CURICULUM VITAE

Name: RA Tuty Kuswardhani MD. PhD, MHA, FINASIM, Geriatrician

Pembina Utama Madya / IV d/ Head Lector
Head of Division Geriatric Internal Medicine UNUD
Vice President of Acossiation Geriatric Indonesia
 Head of Geriatric Acossiation Bali

 EDUCATION
1988: Medical Doctor Udayana University, Denpasar
1999: Internist Airlangga University, Surabaya
2004: Consultant of Geriatriy Indonesia University, Jakarta
2009: PhD. Udayana University, Denpasar
2011: M.HA , Airlangga University, Surabaya
 2017- Now :Student of Law Sem 2

 INFORMAL EDUCATION
2001: Fellow Ship Geriatric Medicine and Rehabilitation, Adelaide, South Australia
2001: Consultant of Geriatric Departement Cipto Mangunkusumo Hospital, Jakarta
2003: Fellow Ship at the Memory Clinic, Tokyo Geriatric Center Hospital, Tokyo, Japan
2005: Post Graduate Course Social Gerontology, International Institute On Aging, Malta
2005: Post Graduate Course WHO UNFDA, Valleta, Malta
2006: Fellow Ship on Gerontology Department, Slotervart Huis - Amsterdam, Holland
2006: Fellow Ship on Respite Care Departement Zaans Centrum Hospital & Utreht Nursing Home Centrum , Holland
2007: Post Graduate Course On Cardiology Geriatry and Anti Aging, Barcelona-Spain
2014:Visiting Doctor in Vienna Austria Hospital ( AKH, Kranken Hausen, Frans Joseph, Sofieen Hospital)
2014: Visiting Doctor in Freiburg Hospital, Germany

 ORGANISATION
1988- now: IDI ( Association of Doctor Indonesia )
1999- now: PAPDI ( Association of Internal Medicine Indonesia)
2002-now: PERGEMI (Association of Gerontology Indonesia)
2010- now: PEROSI ( Association of Osteoporosis Indonesia)
COMPREHENSIVE THERAPY
OF
SARCOPENIA

RA Tuty Kuswardhani

Divisi Geriatri
Departemen / KSM Penyakit Dalam
FK UNUD / RSUP Sanglah Denpasar
NawaCita
 by President RI, JOKO WIDODO
 NawaCita or Nine Priorities Agenda by the government is
‘To improve the quality Indonesians by improving the
quality of education and training through Smart Indonesia
program and increasing Indonesia’s social welfare and
health through the Healthy Indonesia and Prosperous
Indonesia programs’
MUSCULO SKELETAL DISORDER
 Causa musculoskeletal disorder in elderly
Mechanical: OA, Stenosis Spinal
Metabolic: OP, Paget Dissease
Cancer
Drugs / medicine: Steroid, Diuretic
Inflammation: Gouty
Environment: fracture
Immobility: atrophy
Sarcopenia
MUSCULO SKELETAL DISORDER
IN ELDERLY
3 Chief complain:
Pain
Stiffness
Weakness
3 Sign and symptom:
 Inflammation
 Muscle weakness
 ROM / movement disorder
 EPIDEMIOLOGY OF SARCOPENIA
 Data (BPS, 2015): 49% (2015) elderly population in the world > 65 yo

→ ↑: 54% (2020), ↑↑: 59,4 % (2025)

 Old people: ↓ physical , psychological , social, environment adaptation

 Frail: ↓ reserve of physiologis ,↑ frailty (disease), exponential death

 Sarcopenia: correlation with aging :
↑ in 40 years old → ↑↑ in 75 years old → to contribute frailty
 Prevalence of Sarcopenia in UK ( 2014 ) :
mean age 73 yo: in men was 7,8 % and women 8,8 % with DXA
 Sarcopenia: low nutrition / protein ,loss of musle masswith ↓thefunction
→ ↓ quality of life, ↑morbidity, ↑ cost and mortality
 ** * Sarcopenia figure diagnosis :
1).↓ muscle mass 2).↓ strenght muscle 3).↓ physical performance
Social changes
 Social isolation
- Living alone
- Eating alone
 Proverty
 Realiance on others
Physiological
 Functional disabilities
- Impaired vision
- Dementia , Alzheimer
- Amnesia, forgetting to eat
- General functional Eating process: Decreased food
difficulties (shopping) - Slower eating intake: Malnutrition
 Oropharyngeal - Less snacking - Calories
- Poor detition, hence poor - Nutrients
- Mastication
- Less dieatry
- Foods & drink
- Dry mounth variety
- Impaired taste and
olfactory
 Gastric lowProtein
- slower gastric emptying +
- Impaired gut function low exercise
 Satiety
- More rapid and longer
satiation
- Less hungry Sarcopenia
- Less thirsty
Psychological problems
 Depression
 Foods are less liked
 Less motivation to eat
Figure. Personal Factors Using Malnutrition in Older & Sarcopenia
Aging and Sarcopenia

AGING
atrophy of muscle
loss of muscle
loss of bone density
Cartilage joint thinner
connective tissue rigid &
brittle
ligaments & tendon rigid & brittle
ROM joints limited
 5 Factor Sarcopenia Criteria & Frailty:

1). ↓ BMI / ↓ Body Weight : > 10 pounds/ year, 5 kgs/ mnth

2). Exhaustion 3 days or more in a week
3). Weakness of muscle
4). Low speed walking
5). Minimal activities or exercise

 2 or more factor to indicate risk of FRAILTY

CATEGORY OF SARCOPENIA WITH THE ETIOLOGY

PRIMER
SARCOPENIA

SARCOPENIA CORRELATION WITH AGING

CONTRIBUTE AGING

SECUNDER
SARCOPENIA

CORRELATION WITH IMOBILISATION,

ACTIVITY NO GRAVITATION,
↓ ENVIRONMENT

DISSEASE ENDOCRIN, ORGAN FAILURE, Ca

SARCOPENIA
CORELATION MALABSORPTION,
WITH NUTRITION DRUGS
 Diagnosis dan Klasifikasi
Kategori skrining Sarkopenia menurut
AWGS (asean wrk grp sarc,2014)
Populasi Di Tingkat Komunitas Populasi Dengan Kelainan Patologi
 Populasi usia ≥60 tahun atau  Terdapat penurunan fungsi atau gagal pulih
≥65 tahun  Terdapat penurunan berat badan yang tidak
diinginkan sebanyak 5% selama 1 bulan terakhir
 Terdapat gangguan depresi, mood atau gangguan
kognitif
 Jatuh berulang
 Gizi kurang
 Komorbid lainnya (gagal jantung kongestif, penyakit
paru-paru obstruktif kronik (PPOK), diabetes militus,
penyakit ginjal kronik, conective tissue disease,
tuberkolosis, dan lain-lain
 Pathogenesis of Sarcopenia
Lifestyle
↑ Sedentary
↑ Fat Mass Humoral Factors
Obesity Chronic state of inflammation
Smoking (↑IL-1, IL-6, TNF-)
Hormonal Factors Oxidative stress
HGH
IGF-I
↓Testosterone
↓ Estrogens Genetic Factors
Insulin Resistance Genetic Programming
Muscle Factors
↓ Mass and ↓ Strength
Apoptosis

Nutritional Factors Nervous System Factors

↓ Protein Uptake ↓ Alpha motor neurons
↓ Antioxidant Diet SARCOPENIA ( Apoptosis, Neurotoxicity)
Anorexia ↓ Motor Unit
Vitamin D Deficiency ↓ Number of Fibres

↓ Mass, ↓ Activity, ↓Strength

Disability Dependence

Morbidity Mortality
 Diagnosis Sarcopenia
 Masa otot yang rendah : presentase masa otot
dengan standar deviasi < rata rata ( diukur dengan
jenis kelamin & etnis sama )
 Dengan alat : Diagnosis T-score dengan BMD (DXA,
Whole Body) → Sarcopenia berkaitan : Osteoporosis
 Muscle Strenght : Knee flexion,Hand grip strenght
 Performance : Kemampuan berjalan → kecepatan
rendah, saat dilakukan tes berjalan
4- 6m : ≤ 0,80 m/s
 Mengevaluasi berbagai faktor penyebab :
 Penurunan BB, kesehatan umum ,falls, obat2an
yang diminum, kelemahan
 Melakukan tes : gait walk speed, leg strength,
kemampuan duduk bangun/ kursi, grip strength
TABEL. GROUP OF SARCOPENIA IN OLDER
PEOPLE (EWGSOP)/Dx
Older Subject > 65 years old

Measure Gait walkSpeed

> 0,8 m/s ≤ 0,8 m/s

Measure Grip Strenght Measure Muscle Mass

Normal Low Low Normal

No Sarcopenia Sarcopenia No Sarcopenia

TIMED UP AND GO UP TEST

KNEE FLEXION
 DIAGNOSIS SARCOPENIA
■ MUSCLE MASS : Anthropometry, Bio Electrical Impedance, DXA, MRI

Image of Lumbar Spine Used for Quantitive CT Scan for

MRI
Assesment
 Prevention Sarcopenia

DIET :
1. Diet → BW : balance , ↑ protein , PUFA
2. Anti oxidant : Tocopherol, Flavonoid
3. High Calsium
4 .High vitamin D
5. No smoking
6. Decreasing alcohol
7. Visual assesment : avoid falls
8. UV : continue
 DIET
HEALTY EATING PYRAMID
 Healthy Eating
 Regular
carbohydrate
 High in fibre
 Low in fat
(particularly
saturated fat)
 Low in added sugar
 Adequate energy
/protein/fluids/vits
and mins
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 Prevention Sarcopenia
EXERCISE
1.Walking & seating with balance position

2. Seating & standing on the chair

3. weight bearing exercise

4.Timed up and go test

5.Knee flexion

6. Hand grip strenght

 MANAGEMENT THERAPY
Vitamin D Adequacy and Deficiency
 Dietary Adequacy
. @ 5 mcg / day (200 IU) for people < 50 years of age
. > : for older people
. Common food sources Vit D: salmon, egg, asparagus

 Vitamin D Deficiency
 Rickets
 Rare in the U.S. because many food with vit D
 Osteomalacia --“adult rickets”

- A study : correlation of falls risk and Sarcopenia in

Minnesota Hospital and ↓ Vit D diet < 200 IU ( 60-65 yo) ,163
patients = 65% ; p < 0,005)
Vitamin D Toxicity
 Upper Limit (UL)
 50 mcg/day (2000 IU)
 Vitamin D toxicity excess:
 The excess calcium is deposited in soft tissue,kidney
VITAMIN D & Ca DOSAGE
 MANAGEMENT THERAPY
 Hormonal Therapy
 Estrogen & Progesteron → for female
Estrogen or combination Progesterone
 pasca menopause : conjugated estrogen (Premarin) : dosage:
0,3125 – 1,25 mg/ day, medroksiprogesteron asetat (Provera):
2,5 – 10 mg/dy
 pre-menopause, Premarin day: 1 s/d 25 , Provera day 15 - 25,
stop: day 26 to 28 → day 29 → day 1 mens cycle
 Testosteron for male:
Testosterone inj 120-160 mg/day , kronis 40-60 mg inj/day
Patch (androderm), Testosterone gel
 Therapy: IGF 1 3x0,1mg inj,
 Take Home Message
 Sarcopenia diagnosis : 1.↓ muscle massa 2.↓ strenght muscle
3.↓ physical performance
→ 2 or more factor to indicate risk of frailty
 Sarcopenia : ↓ quality of life, ↑ morbidity , ↑ cost and mortality
 Epidemiology : prevalence of Sarcopenia in UK ( 2014) in men (mean
age : 73 years old) was 6, 8 % and women 7, 8 % with DXA
 Exercise therapy : Weight Bearing Exercise, Climb Stair, Timed up
and go test, Knee flexion, Hand Grip Strenght, Standing and sitting in
an upright position
 Diet Therapy : Balance Diet, ↑ Protein, Anti Oxidant ( Tocopherol,
Flavonoid / Resveratrol ) ,High Calsium, Vitamin D supplement, No
smoking, No alcohol, avoid to falls, Visual Assesment , UV
 Hormon Therapy : Estrogen/ Progesteron, Testosteron,
 PA
 Kontributor paling signifikan terjadinya: Sarkopenia adalah
resistensi anabolik dari otot skeletal lansia terhadap protein
• Masalah lain : hilangnya inervasi dan kerusakan oksidatif.
• Hilangnya inervasi miofibre, adalah karakteristik otot yang menua
dengan perubahan terjadi pada berbagai tingkat, dari sistim saraf
sentral dan periferal sampai pada sel jaringan otot skeletal
• Ini meliputi hilangnya motoneuron, demielinasi akson dan
penarikan ujung saraf dari neuromuscular junctions (NMJs)

• Pada lansia, akumulasi reactive oxygen species (ROS) dapat

menyebabkan kerusakan oksidatif biomolekul → hilangnya masa
dan kekuatan otot
• Dilaporkan bahwa peningkatan stress oksidatif dihubungkan
dengan berbagai situasi yang menyebabkan muscle wasting