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1. Etiologi, Faktor Intrinsik dan Faktor Ekstrinsik Jatuh a.

Etiologi Jatuh Penyebab jatuh Kecelakaan Keterangan Kecelakaan murni (terantuk, terpeleset, dll) Interaksi antara bahaya di lingkungan dan faktor yang meningkatkan kerentanan Hilangnya kesadaran mendadak Kelemahan tungkai bawah mendadak yang menyebabkan jatuh tanpa kehilangan kesadaran Penyakit vestibular Penyakit sistem saraf pusat Hipovolemia atau cardiac output yang rendah Disfungsi otonom Gangguan aliran darah balik vena Tirah baring lama Hipotensi akibat obat-obatan Hipotensi postprandial Diuretika Antihipertensi Antidepresi golongan trisiklik Sedatif Antipsikotik Hipoglikemia Alkohol Berbagai penyakit akut Kardiovaskular: aritmia, penyakit katup jantung (stenosis aorta), sinkop sinus karotid Neurologis: TIA, stroke akut, gangguan kejang, penyakit Parkinson, spondilosis lumbar atau servikal (dengan kompresi pada korda spinalis atau cabang saraf), penyakit serebelum, hidrosefalus tekanan normal (gangguan gaya berjalan), lesi sistem saraf pusat (tumor, hematom subdural) Tak ada penyebab yang dapat diidentifikasi

Sinkop Drop attacks Dizziness dan/atau vertigo Hipotensi ortostatik

Obat-obatan

Proses penyakit

Idiopatik

b. Faktor risiko intrinsik Sinkop, drop attacks, dan dizziness merupakan penyebab jatuh pada orang usia lanjut yang sering disebut-sebut. Beberapa penyebab sinkop pada orang usia lanjut yang perlu dikenali antara lain respon vasovagal, gangguan kardiovaskular (bradi dan takiaritmia, stenosis aorta), gangguan neurologis akut (TIA, stroke, atau kejang), emboli paru, dan gangguan metabolik. Drop attacks merupakan kelemahan tungkai bawah mendadak yang menyebabkan jatuh tanpa kehilangan kesadaran. Kondisi tersebut seringkali dikaitkan dengan insufisiensi vertebrobasiler yang dipicu oleh perubahan posisi kepala. Dizziness atau rasa tidak stabil merupakan keluhan merupakan keluhan yang sering diutarakan oleh orang usia lanjut yang mengalami jatuh. Pasien yang mengeluh rasa ringan di kepala harus dievaluasi secermat mungkin adanya hipotensi postural atau depresi volume intravaskular. Di sisi lain, vertigo merupakan gejala yang lebih spesifik walaupun merupakan pemicu jatuh yang lebih

jarang. Kondisi ini dikaitkan dengan kelainan pada telinga bagian dalam seperti labirinitis, penyakit Meniere, dan benign paroxysmal positional vertigo (BPPV). Iskemia dan infark vertebrobasiler, serta infark serebelum juga dapat menyebabkan vertigo. Kebanyakan pasien usia lanjut dengan gejala dizziness dan unsteadiness merasa cemas, depresi, sangat takut jatuh, sehingga evaluasi gejala menjadi semakin sulit. Beberapa pasien, terutama pada mereka dengan gejala ke arah vertigo, memerlukan pemeriksaan otologi, termasuk uji auditori, yang dapat membedakan lebih jelas antara gejala akibat gangguan telinga dalam atau adanya keterlibatan sistem saraf pusat. Sekitar 10-20 persen orang usia lanjut mengalami hipotensi ortostatik yang sebagian besar tidak bergejala. Namun, beberapa kondisi dapat menyebabkan hipotensi ortostatik yang berat sehingga memicu timbulnya jatuh. Kondisi-kondisi tersebut antara lain curah jantung rendah akibat gagal jantung atau hipovolemia, disfungsi otonom (sebagai akibat diabetes melitus), gangguan aliran balik vena (insufisiensi vena), tirah baring lama dengan deconditioning otot dan refleks, serta beberapa obat. Hubungan hipotensi ortostatik dengan hipertensi perlu dipahami sehingga tatalaksana hipertensi yang baik amat diperlukan untuk mencegah timbulnya hipotensi ortostatik tersebut. Beberapa penyakit, terutama penyakit kardiovaskular dan neurologis, dapat berkaitan dengan jatuh. Sinkop dapat merupakan gejala stenosis aorta dan merupakan indikasi perlunya evaluasi pasien akan adanya stenosis aorta yang memerlukan penggantian katup. Beberapa pasien memiliki baroreseptor karotis yang sensitif dan rentan mengalami sinkop karena refleks tonus vagal yang meningkat akibat batuk, mengedan, atau berkemih sehingga terjadi bradikardia atau hipotensi. Stroke akut dapat menyebabkan jatuh atau memberikan gejala jatuh. TIA sirkulasi anterior dapat menyebabkan kelemahan unilateral dan memicu jatuh. TIA sirkulasi posterior (vertebrobasiler) mungkin juga dapat mengakibatkan vertigo, namun perlu disertai dengan satu atau lebih gejala lain seperti disartria, ataksia, kelemahan tungkai, dan berkurangnya lapangan pandang. Insufisiensi vertebrobasiler seringkali disebut sebagai penyabab drop attacks; kompresi mekanik arteri vertebralis oleh osteofit spina vertebra servikal manakala kepala diputar disebutkan pula sebagai penyebab ketidakstabilan dan jatuh. Penyakit lain pada otak dan sistem saraf pusat dapat pula menyebabkan jatuh. Penyakit Parkinson dan hidrosefalus tekanan normal menyebabkan gangguan gaya berjalan yang menyebabkan instabilitas dan jatuh. Gangguan serebelum, tumor intrakranial, dan hematoma subdural juga menyebabkan ketidakstabilan (unsteadiness) dengan kecenderungan mudah jatuh. c. Faktor risiko ekstrinsik Faktor risiko ekstrinsik merupakan faktor-faktor yang berada di lingkungan yang memudahkan orang usia lanjut mengalami jatuh. Berbagai faktor tersebut antara lain lampu ruangan yang kurang terang, lantai yang licin, basah, atau tidak rata, furnitur yang terlalu rendah atau tinggi, tangga yang tak aman, kamar mandi dengan bak mandi/closet terlalu rendah atau tinggi dan tak memiliki alat bantu untuk berpegangan, tali atau kabel yang berserakan di lantai, karpet yang terlipat, dan benda-benda di lantai yang membuat seseorang terantuk. Obat-obatan juga dapat menjadi penyebab jatuh pada orang usia lanjut. Misalnya, obat diuretika yang dikonsumsi menyebabkan seseorang berulang kali harus ke kamar kecil untuk buang air

kecil atau efek mengantuk dari obat sedatif sehingga seseorang menjadi kurang waspada saat berjalan . 2. Gangguan Keseimbangan

What is a balance disorder?

Figure 1: The vestibular system in relation to the ear. Credit NIH Medical Arts. View Larger Image. A balance disorder is a condition that makes you feel unsteady or dizzy, as if you are moving, spinning, or floating, even though you are standing still or lying down. Balance disorders can be caused by certain health conditions, medications, or a problem in the inner ear or the brain. Our sense of balance is primarily controlled by a maze-like structure in our inner ear called the labyrinth, which is made of bone and soft tissue. At one end of the labyrinth is an intricate system of loops and pouches called the semicircular canals and the otolithic organs, which help us maintain our balance. At the other end is a snail-shaped organ called the cochlea, which enables us to hear. The medical term for all of the parts of the inner ear involved with balance is the vestibular system (see Figure 1). Top How does the vestibular system work?

Figure 2: The role of the cupula in balance Credit: NASA Our vestibular system works with other sensorimotor systems in the body, such as our visual system (eyes) and skeletal system (bones and joints), to check and maintain the position of our body at rest or in motion. It also helps us maintain a steady focus on objects even though the position of our body changes. The vestibular system does this by detecting mechanical forces, including gravity, that act upon our vestibular organs when we move. Two sections of the labyrinth help us accomplish these tasks: the semicircular canals and the otolithic organs. The semicircular canals are three fluid-filled loops arranged roughly at right angles to each other. They tell the brain when our head moves in a rotating or circular way, such as when we nod our head up and down or look from right to left. Each semicircular canal has a plump base, which contains a raindrop-shaped structure filled with a gel-like substance (see Figure 2). This structure, called the cupula, sits on top of a cluster of sensory cells, called hair cells. The hair cells have long threadlike extensions, called stereocilia, that extend into the gel. When the head moves, fluid inside the semicircular canal moves. This motion causes the cupula to bend and the stereocilia within it to tilt to one side. The tilting action creates a signal that travels to the brain to tell it the movement and position of your head. Between the semicircular canals and the cochlea lie the otolithic organs, which are two fluid-filled pouches called the utricle and the saccule. These organs tell the brain when our body is moving in a straight line, such as when we stand up or ride in a car or on a bike. They also tell the brain the position of our head with respect to gravity, such as whether we are sitting up, leaning back, or lying down. Like the semicircular canals, the utricle and the saccule have sensory hair cells. These hair cells line the bottom of each pouch, and their stereocilia extend into an overlying gel-like layer. On top of the gel are tiny grains made of calcium carbonate called otoconia. When you tilt your head, gravity pulls on the grains, which then move the stereocilia. As with the semicircular canals, this movement creates a signal that tells the brain the head's position. Our visual system works with our vestibular system to keep objects from blurring when our head moves and to keep us aware of our position when we walk or when we ride in a vehicle. Sensory receptors in our joints and muscles also help us maintain our balance when we stand still or walk. The brain receives, interprets, and processes the information from these systems to control our balance. Top What are the symptoms of a balance disorder? If your balance is impaired, you may feel as if the room is spinning. You may stagger when you try to walk or teeter or fall when you try to stand up. Some of the symptoms you might experience are:

Dizziness or vertigo (a spinning sensation) Falling or feeling as if you are going to fall Lightheadedness, faintness, or a floating sensation Blurred vision Confusion or disorientation

Other symptoms are nausea and vomiting, diarrhea, changes in heart rate and blood pressure, and fear, anxiety, or panic. Some people also feel tired, depressed, or unable to concentrate. Symptoms may come and go over short time periods or last for longer periods of time. Top What causes a balance disorder? A balance disorder may be caused by viral or bacterial infections in the ear, a head injury, or blood circulation disorders that affect the inner ear or brain. Many people experience problems with their sense of balance as they get older. Balance problems and dizziness also can result from taking certain medications. In addition, problems in the visual and skeletal systems and the nervous and circulatory systems can be the source of some posture and balance problems. A circulatory system disorder, such as low blood pressure, can lead to a feeling of dizziness when we suddenly stand up. Problems in the skeletal or visual systems, such as arthritis or eye muscle imbalance, also may cause balance problems. However, many balance disorders can begin all of a sudden and with no obvious cause. Top What are some types of balance disorders? There are more than a dozen different balance disorders. Some of the most common are:

Benign paroxysmal positional vertigo (BPPV) or positional vertigo is a brief, intense episode of vertigo that occurs because of a specific change in the position of the head. If you have BPPV, you might feel as if you're spinning when you look for an object on a high or low shelf or turn your head to look over your shoulder (such as when you back up your car). You also may experience BPPV when you roll over in bed. BPPV is caused when otoconia tumble from the utricle into one of the semicircular canals and weigh on the cupula. The cupula can't tilt properly and sends conflicting messages to the brain about the position of the head, causing vertigo. BPPV sometimes may result from a head injury or just from getting older. Labyrinthitis is an infection or inflammation of the inner ear that causes dizziness and loss of balance. It frequently is associated with an upper respiratory infection such as the flu. Mnire's disease is associated with a change in fluid volume within parts of the labyrinth. Mnire's disease causes episodes of vertigo, irregular hearing loss, tinnitus (a ringing or buzzing in the ear), and a feeling of fullness in the ear. The cause of this disease is unknown. For more information, read the NIDCD fact sheet Mnire's Disease. Vestibular neuronitis is an inflammation of the vestibular nerve and may be caused by a virus. Its primary symptom is vertigo. Perilymph fistula is a leakage of inner ear fluid into the middle ear. It can occur after a head injury, drastic changes in atmospheric pressure (such as when scuba diving), physical exertion, ear surgery, or chronic ear infections. Its most notable symptom, besides dizziness and nausea, is unsteadiness when walking or standing that increases with activity and decreases with rest. Some babies may be born with perilymph fistula, usually in association with hearing loss that is present at birth. Mal de debarquement syndrome (MdDS) is a balance disorder in which you feel as if you're continuously rocking or bobbing. It generally happens after an ocean cruise or other sea travel. Usually, the symptoms will go away in a matter of hours or days after you reach land. However, severe cases can last months or even years.

Gait (the process of walking) and balance are intricate movements. They rely on proper functioning from several areas of the body. These include the ears, eyes, brain, and muscles. Problems with any of these areas can lead to walking difficulties, falls, or injury if not addressed.

Walking difficulties may be temporary or long-term, depending on the cause. What Causes Gait and Balance Problems?

Potential causes of temporary gait or balance problems include injury, trauma, inflammation, or pain. Longer-term difficulties often result from muscular neurological issues.

Problems with gait, balance, and coordination are often caused by specific conditions. These include:

joint pain or conditions, such as arthritis multiple sclerosis (MS) Meniere's disease brain hemorrhage brain tumor Parkinsons disease Arnold-Chiari malformation spinal cord compression or infarction Guillain Barre peripheral neuropathy myopathy cerebral palsy gout muscular dystrophy

Obesity, chronic alcohol abuse, vitamin B12 deficiency, and stroke are other causes. The condition may also be the result of vertigo, migraines, deformities, and certain medications including antihypertensives.

Gait and balance problems can be a result of pain, muscle weakness, muscle tightness or spasticity, loss of balance, or poor posture. Other causes include limited range of motion, numbness (sensory deficit), and fatigue. Muscle weakness can occur in one leg or both, and make walking difficult. Foot numbness makes it difficult to know where the feet are moving or whether they are touching the floor. Symptoms of Gait and Balance Problems

The most common symptoms of gait and balance problems include difficulty walking, trouble with balance, and unsteadiness. Patients can experience dizziness, light-headedness, vertigo, motion sickness, or double vision.

Other symptoms may occur depending on the underlying cause or condition. Diagnosing Gait and Balance Problems

A physical and neurological examination can diagnose gait or balance problems. Doctors typically also ask questions about symptoms and severity.

Performance testing can then be used to assess individual gait difficulties. Potential further tests to identify causes include hearing tests, inner ear imaging, and vision tests including watching eye movement. Magnetic resonance imaging (MRI) or a computed tomography (CT) scan can check the brain and/or blood pressure/heart rates tests. A doctor will look to find which part of the nervous system is contributing to the gait and balance problems. Treating Gait and Balance Problems

Treatment for gait and balance problems depends on the cause. Treatments may include medications and physical therapy, or rehabilitation to learn to function or compensate for lack of balance. Affected patients may also learn how to prevent falls. For vertigo-caused balance issues, you may learn how to position your head to regain balance. Gait and Balance Problem Prognosis

The prognosis of gait and balance problems is dependent on the underlying medical condition.

Falls in older adults, due to gait and balance problems, are a common cause of mortality and morbidity and can lead to injury, loss of independence, and change in lifestyle (Krucik, 2013).

3.

Komplikasi yang Mungkin Timbul Setelah Jatuh pada Geriatri Jatuh pada lansia menimbulkan komplikasi-komplikasi seperti tersebut di bawah ini: 1. 2. 3. 4. 5. Perlukaan (injury) Perawatan rumah sakit Disabilitas Risiko untuk dimasukkan dalam rumah perawatan (nursing home) Kematian (Martono dan Pranaka, 2011)

Lebih dari 50 % jatuh pada orang tua mengakibatkan cedera. Meskipun sebagian besar luka tidak serius ( misalnya , memar , lecet ) , luka jatuh - terkait account untuk sekitar 5 % dari rawat inap pada pasien 65 . Sekitar 5 % dari jatuh menyebabkan patah tulang humerus , pergelangan tangan , atau panggul . Sekitar 2 % dari jatuh menyebabkan patah tulang pinggul . Luka serius lainnya (misalnya , kepala dan luka , lecet ) terjadi pada sekitar 10 % jatuh . Beberapa cedera yang berhubungan dengan jatuh fatal. Sekitar 5 % dari orang tua dengan patah tulang pinggul meninggal saat dirawat di rumah sakit , kematian secara keseluruhan dalam 12 bulan setelah patah tulang pinggul berkisar 18-33 % . Sekitar setengah dari orang tua yang jatuh tidak bisa bangun tanpa bantuan . Sisa di lantai untuk > 2 jam setelah jatuh meningkatkan risiko dehidrasi , ulkus tekanan , rhabdomyolysis , hipotermia , dan pneumonia. Ketika orang tua jatuh, tergantung pada sejauh mana cedera (ies), orang dapat mengembangkan pneumonia sebagai akibat imobilitas, atau berada di tempat tidur. Pneumonia adalah infeksi yang dapat mengembangkan pada orang tua sebagai akibat dari penurunan sistem kekebalan tubuh yang terjadi secara alami dalam penuaan. Orang tua lebih rentan terhadap pneumonia berat dan komplikasi dari pneumonia daripada orang yang lebih muda. Kematian akibat pneumonia berkisar setinggi 80% pada orang 60 dan lebih tua. Jatuh sering menyebabkan imobilitas yang dapat menyebabkan menjadi tempat tidur terikat. Istirahat di tempat tidur dapat menyebabkan peradangan paru-paru yang dapat berkembang menjadi pneumonia. Menurunkan resistensi terhadap infeksi karena berkurangnya kekebalan tubuh secara umum dan infeksi dari pneumonia, khususnya. Setelah usia 60, kemungkinan meningkat untuk orang tua yang lebih tua untuk mengembangkan pneumonia dan komplikasi dari infeksi ini yang dapat berakhir dengan kematian (Fitzwater, 2008). Fungsi dan kualitas hidup dapat memburuk secara drastis setelah jatuh , setidaknya 50 % dari orang tua yang bisa berjalan sendiri sebelum patah pinggul tidak sembuh tingkat sebelumnya mobilitas . Setelah jatuh , orang tua mungkin takut jatuh lagi , sehingga mobilitas kadang-kadang berkurang karena kepercayaan hilang . Beberapa orang bahkan mungkin menghindari kegiatan tertentu (misalnya , belanja , membersihkan ) karena takut ini . Penurunan aktivitas dapat

meningkatkan kekakuan sendi dan kelemahan , lebih lanjut mengurangi mobilitas (Rubenstein, 2013).

Daftar pustaka http://www.merckmanuals.com/professional/geriatrics/falls_in_the_elderly/falls_in_the_elderly.ht ml http://www.netwellness.org/question.cfm/59056.htm http://www.healthline.com/symptom/gait-abnormality http://www.nidcd.nih.gov/health/balance/pages/balance_disorders.aspx