PROCEEDING UDAYANA UNIVERSITY INTERNATIONAL SYMPOSIUM
HOSPITAL BASED GERIATRIC SERVICE
Contents
Nutrition In Elderly : The Role Of Vit D Suplementation In The Healthy Aging 1 R A Tuty Kuswardhani
Hazzard’sInfectionIn Elderly 8
R A Tuty Kuswardhani
Vaccination TravelIn Elderly 15
R A Tuty Kuswardhani
Introduction Of Plant Based Diet Therapy for Hospital Based Geriatric Service 23 Naemi Kajiwara
Elderly Care In Netherlands Hospital 29
Maddy Stienstra Liem
Hospital Accreditation For Quality Improvement Hospital Based Geriatric Service 36 N P Arysta Kusuma Dewi
Research Article
Correlation Between Depression And Cognitive Impairment At Elderly People In Denpasar City 42 Ib Aditya Nugraha, R ATutyKuswardhani ,IgpSuka Aryana
Association Between Sleep Quality And Frailty Syndrome Among Geriatric Patients 48 At Geriatric Polyclinic Sanglah General Hospital
Adrian Tri Sutjahjo, TutyKuswardhani, I.G.P.Suka AryanaNyomanAstika, I.B.Putrawan,RaiPurnami
Correlation Of Visceral Fat Level And Poor Cognitive Function Among Elderly Population 55 In Denpasar
Erick Lios, R A TutyKuswardhani, IgpSuka Aryana
Correlation Between Hypertension And Cognitive Impairment In Elderly People In Denpasar 61 Made Arie Dwi Winarka, R.ATuty Kuswardhani ,Igp Suka Aryana
Albumin Level And Charlson Comorbidity Index Score In Predicting Length Of Hospitalization 67 In Geriatric Patients
1
INFECTION IN THE ELDERLY
Focus on Pneumonia in Elderly
RA Tuty Kuswardhani
Geriatric Division of Internal Medicine of Udayana University / Sanglah General Hospital /
Udayana University Teaching Hospital
Introduction
Generally, diseasses which are attacked elderly including infectious disease are often give
unclear symptomps. Therefore, accuracy is needed to know the diseasses. Late handling and
treatment to the infectious disseases can lead to fatal condition.
The tendency towards infection in elderly, the risk towards infection in elderly lead to multi
factorial. Risk factors consist of: comorbid, decrease of immune, aging process that lead to
complex.
Comorbid Infection in Elderly:
1. Old age and comorbid consist of diabetes, kidney failure, chronic lung disease, immobilization
and lead to decrease of innate immunity (non-specific barrier and immunity towards microbial
product). COPD, Pneumonia and old age lead to mucus clearance, alveolar disfunction, cough
reflex suppression increasing of risk of lower respiratory tract. Infections and old age lead to
poor prognosis
2. Decrease Immune System
Immune senescence lead to disregulation of the immune system
Up regulation of inflammatory response (CRP, IL-6, NFkB)
down regulation innate immunity (NK, PMN), adaptive immunity (decrease of naive T cell,
cytokines, cell surface receptor)
3. Social and Environmental Factors
2
Usually Low Income occurs in eldelry CAP towards elderly lead to poor nutrition and inadequate
vaccination.
Diagnosis and Management Infection in Elderly
Clinical manifestation of Elderly Infection:
In The Elderly the infection a typical features: decreasing of status mental, anorexia, worsening
of comorbid (CHF, diabetes mellitus).
Fever sometimes there is no response towards endogenous pyrogens such as IL-1, IL-6, TNF
lead to reduced
Old age and Frailty lead to decrease of basal temperature
Fever Criteria:
1. Persistent temperature 2 ° C (1.1 ° C) from basal temperature
2. Oral Temperature 99 ° F (37.2 ° C) or higher when the repetition
3. The rectal temperature of 99.5 ° F (37.5 ° C) or higher when the repetition
Decreasing fever response retardation in diagnosis makes poor prognosis, cognitive impairment
could not communicate well
Bacteremia and sepsis
Criteria of Bacteremia and Sepsis in elderly are:
1. 14% of the causes hospitalization
2. Systemic symptoms rarely
3. derived from GI or GU, gram-negative bacteria that cause >>
4. 35-42% mortality 28 days of age> 65 yrs
5. Nosocomial, gram negative à 37-50% mortality
6. Contamination during surgery
Pneumonia
Inflamation and Infection in Lungs like pneumonia are much suffered by elderly.
Fever more than 38 celcius degree, caugh, pain in chest, waekness and no appetite or sometime
3
Etiology
Streptococcus pneumonia, haemophilus influenza
Management:
1. Antibiotic:
2. Pneumococcal vaccine:
Standard vaccines for age more than 65 yrs or age <65 yrs with comorbid
Influenza vaccine
Annual Giving decrease respiratory disease, MRS, mortality
Immunization caregiver for prevent transmission
Pneumonia in Hospital
Pneumonia in hospital or hospital acquired pneumonia (HAP) is pneumonia appears ≥ 48 hours
after being treated at the Hospital and not intubation time of entry. HAP can be divided into: 1.
Early onset: appear 4-5 days after admission, 2. late-onset: appear after> 5 days were treated in
hospital.
Approach to Diagnosis
Anamnesis
HAP Clinical picture is not so clear and could not be used as criteria for the diagnosis of HAP. Can be found fever, sputum purulen.
Physical Examination
Body temperature> 38,3oC, lung examination can be found signs of consolidation as percussion dullness
Support Examination
Blood: leukocytosis> 10,000 / mm3, or leukopenia <4000 / mm3
X-ray of the thorax: infiltrat alveoral
Broncho alveoral lavage (BAL)
Blood cultures
Differential Diagnosis
4
Pneumonia is an inflammation of the lung parenchyma, distal to the terminal bronchioles which
includes the respiratory bronchioles and alveoli, and cause lung tissue.
Pneumonia grouped into:
1. Pneumonia acquired in the community or Community-Acquired Pneumonia (CAP):
Pneumonia in individuals who become ill outside the hospital, or within 48 hours after entering the hospital.
2. Pneumonia in the hospital or Hospital-Aqcuired Pnumonia (HAP).
3. Pneumonia related health services or Health Care Associated Pneumonia (HCAP)
4. Pneumonia due to the usage of a ventilator or ventilator-associated pneumonia (VAP)
Etiology of Pneumonia
Group l: Outpatient, without cardiopulmonary disease, without modification factor
Hemophilus influenza
Mycoplasma pneumonia
Streptococcus pneumoniae
Chlamydia pneumoniae
Virus respiratory tract
Therapy of Pneumonia
Pneumonia can be treated by giving Macrolides : azithrromycin 1x500mg orally (po), and clarithromycinc 2x500mg 1x250 mg po or 4x500mg po, Doxycycine2x100 mg po
Pneumonia Obtained in Community
Therapy
fluoroquinolones (moxifoxocin1x400mg po, gemifloxacin, or levolloxacin
1x500mg po / iv).
b-lactam + makrolia [selection amoxicillinhigh doses of 3x1 gram iv or
clavulanate amoxixillin 2x2 gram
5
Heart disease, liver, or kidney chronic, diabetes mellitus, alcoholism, malignancy, asplenia,
immunocompromised, use of antibiotics in the last 3 months. the risk of drug-resistant
Streptococcus pneumonia diagnosis.
Physical examination
Physical examination of Pneummonia can be seen in the explanation above.
laboratory
Routine Laboratory, Full blod count, erythrocyte sedimentation rate, blood glucose, ureum, creatinine, ALP
Blood gas analysis
sputum cultures
CRP
Differential Diagnosis
Acute bronchitis, acute exacerbation of chronic bronchitis
Management
Outpatient
It is recommended not to smoke, take a rest and drink plenty of fluids
Pleuritic pain / fever relieved by paracetamol
expectorants / mucolytics
Additional nutrients in a prolonged illness
Control after 48 hours or earlier if necessary
If you do not improve within 48 hours be considered for treated in a hospital, or do toto thorax
Inpatient Hospital
Oxygen, if necessary, by monitoring oxygen saturation and inspired oxygen concentration
Oxygen therapy for patients with complications of underlying disease with respiratory failure led to periodic measurements of blood gas analysis.
6 Nutrition
Ekspetoran / mukolitik
Chest X-ray was repeated in patients who do not show satisfactory improvement
antibiotic therapy was administered .
Refferences
Hernandez PSS, Reyes MV, Gonzales EG, Alvarez GG, Moreno SC, Ortiz AC. 2015.
Hospital-Acquired Infections in Elderly Versus Younger Patients in an Acute Care Hospital.
http://www.jmidonline.org/upload/sayi/20/JMID-00829.pdf. Accessed on October 27th 2015.
Ozdemir K, Dizbay M. 2015. Nosocomial infection and risk factors in elderly patients in
intensive care units. www.jmidonline.org/upload/JMID-00829.pdf. Accessed on October 27th
2015.
Nicolle NE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. 2011. Infectious Diseases
Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in
Adults. www.idsociety.org/Guidelines/Asymptomatic.pdf. Accesed on October 28th 2015.
Castillo JG, Sanchez FJM, Llinares P, Menendez R, Mujal A, Navas E, Barberan J. 2014.
Guidelines for the management of communityacquired pneumonia in the elderly patient.
http://www.seq.es/consensos/38--consensos-de-la-seq-infecciones-respiratorias/364-guidelines-for-the-management-of-community-acquired-pneumonia-in-the-elderly-patient.pdf. Accessed on
October 29th 2015.
Lindhardt T, Klausen HH, Christiansen C, Smith LL, Pedersen J, Andersen O. 2013. Elderly
patients with community-acquired pneumonia are not treated according to current guidelines.
http://www.danmedj.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname=9622976.pdf
7
Thiem U, Heppner HJ, Ludger Pientka. 2011. Elderly Patients with Community-Acquired
Pneumonia. Vol 28, Issue 7, pp 519-537.
http://link.springer.com/article/10.2165/11591980-000000000-00000. Accesed on October 30th 2015.
Fieldman C, Brink AJ, Richards GA, Maartens G, Bateman ED. 2011. Management of
Community-Acquired Pneumoniain Adults.
http://www.acutemed.co.uk/docs/Pneumonia,%20comm-acquired,%20SAMJ,%2007.pdf.
