gangguan psikiatri pada lansia
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psikiatri pada lansiaTRANSCRIPT
Gangguan Psikiatri pada orang berusia lanjut
DR. Dr. Martina WS Nasrun, SpkJ (K)Divisi Psikiatri GeriatrikDep Psikiatri FKUI / RSCMTim Terpadu Geriatri RSCM
Masalah usila Indonesia
8,5 % jumlah penduduk 19 juta (2000 – 2005) Urutan ke 4 di dunia
Sistim pelayanan usia lanjut? Jaminan kesehatan, akses kesehatan? Kesadaran masyarakat masih kurang Infrastruktur belum memadai
Masalah Usia lanjut:
1. Kesehatan (fisik & mental)2. Sosial3. Ekonomi4. Psikologis5. Spiritualitas / religiusitas6. Hak azasi (human right)
Kesehatan
Multipatologi 80 % usila: 1 penyakit PHBS (life style) Asuransi kesehatan Successful aging Quality of life
Kesepian (loneliness)
Pensiun Anak sibuk Tak punya aktivitas Pasangan meninggal Terisolasi sosial Tak ada teman bicara
Sosial
Peran sosial usia lanjut (masyarakat dan keluarga)
Pergeseran peran (IRT, KK pasif) Kesepian, frustasi, depresi Post power syndrome Gangguan adaptasi
Ekonomi Penghasilan menurun Masa persiapan pensiun, no pensiun Tingkatkan aktivitas, kreativitas Kembangkan hobi, ciptakan hobi Independensi keuangan?
Psikologis
Kepribadian masa dewasa muda Coping mechanism, problem solving Kegagalan beradaptasi potensial
gangguan jiwa dan fisik lainnya Integrity vs isolation Dignity in old age Arti hidup / cara pandang kehidupan
Spiritualisme / religiusitas Penghayatan keimanan Sikap hidup / persepsi diri Minat keagamaan meningkat Fungsi kognitif maningkat saat puasa Penelitian Larson: Non religius: kurang tabah, kurang
kuat mengatasi stres, kurang tenang, takut mati dsb dibandingkan yang usia lanjut yang “religius”
Hak azasi usia lanjut Hindari abuse dan neglect (mental, emosional & fisik) Hak untuk mengatur diri sendiri Hak & kewajiban dalam masyarakat Hak berobat dan bertempat tinggal Mendapat perlakuan yang pantas Human right of people with dementia
(Kyoto, 17 Oct 2004, ADI conference)
Gangguan Psikiatri pada usia lanjut
Case finding: temuan kasus dini Intervensi segera Cegah disabilitas Optimalkan fungsi Identifikasi faktor risiko Kendalikan penyakit
Gangguan Psikiatri pada usia lanjut:
Gangguan Depresi Gangguan Cemas Demensia (‘pikun’) Insomnia (gangguan tidur) Delirium (kebingungan akut)
GANGGUAN DEPRESI
Tertekan, sedih, menetap dan tidak dapat berfungsi seharihari
Penyebab: berbagai ‘kehilangan’ Sikap anggota keluarga Peka terhadap tandatanda dini Gejala depresi pada usia lanjut tidak
khas, gejala somatik menonjol !
4 Tanda pengenal gangguan depresi:
Ada perasaan kosong / hampaPesimis, kuatir masa depanTak ada kepuasan hidupMerasa hidupnya tidak bahagia
Gangguan Cemas
Gejala fisik muncul dahulu Cemas & kuatir berlebih Ketegangan fisik dan mental Gejala otonom (keringat, debardebar,
sakit perut, pusing dll) Berlangsung kronis, hilang timbul PTSD: pada usila lebih berat
Demensia
Kemunduran mental progresif Defisit berbagai fungsi kognitif Sindrom ABC
(Activity, Behavior, Cognitive) Penyebab: AD, Stroke, Parkinson, dll Tanda – tanda dini demensia BPSD (behavior & psychological
symptoms of dementia)
AD prognosisOptimal case
Min
i Men
tal S
tate
Exa
min
atio
n sc
ore
1 2 3 4 5 6 7 8 9
25 | Symptoms
20 || Diagnosis
15 || Loss of functional independence
10 || Behavioral problems
5 ||
0 Death |
Nursing home placement
Feidman and Gracon, 1996Years
18
Demensia: kumpulan gejalagejala dis eksekutif
Aktivitas seharihari (ADL & IADL)
Amnesia ApraxiaAgnosiaAphasia
Aspek neuropsikologis
(kognitif)
Gejala Psikiatrik /Psikologis
Gangguan Perilaku
Gejala neuropsikiatrik (nonkognitif: BPSD)
BPSD, behavioral and psychological symptoms of dementia
What is Dementia?
A: activity decline B: behavior disturbances C: cognitive impairment
Sebab: gangguan fungsi otak! > kemunduran mental (De Ment)
Activity decline Instrumental ADL: Berkendaraan Bepergian sendiri Berbelanja Memasak Menggunakan
telepon Mengelola keuangan
Basic ADL: Makan Mandi Naik turun tangga Buang air besar /
kecil Berpakaian
Behavior disturbances Apatis
Pencuriga Mudah tersinggung
Mudah marah Hiperaktif Insomnia
Murung / sedih
Cognitive impairment: Kelemahan memori (mudah lupa) Kesulitan berbahasa (afasia) Kesulitan mengeksekusi (rencana, kegiatan) Pengenalan benda, wajah, bentuk, ruang dll Kemerosotan daya nilai, abstraksi, judgment,
dan fungsifungsi otak lainnya
Hypothesized natural course of sporadic Alzheimer’s disease (AD)
40 50 60 70 80
Asymptomatic Preclinical Clinical phase phase phase
Onset of MCI* Clinical diagnosis of AD
0
25
50
75
100
% o
f end
sta
ge A
D
Age (years)
Estimated start of amyloid depositionModified from PJ Visser, 2000 *MCI mild cognitive impairment
MCI is a real entity and part of a continuum
Normal – MCI Dementia An inbetween, transitional diagnosis A prodromal of dementia ! A good label for patients who are not normal,
and clearly not yet demented
What is MCI?
MCI is also described as
Age Associated Memory Impairment (AAMI) Age Related Cognitive Decline (ARCD)
Questionable Dementia Mild Cognitive Disorder
MCI is a transitional phase between aging and dementia
Mild (not demented; mild enough so that psychometric testing is needed to
detect)
Cognitive (more than memory other cognitive processes)
Impairment (disease = real decline)
Flicker, Ferris & Reisberg, 1991 Petersen, 1996
MCI is not equivalent to Age Associated Cognitive Decline (which is considered “normal” when aging) but MCI is malignant in its evolution towards dementia
Definition of MCI
Mild cognitive impairmentVarious definitions main features
Subjective memory complaint by self or informant Objective findings: memory performance within 1 or 1–1.5 or 2
SD below age and education norms Normal global cognitive function And / or clinical dementia rating (CDR) 0.5 And / or global dementia scale (GDS) 3 Or MMSE below age and education cutoff norms
Common denominator Normal activities of daily living (ADL), no dementia IADL performances normal or slightly decreased
Evolution of the Mayo Clinic criteria for MCI
Petersen et al, 2001
A Amnestic MCI AD
B Multiple domains slightly impaired AD, normal aging?
C Single nonmemory domain FTDPPADLBDVa D
Normative Aging Dementia
Stable ageappropriatememory impairment
Reversible cognitiveimpairment (ie confusion)
Physical illness
Depression
Incipient dementia
• prodromal AD• prodromal VaD• prodromal mixed AD/VaD• prodromal DLBD• prodromal FLD
DementiaMCINormative
aging
Towards a broader concept of MCIConsidering heterogeneity of MCI
HKND / CIND
H+
H+
PyruvateFatty acids
Pyruvate Fatty acids
Acetyl CoA
H+ H+ H+
e2 H2O
O2 O2
NADHH+
ADP + Pi
ATP
Citric acid cycle CO2 CO2
Matrix
Inner membrane
Inner membrane area
Outer membrane
ATPSynthaseComplexes ofthe respiratory
chain IIIIIV
++
ATP
Membrane potential can be measured by fluorescence probes
R 123 TMRE
JC1
Ψ m
Organisation and function of mitochondria
mtDNA mutationsGenetic
defects
Respiratory chain
Hypoxia
Direct damage of respiratory
chain
+
++
+ Q. O2.
ATP↓
Xenobiotics
Xray
Aging
Hypoglycemia
Damagedrespiratory chain
Reduced mitochondrialmembrane potential
Causes of mitochondrial damage
Selkoe. Science Oct 2002
DOMINANTLY INHERITEDFORMS OF AD
NONDOMINANT FORMS OF AD(Including "Sporadic" AD)
Missense mutations in the APP orPresenilin 1 or 2 genes
Failure of Aß clearance mechanisms(e.g., inheritance of APOE4, faulty Aßdegradation, etc.)
Increased Aß42 production throughout life Gradually rising Aß levels with age
Subtle effects of Aß42 oligomers on synaptic efficacy
Gradual deposition of Aß42 oligomers as diffuse plaques
Widespread neuronal/synaptic dysfunction and selective neuronal loss,with attendant neurotransmitter deficits
DEMENTIA
Accumulation and oligomerization of Aß42 in limbic and association cortices
Aggressive resistancePhysical aggressionVerbal aggression
‘Aggression’
HallucinationsDelusions
Misidentifications ‘Psychosis’
WithdrawnLack of interest
Amotivation
‘Apathy’
Adapted from McShane R. Int Psychogeriatr 2000; 12(Suppl 1): 147–54Finkel SI et al. Am J Geriatr Psychiatry 1998; 6: 97–100
Alessi C et al. J Am Geriatr Soc 1999; 47: 784–91
Kelompok Gejala BPSD
SadTearful
HopelessLow selfesteem
AnxietyGuilt
‘Depression’
‘Agitation’
Walking aimlesslyPacing Trailing
RestlessnessRepetitive actions
Dressing/undressingSleep disturbance
Insomnia Sulit masuk tidur dan atau
mempertahankan tidur, atau sulit tertidur lagi setelah terbangun
Kurang tidur atau berlebihan tidur Dampak kurang tidur, distress Cari underlying disease insomnia Hygiene tidur & variasi individu
Delirium
Kebingungan akut, disorientasi, melantur, halusinasi dll
Penyebab: infeksi, ggn elektrolit dll Tanda: hiperaktif / hipoaktif Kondisi medik emergensi
In patient geriatric ward in RSCM
Tim Terpadu Geriatri RSCM Interdisiplin Psikiater, Internist, Rehabilitasi Medik,
Gizi, Neurolog, dan spesialis lainnya khusus geriatri / usia lanjut
Acute Ward Inpatient Ward Homecare Daycare / Day hospital
People do not consist of memory alone … … … They have feeling, will, sensibility and
moral being It is here that you may touch them And see a profound change
A. Luria
Cognitive training
Cognitive stimulation
World Alzheimer Day: 21 September
No Time To Lose (2004. 2006)
TO CARE THE PERSON (PWD) FOR EARLY DIAGNOSIS
Tak ada waktu yang percuma Jangan menunda waktu berobat