconditional positive

regard

sensory stimulation

sense of responsibility,meaningful role

aroma therapy

maintain mobility



Encourage Group Activities

Psychosocial therapies

Reminiscence

Remotivation

Health, stress management

Sensory stimulation

Many benefits

Social interaction

Mastery experiences

Realization “I am not alone in this!



Promote Creativity

Lots of alternatives:

Singing, playing music

Story-telling

Drawing, painting

Poetry, writing

Making crafts, jewelry

Associated with positive health outcomes Decreased depression, loneliness

Increased health, morale, satisfaction, activity



Enhance Social Support

Identify a “point person” to

help identify, mobilize

resources

family member friend, neighbor

church members

clergy

volunteer visitor peer counselor



Professional Interventions

Individual therapy

Group therapy

Medication therapy

Antidepressants

– most common

Others may be needed

for anxiety or psychotic symptoms

Depression



Depression

A

REASONFOR

HOPE



Sleep Disturbances-Incidence increase with aging

-Difficulty sleeping, Daytime drowsiness & Daytime napping

-Causes:

*medical conditions.

*Environment.*Medications.

*Normal changes associated with aging .



Examples of „Legal‟ Drugs That



p g gCause Insomnia

AlcoholDecongestants

CNS stimulants

Stimulatingantidepressants

Beta-blockers

Diuretics

Thyroid hormones

Bronchodilators

NicotineCalcium channel

blockers

CaffeineCorticosteriods

CNS Depressants

Quinidine Anticonvulsants

Antiparkinsonian agents

Consequences of Poor Sleep



q p

in older adults Ancoli-Israel s, Cook JR. J Am Geriatr Soc 2005;53 (suppl):S264-S271

Difficulty sustainingattention and slowedresponse time

Decreased ability to

accomplish daily tasksImpairments in memoryand concentration

Increased consumption of

healthcare resourceshigher incidence ofsymptoms related todepression and anxiety

Increased risk of falls (evenafter controlling formedication use, age,difficulty walking, difficulty

seeing and depression)Shorter survival/increasedinstitutionalization rate

Inability to enjoy socialrelationships/decreasedQOL

Increased incidence ofcognitive decline

Increased incidence of pain



Tx of Sleep Disturbances-Approaches should be tried first: Alcohol cessation, Increased structure of daily routine, Elimination of

daytime naps & treatment of underlying medical conditions

-Sedative HypnoticsHydroxyzine (Vistaril) & Zolpidem (Ambien)

Important Note prefer not to be used due to their S/E in elderly likememory impairment, ataxia, paradoxical excitement & reboundinsomnia



CaseNy. S, 69 th tinggal di rumah dg suaminya 72 th yg pensiun, dan2 anaknya laki2 yg telah menikah. Suaminya punya toko baju,dan skrg dijalani oleh anak2nya. Ny. S adalah IRT, lulusan S1.

Bbrp thn setelah anaknya menikah, mereka minta sharing dantokonya, dan skrg mereka hidup terpisah di rumah yg sama,tmasuk masak. Ny. S masak sndr u/ dia dan suaminya, dan punyapembantu u/ bersih2. Namun skrg, anak2nya suka teriak,marah2 dan mengancam akan mengeluarkan mereka dr rumah .Sementara istri mereka pura2 tdk tahu. Ny. S berpikir ini mgknhasutan dr istri2nya. Ny. S merasa tdk berdaya dan tdk punyakekuatan u/ melawan. Selama ini Ny.S hidup dgn uang pensiundan anak2nya tdk pernah memberikan uang.





Eld Ab



Elder Abuse

Elder abuse is physical or psychologicmistreatment, neglect, or financialexploitation of the elderly.

Common types of elder abuse include

physical abuse, psychologic abuse,neglect, and financial abuse. Eachtype may be intentional or unintentional.The perpetrators are usually a spouseor adult children but may be otherfamily members or paid or informalcaregivers. Abuse usually becomes

more frequent and severe over time.



Physical abuse is use of force resulting in physical orpsychologic injury or discomfort. It includes striking, shoving,shaking, beating, restraining, and forceful or improper feeding.It may include sexual assault (any form of sexual intimacy

without consent or by force or threat of force).Psychologic abuse is use of words, acts, or other means tocause emotional stress or anguish. It includes issuing threats(eg, of institutionalization), insults, and harsh commands, as

well as remaining silent and ignoring the person. It alsoincludes infantilization (a patronizing form of ageism in whichthe perpetrator treats the elderly person as a child), whichencourages the elderly person to become dependent on theperpetrator.



Neglect is the failure to provide food, medicine,personal care, or other necessities. Neglect thatresults in physical or psychologic harm is consideredabuse.

Financial abuse is exploitation of or inattention to a

person's possessions or funds. It includes swindling,pressuring a person to distribute assets, andmanaging a person's money irresponsibly.

Risk Factors for Elder Abuse



Factor Comments

For the victim

Social isolation Abuse of isolated people is less likely to bedetected and stopped. Social isolation can

intensify stress.

A chronic disorder,

functional impairment,or both

The ability to escape, seek help, and

defend self is reduced.Such elderly people may require more

care, increasing stress for the caregiver.

Cognitive impairment Risk of financial abuse and neglect is

particularly high.

People with dementia may be difficult to

care for, frustrating caregivers, and may be

aggressive and disruptive, precipitating

abuse by overwhelmed caregivers.

For the perpetratorSubstance abuse Alcohol or drug abuse, intoxication, or substance withdrawal may

lead to abusive behavior Substance dependent caregivers may



lead to abusive behavior. Substance-dependent caregivers may

attempt to use or sell drugs prescribed to the elderly person,

depriving the person of treatment.

Psychiatric disorders Psychiatric disorders (eg, schizophrenia, other psychoses) may

lead to abusive behavior.Patients discharged from an inpatient psychiatric institution may

return to their elderly parents' home for care. These patients,

even if not violent in the institution, may become violent at home.

History of violence A history of violence in a relationship (particularly between

spouses) and outside the family may predict elder abuse. One

theory is that violence is a learned response to difficult life

experiences and a learned method of expressing anger and

frustration. Because reliable information about past family

violence is difficult to obtain, this theory is unsubstantiated.

Dependence of the

perpetrator on theelderly person

Dependence on the elderly person for financial support, housing,

emotional support, and other needs can cause resentment,contributing to abuse. If the elderly person refuses to provide

resources to a family member (especially an adult child), abuse is

more likely.

Stress Stressful life events (eg, chronic financial problems, death in the

family) and the responsibilities of caregiving increase the

likelihood of abuse.



For both victim and perpetrator

Shared livingarrangements Elderly people living alone aremuch less likely to be abused.

When living arrangements are

shared, opportunities for the

tension and conflict that usuallyprecede abuse are greater.

Clinical Situations Suggesting Elder Abuse



gg g

• Delay between an injury or illness and the seeking of medical

attention

• Disparities in the patient's and caregiver's accounts• Injury severity that is incompatible with the caregiver's

explanation

• Implausible or vague explanation of the injury by the patient or

caregiver

• Frequent visits to the emergency department for exacerbations of

a chronic disorder despite an appropriate care plan and adequate

resources

• Absence of the caregiver when a functionally impaired patient

presents to the physician• Laboratory findings that are inconsistent with the history

• Reluctance of the caregiver to accept home health care (eg, a

visiting nurse) or leave the elderly patient alone with a health care

practitioner





Preventing elder abuse and neglect

Listening to seniors and their caregivers

Intervening when you suspect elder abuse

Educating others about how to recognize andreport elder abuse

Latihan Kesadaran Diri: Intensitas marah Bayangkan situasi ini:



y g

Anda pulang telat setelah belajar di perpustakaan untuk ujian semester

dan Anda merasa lelah. Saat berjalan ke rumah, tanpa disadari seorang

anak remaja yang mengendarai sepeda motor menabrak Anda. Seperti apakah emosi yang anda rasakan saat itu? Hal apa sajakah yang

mempengaruhi intensitas marah yang anda rasakan?

- Rasa nyeri yang anda rasakan saat tertabrak?

- Keadaan tubuh anda yang lelah? - Kenyataan bahwa anda belum sempat makan malam?

- Seorang anak remaja yang tidak sengaja menabrak anda?

- Rasa stres akan menghadapi ujian?

Jika situasi yang sama terjadi pada saat tubuh anda tidak lelah, dalamkeadaan tenang, tidak mengalami beban pikiran, apakah perasaan dan

intensitas marahnya akan sama?



―We need to meet all kinds of people so that we

can find ourselves. Young people need olderpeople just as older people need young people in

order to become more themselves and more

human. That humanizing process will teach usthat there is a child behind the mask of each

older face, just as there is already an older

person behind the mask of each young face.‖

– Leo. E. Missinne (1990)

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5. psikogeroB11