PERAN REHABILITASI MEDIK PADA GERIATRI Afriwardi

THE GERIATRIC TEAM PHYSICIAN / GERIATRICIAN :CLINICAL COORDINATOR / LEADER - Clinical Assessment & Treatment, rehabilitation etc. - Functional assessment. NEURORLOGIST PSYCHOLOGIST, PSYCHIATRICS NURSE : - Patients Care - Supporting other members of team - Functional assessment etc. MED. SOCIAL WORKER : Social & environmental ass. Other consultants : - Rehabilitation doctors& Physiotherapist - Nutritionist. - Pharmacyst Other consultants in relevant Specialistic Med.care

cepat atau lambat memerlukan Kelompok usia lanjut cepat atau lambat memerlukan Rehabilitasi Medis ?

FALSAFAH & TUJUAN REHABILITASI MEDIK Falsafah rehabilitasi medik ialah meningkatkan kemampuan fungsional seseorang sesuai dengan potensi yang dimiliki untuk mempertahankan dan atau meningkatkan Kualitas hidup dengan cara mencegah atau mengurangi Impairment, Disability dan handicap semaksimal mungkin

KATA KUNCI Kemampuan fungsional seseorang Potensi yang masih dimiliki Kualitas Hidup Diagnosis Kecacatan : Impairment Disability Handicap

3 STADIA FUNGSIONAL PERJALANAN PENYAKIT / CEDERA YANG DIDERITA SESEORANG : “IMPAIRMENT” (tingkat organ) : Stadia dimana penderita masih memerlukan / tergantung pada perawatan dan terapi secara aktif, sehingga tidak mampu melaksanakan kegiatan sehari-hari (ADL), “temporary disability” “DISABILITY” (tingkat manusia) : Stadia disebut juga “recovery period” dimana penderita mulai dapat melaksanakan pekerjaan sesuai keadaan kesembuhan penyakitnya “HANDICAP” (tingkat sosial) : Stadia cacat menetap, keterbatasan kemampuan dan melaksanakan tugas pekerjaan Prof. Soelarto Reksoprodjo Unit Rehabilitasi Medis Jakarta - Indonesia

REHABILITASI MEDIS Pendekatan medis, psikis, sosial, kultural, spiritual untuk meningkatkan kemampuan fungsional pasien atau para penyandang cacat. Rehabilitasi medis aspek yang sangat mendasar pada perawatan geriatri

Upaya Rehabilitasi Medik Bagian integral dari pelayanan Kedokteran/Kesehatan yang berkaitan langsung dengan terwujudnya kualitas hidup seorang pasien

Proses Rehabilitasi Medik adalah Proses mengembalikan Seseorang, dari perannya sebagai pasien, menjadi seorang manusia seutuhnya

Konsep Upaya Pencegahan dari Sudut Rehabilitasi Medis Pencegahan Primer Sehat  cegah jangan sakit (impairment) Pencegahan Sekunder Sakit (impairment)  cegah jangan cacat (disable) Pencegahan Tertier Cacat (disable)  cegah jangan handicap

THE ESSENTIAL COMPONENTS OF A COMPREHENSIVE REHABILITATION PROGRAM PATIENT PATIENT TRAINING EXERCISE PSYCHOSOCIAL INTERVENTION FOLLOW UP PREVENTION ASSESMENT Prevention Strategies

EVALUASI REHABILITASI DIAGNOSIS FUNGSIONAL GOAL JANGKA PENDEK GOAL JANGKA PANJANG PROGRAM REHAB/ TERAPI REEVALUASI REPROGRAM

Rehabilitation Rehabilitation efforts for frail elders may be directed to avoid loss of function, to help promote return or lost function, or both. Rehabilitation of older adults can take place in an acute hospital medical or rehabilitation unit, the nursing home, an outpatient area, or at patient’s home An important preventing measure in primary care is to encourage physical activity to help patients achieve a higher level of baseline function, so that they will have more functional reserve during an illness. Nusbaum NJ primary geriatric care a cased based approach 2007

Early Instruments Used in Rehabilitation In selecting an assessment instrument to be used in rehabilitation, choose those that are able to measure changes over a relatively short period of time, can detect small changes in function, and are based on a variety of sources of information.

Functional Status Functional status has been defined as “a person’s ability to perform tasks and fulfill social roles associated with daily living cross a broad range of complexity”. Measures of functional status are used for a wide variety of purposes. Clinicians apply them to establish baselines, to monitor the course of treatment, or for prognostic purposes. The assessment can also be used for screening. Gallo JJ, ADL & Instrumental ADL Assessment in and book of Geriatric Assessment 4th ed, 2006

Functional Status The capacity to function independently is poorly described by the constellation of medical diseases alone. Performance on mental status testing does not necessarily predict functional status. The severity of disease as measured by standard laboratory tests does not necessarily imply disability. Functional status should be assessed directly and independently of medical and laboratory abnormalities or cognitive impairment. Gallo JJ, ADL & Instrumental ADL Assessment in and book of Geriatric Assessment 4th ed, 2006

Functional Status Examinations of function divided into three levels: Basic Activities of Daily Living (BADL or ADLs) Instrumental Activities of Daily Living (IADL) Advanced Activities of Daily Living (AADL).

Barthel Index The Barthel Index (Mohaney & Barhel, 1965) was originally devised as a means of clearly differentiating patients who are dependent in ADL from those who are not. It is a 10 category, weighted index, which includes ambulation and stairs as well as self-care and has a perfect score of 100. At least five versions (including the original) have been used. These include zero to 20-point scoring modification (Collin, Wade, Davies, & Horne, 1988). The Index should be used as a record of what a patient does, NOT as a record of what a patient could do.

Barthel Index The Barthel Index was used to document improvement. Patients who did not improve their score during rehabilitation were believed to have poor potential for recovery.

INDEKS ADL BARTHEL (BAI) NO FUNGSI SKOR KETERANGAN 1 Mengendalikan rangsang pembuangan tinja 2 Tak terkendali/tak terukur (perlu pencahar) Kadang-kadang tak terkendali (1x seminggu) Tak terkendali Mengendalikan rangsang berkemih Tak terkendali atau pakai kateter Kadang-kadang tak terkendali (hanya 1x/24 jam) Mandiri 3 Membersihkan diri (seka muka, sisir rambut, sikat gigi) Butuh pertolongan orang lain 4 Penggunaan jamban, masuk dan keluar (melepaskan, memakai celana, membersihkan, menyiram) Tergantung pertolongan orang lain Perlu pertolongan pada beberapa kegiatan tetapi dapat mengerjakan sendiri beberapa kegiatan yang lain 5 Makan Tidak mampu Perlu pertolongan memotong makanan 6 Berubah sikap dari berbaring ke duduk Perlu banyak bantuan untuk bisa duduk (2 orang) Bantuan minimal 1 orang

INDEKS ADL BARTHEL (BAI) (lanjutan) NO FUNGSI SKOR KETERANGAN 7 Berpindah/berjalan 1 2 3 Tidak mampu Bisa (pindah) dengan kursi roda Berjalan dengan bantuan 1 orang Mandiri 8 Memakai baju Tergantung orang lain Sebagian dibantu (mis mengancing baju) 9 Naik turun tangga Butuh pertolongan 10 Mandi TOTAL SKOR 19 Skor BAI : Mandiri 5-8 : Ketergantungan berat 12-19 : Ketergantungan ringan 0-4 : Ketergantungan total 9-11 : Ketergantungan sedang

Lawton IADL Scale No 1 Dapatkah menggunakan telephone 2 Mampukah pergi kesuatu tempat 3 Dapatkah berbelanja 4 Dapatkah menyiapkan makanan 5 Dapatkah melakukan pekerjaan rumah tangga 6 Dapatkah melakukan pekerjaan tangan 7 Dapatkah mencuci pakaian 8 Dapatkah mengatur obat-obatan 9 Dapatkah mengatur keuangan Keterangan : 1 = mandiri 2 = butuh bantuan 3 = ketergantungan Nilai maksimal = 27

A HIERARCHICAL MODEL OF PHYSICAL FUNCTION When selecting a performance-based measure of function, rules that are used to choose any functional status measure apply

Hierarchy of physical function Balance Strength Flexibility Endurance Coordination Line motor Role function Task or goal-oriented function (e.g., ADL, IADL) Specific physical Movements (e.g., 8-foot walk) Integration level III Integration level II Integration level I Basic component

Hierarchy of Physical Function and Disability ADL = activities of daily living BADL = basic ADL Physically elite Sports competition, Senior Olympics High-risk and power sports (e.g., hang- gliding, weight lifting Physically fit Physically independent Moderate physical work All endurance sports and games Most hobbies Physically frail Physical function Very light physical work Hobbies (e.g., walking, and games Low physical demand activities (e.g., golf, social dance, hand crafts, traveling, auto- mobile driving) Can pass all IADLs Physically dependent Ligtht housekeeping Food preparation Grocery shopping Can pass some IADLs, all BADLs May be homebound Cannot pass some or all BADLs : waling bathing dressing eating transferring Needs home or institutional care Disability Adapted from Spicduso WW. Physical Dimensions of Aging. Champaign, IL; Human Kinetics; 1995

PROSES REHABILITASI Langkah 1 Atasi masalah medis utama Kondisi stabil, menjadi landasan untuk mengawali program Rehabilitasi Medis

Cegah Komplikasi Sekunder PROSES REHABILITASI Langkah 2 Cegah Komplikasi Sekunder Malnutrisi Inkontinensia Gangguan kognisi Pneumonia Kontraktur Dekubitus Sindroma dekondisi Ketergantungan Psikologis Depresi Trombosis Vena

Mengembalikan fungsi yang hilang PROSES REHABILITASI Langkah 3 Mengembalikan fungsi yang hilang Nilai kemampuan fungsional yang masih tersisa, dan maksimalkan Bila perlu, gunakan alat bantu agar mandiri, bersosialisasi Walau penyebab gangguan fungsi tak dapat dihilangkan, pasien tetap mampu beraktifitas

PROSES REHABILITASI Langkah 4 Ciptakan kemampuan adaptasi bagi pasien Adaptasi Fisik Adaptasi Psikis Adaptasi Sosial

PROSES REHABILITASI Langkah 5 Adaptasi Lingkungan Ciptakan lingkungan yang bersahabat, baik dirumah sakit, dirumah, dilingkungan, untuk kemudahan pasien beraktifitas

PROSES REHABILITASI Langkah 6 Adaptasi Keluarga 85% aktifitas usia lanjut, dirumah Para usia lanjut butuh waktu untuk ‘menerima’ kondisinya Keluarga, makna hidup bagi para usia lanjut Keluarga, mitra kerja tenaga medis/paramedis

PENGAWASAN & EVALUASI Lakukan Reevaluasi dan Reprogram Setiap kali, tentukan target baru, agar motivasi terjaga Target pencapaian merupakan kesepakatan dokter dan pasien

PEMILIHAN PROGRAM TERAPI REHABILITASI MEDIK Tujuan Rasional Dosis latihan tepat & jelas Latihan bertahap Jenis latihan mudah dan aman

Basic Consideration If we are to rehabilitate our elderly patient successfully we need: Timing of treatment The team Techniques

Basic Consideration Timing of treatment When does rehabilitation begin Frequency and intensity of therapy When to stop The team Involvement of patient and family Team coordinator Involvement of nurse in rehabilitation (enablement) Focusing on goals Concern with the well-being of the team

Basic Consideration Techniques Accurate assessment and recognition of all problems Prevention of complications Physical agents Physical techniques Compensating for disability Rating scales Morale and motivation

Age-related factors that may affect rehabilitation Biologic Muscle strength Cardiac function Pulmonary function Aerobic capacity Vital capacity Minute volume Orthostatic changes Peripheral resistance Psychologic Slow learning pace More repetitions Belief about rehab Belief about recovery Belief about self Social Negative views of aging Less frequent referrals Self-ageism Financial barriers

Disease-related factors that may affect rehabilitation Biologic Multiple diseases Deconditioning Contractures Disease-disease interactions Polypharmacy Subclinical organ dyfunction Psychologic Cognitive deficits Depression Atypical presentations motivation Social Societal prejudice (“Disabilityism”) Lack of services Inaccessible buildings Reimbursement regulations

Rehabilitation Problem List Primary rehabilitation diagnosis or anatomic injury Other associated diagnoses with severity measures Impairments (e.g., neurogenic, bladder, bowel, sexual function) Activity limitations (e.g., mobility, ADLs, communication) Education Participation barriers Psychological adaptation Social role function Architectural accessibility Community reintegration Vocational adaptation Spiritual practice

Quality of Life Paradigm has meaning for both patient and physician

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