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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


Others:

Alzheimers disease
Vascular Dementia Dementia with Lewy bodies Fronto-Temporal Dementia

Parkinsons Disease
Huntingtons Disease Creutzfeldt Jakob Disease Progressive Supranuclear Palsy Korsakoffs Syndrome Infection-Related Dementia (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/k peny.ttt Massa otak dpt ber< s.d 50%

Beberapa tipe:

Alzheimers (~55%), vascular dementia (~20%), dementia with Lewy bodies (~15%), and frontotemporal dementia (~5%). Parkinsons with dementia, Creutzfeldt-Jakob and Huntingtons disease.

Dementia- defined
Memory problems AND at least one

additional cognitive deficit:


Aphasia Apraxia Agnosia Problems with executive functioning

Details, Details: Aphasia


Aphasia is a drop off in language function

that shows up in a variety of ways

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 cant recognize a stop sign) May include difficulty recognizing family members or even themselves in the mirror

Disturbances in Executive Functioning


Abstract 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 abstract thinking

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 Demensia

Orientasi

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 yg salah Empati, hangat, perhatian Kaji sumber kecemasan, koping masa lalu Beri penjelasan, pilihan Jadual harian Penyaluran energi Saat agitasi: senyum, sikap bersahabat

Penguatan koping

Kurangi agitasi

Keluarga dan Masyarakat


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

CHARACTERISTICS
Onset Course over 24 hours Consciousness Alertness Psychomotor activity Duration

DEMENTIA
Tdk terlihat, lambat dan tdk dikenali Cukup stabil, berubah jika ada stres Sadar Normal Normal, apraxia Berbulan2 s.d bertahun2 umumnya normal Sering ggn (answer may be close to right)

DELIRIUM
Tiba2, mendadak Fluctuasi, gelisah malam hari berkurang kesadaran Meningkat, menurun, variasi Meningkat, menurun, kombinasi Ebrjam2 s.d berminggu2 Berubah, fluktuasi Biasanya terganggu, variasi

DEPRESSION
Baru2 ini, b.d perub. hidup Cukup stabil, mgkn buruk saat pagi hari sadar Normal Variasi, agitasi/ retardasi Variasi (min 6 mgg), dpt berbulan2 s.d bertahun2 Sedikit ggn, mudah terdistraksi biasanya normal, jawaban saya tdk tahu

Attention Orientation

Speech
Affect

Sulit mencari kata


Labile

Sering incoherent, slow or rapid


Variable

Mungkin lambat
Flat

Dementia Insidious onset Delights in accomplishments Sun downing Common (increase confusion at night)

Pseudo Dementia ( Depression ) More acute onset Emphasizes failure Uncommon

Guess at answer ( confabulate )


Pt unaware of problem

Often answer Dont Know


Pt is aware 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, pikiran bunuh 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 many other problems medical physical social economic normal aging May mask depression

TRUE

FALSE

Suicide in Older Adults


Represent 13% of the population Account for 1/5 (20%) of all reported suicides Lowest rate of ATTEMPTS Highest rate of COMPLETED SUICIDE

Indirect Suicide
Starvation, refusing to eat Refusing needed medications Mixing medications Alcohol abuse Loss of will to live

Poor Outcomes
Comorbid Conditions Anxiety Medical problems Cognitive impairment Concurrent Problems & Issues Psychotic depression Impaired social support Stressful life events Multiple previous episodes

Major Depression
Depressed mood most of the day, everyday

OR
Loss of interest or pleasure nearly every day and at least 4 additional symptoms . . .

Major Depression, cont.


FOUR ADDITIONAL SYMPTOMS

Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy

Feelings of worthlessness, inappropriate guilt Loss of ability to think, concentrate, make decisions Recurrent thoughts of death, suicidal ideation

MINOR Depression
Also known as

Associated with:

subsyndromal depression subclinical depression mild depression

2 - 4 times more common than major depression

subsequent major depression greater use of health services reduced physical, social functioning loss of quality of life

Responds to same treatments!

Common Causes of Depression


CHAIN OF EVENTS Stress & loss Biological depression Physical illness and its treatment interact with depression in older adults

Stress and Loss in Late Life


Decreased sensory capacity

vision hearing

Changes in social status, responsibility to others Loss of family, friends

Relocation due to changing abilities Declining social contacts due to health limitations Reduced functional status Dwindling financial resources

Stress and Loss in Late Life


Loss of meaningful roles

productivity purpose in living helplessness powerlessness

Loss of self-esteem

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 physical illness are still important to address!!

Physical Illness & Depression


Physical illness directly cause symptoms of depression

metabolic endocrine neurologic pulmonary cardiovascular musculoskeletal others: cancer, anemia

Physical Illness & Depression


Physical illness can cause a reaction of depression by causing

chronic pain, fear of pain disability, loss of function loss of self esteem increased dependence fear of death

Physical Illness & Depression


Depressed elderly may present with somatic (physical) complaints

aches, pains appetite, weight fatigue, loss of energy constipation tachycardia insomnia

Physical Illness & Depression


Medications can cause symptoms of depression

antihypertensives psychotropics analgesics cardiovacscular antimicrobials steroids others

Physical Illness & Depression


Environment in which physical illnesses are treated may contribute to depression . . .

Isolation Sensory deprivation Enforced dependency

Assessment
Depression symptoms Suicidal thoughts Psychiatric history

personal family

Physical health/illness Medications Recent loss/stress Resources/abilities

Geriatric Depression Scale


Score 0 or 1 Add up points (0-30) Further assessment if > 10 Remember! Screening tool; assess symptoms further!!

Suicide Assessment
Always ASK!!! Have you thought that life isnt 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?

Psychiatric History
Previous episodes of depression

Look carefully!!

Check chart/record Undiagnosed Bad nerves; nervous breakdown; went to bed sick After childbirth, (postpartum), children leave (empty nest), death of loved one, retirement

Physical Health/Illness
Consider factors that increase isolation, loneliness, fear, or worthlessness!!

Look for factors that directly increase depression symptoms

Medications
New? Change in dose?

Loss of mobility Level of disability Worry about declining abilities Pain resulting from health conditions

New onset of physical illness


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 persons perspective and experience:

Facility, Staff

control, power loss unwanted dependency meaning of functional losses, relationship to activity, meaning and purpose in living

Interventions
Depression is highly treatable Depression is sometimes called A reason for hope Many treatments

Talking therapy Medications Daily contacts

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 social environment.

Interventions
Communicate caring

Remind: WE VALUE THEM even if they don't seem to care about themselves right now Ask: how they feel or what they think Encourage: to talk about issues, fears Understand: their point of view Accept: sadness, other feelings

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 information about DEPRESSION

An ILLNESS, like physical illness Symptoms are part of depression Common in people of all ages Has a treatment AND treatment works
Medications 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 Activity


Exercise program Referrals

physical therapy occupational therapy recreational therapy

Develop daily activity schedule Involve in meaningful activity

Promote Autonomy

Create mastery experiences


break tasks into steps assure success promote self worth, build confidence

Encourage personal control, power


independent activity decision-making involvement in care

Focus on Positive
Current abilities

knowledge, wisdom experiences attitudes, beliefs attributes promotes self worth strengthens tie to identify, former self stimulates interests, conversation

Reminiscence

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


Social interaction Mastery experiences Realization I am not alone in this!

Many benefits

Promote Creativity
Lots of alternatives:

Singing, playing music Story-telling Drawing, painting Poetry, writing Making crafts, jewelry
Decreased depression, loneliness Increased health, morale, satisfaction, activity

Associated with positive health outcomes


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

A REASON FOR HOPE

Sleep Disturbances
-Incidence increase with aging -Difficulty sleeping, Daytime drowsiness & Daytime napping -Causes: *medical conditions. *Environment. *Medications. *Normal changes associated with aging .

Medications Medical Conditions Primary Sleep Disorders

Complaint of Insomnia

Psychiatric Conditions

Psychosocial Factors

Poor Sleep Hygiene

Examples of Legal Drugs That Cause Insomnia


Alcohol
Decongestants CNS stimulants Stimulating antidepressants Beta-blockers Diuretics Thyroid hormones Bronchodilators

Nicotine
Calcium channel blockers

Caffeine
Corticosteriods CNS Depressants Quinidine Anticonvulsants Antiparkinsonian agents

Consequences of Poor Sleep in older adults


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

Difficulty sustaining attention and slowed response time Decreased ability to accomplish daily tasks Impairments in memory and concentration Increased consumption of healthcare resources higher incidence of symptoms related to depression and anxiety

Increased risk of falls (even after controlling for medication use, age, difficulty walking, difficulty seeing and depression) Shorter survival/increased institutionalization rate Inability to enjoy social relationships/decreased QOL Increased incidence of cognitive 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 Hypnotics
Hydroxyzine (Vistaril) & Zolpidem (Ambien) Important Note prefer not to be used due to their S/E in elderly like memory impairment, ataxia, paradoxical excitement & rebound insomnia

Case
Ny. S, 69 th tinggal di rumah dg suaminya 72 th yg pensiun, dan 2 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 dan tokonya, dan skrg mereka hidup terpisah di rumah yg sama, tmasuk masak. Ny. S masak sndr u/ dia dan suaminya, dan punya pembantu 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 mgkn hasutan dr istri2nya. Ny. S merasa tdk berdaya dan tdk punya kekuatan u/ melawan. Selama ini Ny.S hidup dgn uang pensiun dan anak2nya tdk pernah memberikan uang.

Elder Abuse
Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of the elderly. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial abuse. Each type may be intentional or unintentional. The perpetrators are usually a spouse or adult children but may be other family members or paid or informal caregivers. Abuse usually becomes more frequent and severe over time.

Physical abuse is use of force resulting in physical or psychologic 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 to cause 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 also includes infantilization (a patronizing form of ageism in which the perpetrator treats the elderly person as a child), which encourages the elderly person to become dependent on the perpetrator.

Neglect is the failure to provide food, medicine, personal care, or other necessities. Neglect that results in physical or psychologic harm is considered abuse. Financial abuse is exploitation of or inattention to a person's possessions or funds. It includes swindling, pressuring a person to distribute assets, and managing 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 be detected and stopped. Social isolation can intensify stress. A chronic disorder, The ability to escape, seek help, and functional impairment, defend self is reduced. or both 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 perpetrator Substance abuse

Psychiatric disorders

History of violence

Dependence of the perpetrator on the elderly person

Stress

Alcohol or drug abuse, intoxication, or substance withdrawal 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 (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. 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 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. 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 living Elderly people living alone are arrangements much less likely to be abused. When living arrangements are shared, opportunities for the tension and conflict that usually precede abuse are greater.

Clinical Situations Suggesting Elder Abuse 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

Signs of Elder Abuse Item Sign Behavior Withdrawal by the patient Infantilization of the patient by the caregiver Caregiver's insistence on providing the history General appearance Poor hygiene (eg, unkempt appearance, uncleanliness) Inappropriate dress Skin and mucous Poor skin turgor or other signs of dehydration membranes Bruises, particularly multiple bruises in various stages of evolution Pressure ulcers Deficient care of established skin lesions Head and neck Traumatic alopecia (distinguished from male-pattern alopecia by distribution) Trunk Bruises Welts (shape may suggest implementeg, iron or belt) GU region Rectal bleeding Vaginal bleeding Pressure ulcers Infestations Extremities Wrist or ankle lesions suggesting use of restraints or immersion burns (ie, in a stocking-glove distribution) Musculoskeletal Previously undiagnosed fracture system Unexplained pain Unexplained gait disturbance Mental and emotional Depressive symptoms health Anxiety

Preventing elder abuse and neglect

Listening to seniors and their caregivers Intervening when you suspect elder abuse Educating others about how to recognize and report elder abuse

Latihan Kesadaran Diri: Intensitas marah Bayangkan situasi ini: 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, dalam keadaan 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 older people just as older people need young people in order to become more themselves and more human. That humanizing process will teach us that 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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