GANGGUAN

Genitourinaria/Gastro
Intestininal
Pada Geriatri

Prof.Barmawi H.
Depart.of Internal Med.
Fac.of Med.Gadjah Mada Univ./UII.jogja
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Urinary System

• Poor circulation to the

kidneys and a decrease
in the number of
nephrons result in a loss
of ability to concentrate
the urine, which causes
a loss of electrolytes
and fluids

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Urinary System

• With aging, the kidneys

decrease in size and
become less efficient at
producing urine.

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OVERACTIVE BLADDER

• Urgency adalah keluhan keinginan berkemih yang kuat yang datang

secara mendadak, dan sulit ditahan.
• Frekwensi berkemih meningkat yang dikeluhan oleh pasien
pada siang hari ( setara dengan polyuria)
• Nocturia adalah keluhan dimana terbangun dari tidur
malam untuk berkemih lebih dari 1 x.

Abrams P et al. Neurourol Urodyn 2002;21:167-178

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Urinary System

Tips/ptunjuk keshatan for the elderly:

• Increase fluid intake to improve kidney function

• Drink most fluids before evening
• Regular trips to bathroom
• Wear easy to remove clothing
• Use absorbent pads
• Bladder training programs
• Indwelling catheter may be needed if all urinary
control is lost
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• PASIEN GERIATRI  JIKA TERSERANG KONDISI
AKUT :

GERIATRIC GIANTS :

SINDROM DELIRIUM/BINGUNG,PENURUNKSADARAN
DEPRESI
JATUH / INSTABILITAS POSTURAL
INKONTINENSIA
IMOBILISASI
GEJALA DEKONDISI

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 BASICS MECHANISMS

Three basic mechanisms serves as “final common pathways”

in nearly all causes of incontinence :
• Urge incontinence
 Hyperactive / irritable
bladdder
• Stress incontinence
 Urethral incompetence
• Overflow bladder

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INKONTINENSIA URGENSI

Tnpa sngaja

8
Urodynamics Made Easy – third edition
INKONTINENSIA STRESS

Tmp ddr gantung

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Urodynamics Made Easy – third edition
. GANGGUAN ELIMINASI/geriatri
. Inkontinentia atau ngompol adalah : pengeluaran urinetanpa
disadari dalam jumlah dan frekwensi yang cukup sehingga
mengakibatkan masalah ganggunan kesehatan atau sosial.

Penyebab :
- Melemahnya otot dasar panggul yang menyangga kandung
kemih/sphincter muscle dan memperkuat sfingter uretra.
- Kontraksi abnormal pada kandung kemih

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Urinary System

• The ability of the

bladder to hold/mnyimpan
urine decreases

• Sometimes the bladder

doesn’t empty all the
way.

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GANGGUAN ELIMINASI

- Obat diuretik yang mengakibatkan sering berkemih dan obat

penenang terlalu banyak.
- Radang kandung kemih
- Kelainan kontrol
- kandung kemih
- Kelainan persyarafan
- pada kandung kemih
- Akibat adanya hipertropi prostat
- Faktor psikologis

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 Penyebab inkontinentia urine ada dua yi :
akut dan kronis.
• jika akut dapat diatasi dan dapat dihilangkan dan sembuh, antara lain
karena delirium (kesadaran menurun/terganggu) karena gangguan
bergerak, dan karena obat-obatan mis : diuretika, antidepresan yg
berlebih
• Jika kronis, tidak dapat dihilangkan secara tuntas antara lain disebabkan
kelemahan otot dasar panggul, instabilitas otot kandung kemih sudah
berat, gangguan neurologis seperti stroke, penyakit parkinson.

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 Urinary Incontinence

Acute chronic

• Stress UI
• Overflow UI
• Urgency UI
• Functional UI
• Mixed UI

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 Ada 7 tipe inkontinentia urine yaitu :
a. Inkontinentia urine akut, bersifat mendadak dan dapat
disembuhkan
b. Inkontinentia urine kronis, bersifat
menetap, tidak dapat disembuhkan
tetapi gejala dapat dikurangi
c. Inkontinentia fungsional, tanpa gangguan pada saluran kemih,
merupakan akibat ketidak mampuan pasien mencapai toilet,
akibat gangguan muskuloskeletal

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d. Inkontinentia urgensi, akibat ketidakmampuan
menunda berkemih, jumlah urinenya sedikit,
frekwensi berkemih sering, tidak ada hubungan
dengan akitivitas kandung kemih. Tipe seperti ini
berhubungan dengan penyakit parkinson, stroke.
Lansia biasanya tidak punya cukup waktu dan
tempat yang layak untuk berkemih, dan paling
banyak tipe ini ditemukan pada lansia.

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e. Inkontinentia stres,urine keluar ketika
tekanan intra-abdomen meningkat seperti
pada saat batuk, bersin, tertawa, atau
latihan fisik. Hal ini disebabkan melemahnya
otot dasar panggul, jumlah urine yang keluar
bisa sedikit bahkan banyak.

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f. Inkotinentia overflow, lebih sering terjadi pada pria
daripada wanita, terjadi karena menggelembungnya
kandung kemih, seperti pada hipertrofi prostat. Pada
wanita biasanya akibat neuopati diabetik, trauma medula
spinalis atau efek obat. Pasien mengeluh adanya sedikit
urine keluar tanpa adanya sensasi kandung kemih
penuh. Tipe ini terjadi karena pengisian kandung kemih
melebihi kapasitas kandung kemih.

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Urinary System

• Nocturia may occur.

• Males may experience

an enlargement of the
prostate gland which
can make urination
difficult and causes
urinary retention.

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g. Inkontinentia campuran, merupakan
campuran tipe urgensi & stres, dpt terjadi pd
psn geriatri lebih mudah ditemukan tipe stres,
dan semakin tua biasanya kombinasi dgn tipe
urgensi.

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CAUSES OF REVERSIBLE URINARY
INCONTINENCE
D DELIRIUM D DELIRIUM
I INFECTION R RESTRICTED MOBILITY, RETENTION
A ATROPHIC VAGINITIS I INFECTION, INFLAMMATION, IMPACTION
P PHARMACEUTICAL P POLYURIA, PHARMACUTICAL
P PHYSIOLOGICAL DISORDERS
E ENDOCRINE DISORDERS
R RESTRICTED MOBILITY
S STOOL IMPACTION
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COMPLICATION OF URINARY
INCONTINENCE
• SKIN INFECTIONS
• FALLS
• FRACTURES
• DEPRESSION
• DECREASED LIBIDO AND SEXUAL DYSFUNCTION
• ACUTE HOSPITALIZATION
• SOCIAL ISOLATION
• STRESS
• REDUCED FEELING OF WELL-BEING
• INCREASED HEALTH-CARE 22
COSTS
Diagnosis

• Pemeriksaan Fisik

• Melakukan pemeriksaan umum, abdomen dan pemeriksaan neurologi

• Melakukan pemeriksaan panggul dan pemeriksaan dubur pada laki-
laki/prostat
• Mengobservasi keluarnya urine padastress (misalnya batuk, dll)
• Melakukan pemeriksaan residu urine apabila diduga ada obstruksi
bagian bawah (kesulitan berkemih, BPH, operasi daerah panggul
sebelumnya)

Fantl JA al. Agency for Healthcare Policy and

Research 1996;AHCPR Publication No. 96-0686

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Diagnosis

• Pemeriksaan Laboratorium

• Urinalysis
- untuk melihat adanya hematuria, pyuria,
bacteria, glucosuria, proteinuria
• Pemeriksaan darah bila diperlukan
- Glucose
- PSA (laki-laki di atas 50 tahun)
- Lain-lain

Fantl JA al. Agency for Healthcare Policy and Research

1996;AHCPR Publication No. 96-0686
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Diagnosis

• Obat-obatan yang mungkin berpengaruh

terhadap fungsi berkemih
• Diuretik • Narkotika
• Antidepresan • Sedatif
• Antihipertensi • OTC obat tidur dan
• Hipnotik demam
• Antipsikotik
• Analgesik
• Herbal

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 Diagnosis

• Deferensia diagnosis

~ BPH ~ Interstitial cystitis

~ Prolapse ~ Diabetes
~ Atrophic vaginitis ~ Urinary tract infection
~ Pelvic floor dysfunction ~ Urinary tract infection

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Peny.Gastro Intestinal
Ketidakseimbangan Faktor Invasif dan
Protektif

/berseteru

Host bermusuhan
Digestive System

Physical changes in the digestive system occur

when:

• Fewer digestive juices/asam and enzymes are

produced
• Muscle action becomes slower and peristalsis
decreases
• Teeth are lost
• Liver function decreases

Bio-Med Academy 29
Digestive System

Dysphagia

• Difficult swallowing
• Less saliva and a slower
gag reflex

Bio-Med Academy 30
Digestive System

Complaints

• Indigestion- slower
digestion of foods
• Flatulence
• Constipation

Bio-Med Academy 31
Digestive System

Tip for the Elderly:

• Repair or replacement of damaged teeth

• Relaxed eating atmosphere
• Avoid dry, fried, and/or fatty foods
• Recommend high-fiber and high-protein foods
• Careful use of seasoning to improve taste of food
• Increase fluid intake

Bio-Med Academy 32
Specific Illnesses
• The Gastrointestinal System
• Upper gastrointestinal tract
• Lower
gastrointestinal
tract
• Liver
• Gallbladder
• Pancreas
• Appendix

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 Bagan Teori keseimbangan integrasi mukosa saluran
cerna khususnya lambung & duodenum

Faktor
Faktor Agresif
Agresif Faktor
Faktor Defensif
Defensif
• Faktor Agresif • Faktor Defensif
• Asam lambung • Aliran darah mukosa
• Pepsin (mikrosirkulasi)
• Refluks cairan empedu • Sel epitel permukaan
• Nikotin • Prostaglandin
• Alkohol • Fosfolipid/Surfactans
• Obat antiinflamasi nonsteroid • Musin
• Kortikosteroid • Bikarbonat
• Helicobacter pylori • Motilitas

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Acute Gastritis

• Causes:
1. Eating too much or too rapid.
2. Eating contaminated foods.
3. Alcohol, NSAID, and bile reflux.
• Clinical Manifestations:
1. Abdominal discomfort.
2. Nausea, vomiting, and anorexia.
3. Headache.
4. Hiccuping.

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Acute Gastritis (cont’d)

• Management:
1. The patient usually recovers within few days
spontaneously.
2. If bleeding present, it needs surgery.

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Chronic Gastritis

• Causes:
1. Benign or malignant ulcers of stomach.
2. Bacteria Helicobacter Pylori (H. Pylori).
3. Smoking and alcohol.
• Diagnostic Investigation:
1. Upper GIT endoscopy and biopsies.
2. Serologic testing for H. Pylori antigen-
antibodies.

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Chronic Gastritis (cont’d)
• Clinical Manifestations:
1. Heart burn after eating.
2. Anorexia, nausea and vomiting.
3. Sour taste in the stomach.
4. Belching.
5. Vitamin B12 deficiency.
• Medical Management:
1. No irritating diet.
2. Antibiotics.
3. Vit. B12 IM injection.
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Chronic Gastritis (cont’d)
• Management:
1. Stress reduction techniques.
2. Promoting optimal nutrition:
a. Keep patient NPO.
b. When the symptoms subside , offer ice chips
followed by clear fluid diet then regular diet.
3. Promoting fluid and electrolytes balance.
4. Relief pain:
a. Avoid irritating foods.
b. Discourage smoking and alcohol.

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Terapi Gastritis Kronis

1. Antasida
• Bentuk tablet/gel. Yang terbaik gel.
• Dosis : (15-30) cc 3-4 kali sehari 1 jam sesudah makan.
• (Murah,)

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2. Penyekat reseptor-H2
a. Cimetidin
dosis 2x (200-400) mg tiap hari pagi dan malam atau
800 mg malam hari
b. Ranitidin
dosis 2x (150-300) mg tiap hari pagi dan malam atau
(300-600) mg malam hari
c. Famotidin
dosis 200 mg tiap hari
3. Golongan motilitas
• Donperidon 3x1
• Cisapride 3x (5-10) mg/hari

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4. Golongan prostaglandin E
• Misoprostol
• emprostil
5. Sitoprotektif :
Sukralfat, setraksat, Teprenon
6. Obat lainnya :
• Anti ansietas
• Anti depresi
• Anti ketegangan emosi
7. Bila diperlukan :
Terapi pembedahan : vagotomi

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Proton Pump Inhibitors (PPI)

• Omeprazole (Protonix), Esomeprazole (Nexium)

• Inhibit proton pump mechanism responsible for secretion of H ion
• May increase effects of Dilantin, Coumadin
• Give on empty stomach
Antiulcer Medication

• Sucralfate (Carafate)
• Cytoprotective agent
• Adheres to an ulcer site
• Give 1 hour before meals and at bedtime
• Do not crush/Liquid form available
• Side effect: constipation, dizziness
Penyakit sistem pencernaan/Usila
Gangguan pada lambung meliputi :
• Terjadi atrofi mukosa, atrofi sel kelenjar menyebabkan
sekresai asam lambung
• Gastritis adalah suatu proses inflasi pada lapisan
mukosa lambung.
• Ulkus peptikum pada esophagus, lambung dan
duodenum.
Gejala :
• Biasanya tidak spesifik
• Penurunan berat badan
• Mual
• Perut rasa tidak enak
Drug Therapy in the Elderly

• Prescription drug expenses make up ~ 7% of total

health care spending in elderly
• 65% of Americans age 65+ use at least one
prescription medication
• Elderly (65+) use 30% of Rx drugs and 40% of OTC
drugs
• Elderly with drug coverage average-18
prescriptions per year
• Elderly in nursing homes receive an average of 7
different medications
Geriatrics 46
Pharmacokinetics: Absorption

• Physiologic change • Clinical significance

• No significant change • Little to none
in gastric pH;
decreased absorptive
surface and splanchnic
blood flow; generally
preserved gastric
emptying time

Geriatrics 47
Pharmacokinetics: Distribution

• Increased body fat

• Significance: Fat soluble drugs cross membranes more easily and spread
widely (diazepam)
• Decreased lean body mass
• Significance: Water soluble drugs cross barriers less easily and are largely
confined/mlahirkan to lean body tissue (cimetidine, digoxin, ethanol)

Geriatrics 48
Pharmacokinetics: Distribution (Cont’d)

• Decreased serum albumin and lower protein binding

• Significance: Lower protein binding in elderly (theophylline, warfarin,
cimetidine)
• Exception: lidocaine binds primarily to alpha-1-acid-glycoprotein and it
shows higher binding in the elderly

Geriatrics 49
 Pharmacokinetics:
Hepatic Metabolism

• Physiologic change • Clinical significance

• Decreased liver mass • Phase 1 reactions altered
and hepatic blood flow (oxidation, reduction,
hydrolysis)
• Phase 2 reactions
(conjugation) not
significantly affected

Geriatrics 50
Pharmacokinetics:
Renal Elimination
• Physiologic change
• Creatinine clearance
reduced with aging or
disease
Geriatrics 51
• Clinical significance
• Dose adjustments
required for drugs
predominantly excreted
by the kidneys (digoxin,
LMWH)
 Contributors to Noncompliance
in Older Adults

• Complex treatment regimens and dosing schedules

• Medication side effects
• Physical disability (dysphagia, arthritis)
• Cognitive impairment
• Poor communication
• Inadequate understanding of therapy
• High cost of medications

Geriatrics 52
Contributors to Polypharmacy

• Patient
• Borrowing or sharing medications
• Failing/kekurangan to understand instructions
• Saving medication for later use
• Combining Rx’s with OTC’s and Herbals
• Visiting more than one physician
• Doctor
• Failing to review the patient’s medications
• Prescribing medications for common and non-life
threatening symptoms
• Treating multiple symptoms or illnesses with several drugs

Geriatrics 53
Principles of Appropriate Drug Prescribing

• Be alert to the possibility of drug interactions and adverse drug

reactions
• Consider efficacy, cost (generic vs. brand), and ease of administration
• Avoid using multiple drugs with similar actions and toxicity
• Do not prescribe drugs longer than necessary; discontinue if no
longer indicated

Geriatrics 54
Principles of Appropriate Drug Prescribing
(Cont’d)
• Psychotropic drugs (all of them) and cardiovascular
drugs (all of them) cause undesirable side effects.
Use them with caution
• Review all meds at each patient visit (“brown bag
test”) including indications and dosing
• Ask about the use of OTC’s and herbals
• Involve the patient in decision making and maintain
open communication
• Encourage the patient to report any new or unusual
symptoms
Geriatrics 55 THE END
Thanks for your attention!!

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