KOGNITIF PADA GERIATRI dr. Dani Rosdiana, SpPD SMF Penyakit Dalam/ FK Univ Riaupppppppppppppppppppppp

TUJUAN 1.Mampu mendemonstrasikan cara penilaian fungsi kognitif pada pasien geriatri 2.Mampu melakukan penyuluhan dan edukasi pada pasien geriatric 3.Mengetahui pencegahan dan rehabilitasi terkait gangguan kognitif dan perilaku

MILD COGNITIVE IMPAIRMENT

KOGNITIF? FUNGSI KOGNITIF: kemampuan mental yang meliputi ranah: –Atensi –Verbal (kemampuan berbahasa) –Daya ingat –Visuospasial –Kemampuan membuat konsep Seiring dengan penuaan : akan mengalami perubahan 50% populasi lansia akan mengalami penurunan fungsi kognitif

MILD COGNITIVE IMPAIRMENT  Clinically defined by an impairment in one or more cognitive domains for age, but do not meet criteria for dementia ( Peterson et al. 1999)  MCI: is clinically identifiable precusor of dementia, particularly Alzheimer’s disease (AD) DEFINITION

Prevalence-population studies (pranza et al, 2005) – 3-5% for age 60 and older – 15% for age 75 and older Incidence: – Slighty higher for men than women – Higher in older or with less education per 1000 person- years for 65 and older 54 per 1000 person- year for age 75 and older PREVALENCE

CONSENSUS Patient is not normal but not demented (DSM IV) Evidence of cognitive deterioration for age – Objective measured decline over time in cognitive task performance, and /or – Subjective report of decline by patient and/or informant and objective cognitive deficits Preserved activities of daily living and minimal to no impairment on complex instrumental functions CLINICAL APPROACH

Rate of progression to dementia: – Almost 12 % per year Can progress to AD, vascular dementia (Solfrizzi et al 2004), Lewy Body Dementia (Bennett et al, 2005)

Neuropsychological impairments initially described for verbal and visual memory-amnestic MCI Deficits now described in single or multiple cognitive domains (eg language, visuospatial) yielding –Multidomain amnestic –Multidomain nonamnestic –Single domain non memory

PATHOLOGY Possible: –Degenerative –Vascular –Metabolic –Traumatic –Psychiatric or combination Pathology reflects condition as progresses If deceased prior to conversion to dementia, pathology is intermediate between normal and pathology

DEMENTIA  An acquired syndrome :  Persistent impairment of cognitive abilities ( at least 2 ): orientation, attention, verbal capacity, visuo-spasial, calculation, executive function, motoric, judgment, praxia, abstraction.  Severe enough to interfere with occupational & social activities ( Green R.C )  Alzheimer’s disease : The most common aetiology of dementia

ALZHEIMER DISEASE The most devastating & dehumanizing among late – life illness Damage the ability to think, communicate and perform Dr. Alois Alzheimer

ALZHEIMER DISEASE  What is it like to have A.D. ?  How can we best care ?  How close are we to developing a cure ? ( Understanding Alzheimer’s Disease )

CHARACTERISTIC SIGNS OF ALZHEIMER DISEASE  Progressive memory loss  Misplacing things  Difficulty planning and performing familiar task  Disorientation in time, place and person

 Problems with language & speaking  Poor judgement Irritability Changes in mood & personality Severe depression Agitation Verbal & physical aggresion Delusions / false beliefs Failure to do rudimentary things

GUIDELINES FOR EFFECTIVE MANAGEMENT “Alzheimer disease is a family-systems disease”  Determine the patient’s subjective experience of the illness  Determine the family’s ability to care for the patient and who helps with care giving Nutritional status Ethical dilemmas of caring Community & social services Non pharmacological therapy & pharmacological therapy

ASSESSING SUBJECTIVE EXPERIENCE OF THE PATIENT Recognition and concern : “Something is wrong” Denial : “Not me” Anger, Sadness, Shame : “Why me” Coping : “In order to go on, I must do” Maturation : “Living each day till I die” Separation from self Evaluate & Respond To patient needs

VASCULAR DEMENTIA  Known as dementia associated with cerebro-vascular disease  Second most common form of dementia in the elderly, 15 % - 30 %  Substansial overlap with alzheimer’s disease  Multi infarct dementia ( Hachinski, 1974 ) DIAGNOSIS OF VASCULAR DEMENTIA Cognitive impairment or dementia Presence of cerebrovascular disease Establishment of a causal link between Dementia and the C.V.D

DIAGNOSTIC CRITERIA FOR ISCHEMIC VASCULAR DEMENTIA Essential Requirements  Dementia involving memory failure and other cognitive function in daily living  Cerebrovascular disease (determined through history, examination, or brain imaging)  Evidence that the above are causally related ; features that support causality include : Temporal relationship between stroke and dementia Abrupt or stepwise deterioration in mental function or fluctuating course Specific brain imaging findings. Indicating damage to regions important for higher cerebral function

Supportive Clinical Features  History of cerebrovascular risk factors (e.g, hypertension, diabetes mellitus, cardiac disease, elevated cholesterol, smoking)  Early appearance of gait disturbance or history of frequent falls  Early appearance of urinary incontinence, not explained by urologic disease  Frontal lobe or extrapyramidal features  Pseudobulbar features with or without emotional incontinence Adapted from : Roman GC, et al. 1993

( ACUTE ) CONFUSION 5 – 20 % of the elderly in the community 30 – 50 % of elderly patients DEFINITION A syndrome in which normal coherence on thought and action is lost CONFUSION : WHAT IS IT ? Attentional deficit To internal/external stimuli Unable to selectively respond Distractable Rigid Unable to order input Spatial Memory and Cognitive disorders Unable to order input Errors Misinterpretations With Acute onset ( hours to days ) and fluctuating course CREASEY,1995

PENGKAJIAN STATUS KOGNITIF – Sejalan dengan usia faal memori bisa berkurang Proses aging  kemampuan jaringan untuk recover menurun  tidak dapat bertahan dengan berbagai jejas termasuk infeksi – Memerlukan pengkajian status kognitif – MMSE atau AMT

Pemeriksaan MMSE (Mini Mental State Examination) Pemeriksaan STATUS MENTAL MINI NILAI MAKSNILAIORIENTASI 5( )Sekarang ini (tahun), (musim), (bulan), (tanggal), (hari) apa?  ORIENTASI WAKTU 5( )Kita berada dimana? (negara), (propinsi), (kota), (rumah sakit), (lantai/kamar)  ORIENTASI TEMPAT REGISTRASI 3( )Pewawancara menyebutkan nama 3 buah benda : satu detik untuk setiap benda. Kemudian pasien diminta mengulangi nama ketiga objek tadi. Berilah nilai 1 untuk tiap nama objek yang disebutkan benar. Ulangi lagi sampai pasien menyebut dengan benar : (bola, kursi, buku) Hitunglah jumlah percobaan dan catatlah : …………… kali

NILAI MAKSNILAI ATENSI DAN KALKULASI 5( )Pengurangan 100 dengan 7. Nilai 1 untuk setiap jawaban yang benar. Hentikan setelah 5 jawaban, atau eja secara terbali kata “ W A H Y U” (Nilai diberi pada huruf yang benar sebelum kesalahan: misal : UYAHW = 2 nilai) MENGENAL KEMBALI 3( )Pasien disuruh menyebut kembali 3 nama objek diatas tadi. Beirikan nilai 1 untuk tiap jawaban yang benar. BAHASA 2( )Apakah nama benda ini? Perlihatkanlah pinsil dan arloji 1( )Pasien disuruh mengulangi kalimat berikut : “JIKA TIDAK, DAN TAPI”

NILAI MAKSNILAIEKSEKUSI, VISUOSPASIAL 3( )Pasien disuruh melakukan perintah : “Ambil kertas itu dengan tangan anda, lipatlah menjadi dua dan letakkan di lantai” 1( )Pasien disuruh membaca, kemudian melakukan perintah kalimat “Pejamkan mata anda” 1( )Pasien disuruh menulis kalimat lengkap dengan spontan (tulis apa saja) 1( )Pasien disuruh menggambar bentuk dibawah ini JUMLAH NILAI : ( )

NILAI MAKSIMAL : 30 NORMAL : PROBABLE COGNITIVE IMPAIREMENT : DEFINITIVE COGNITIVE IMPAIREMENT : 0- 16