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Tips Praktis
Menangani Masalah Kesehatan Pasien Geriatri
Tim Editor:
Purwita Wijaya Laksmi Risca Marcelena
Prosiding Temu Ilmiah Geriatri 2016
Tips Praktis Menangani Masalah Kesehatan Pasien Geriatri
Tim Editor: Purwita Wijaya Laksmi, Risca Marcelena
© 2016 Perhimpunan Gerontologi Medik Indonesia Cabang Jakarta
vii + 202 halaman 15 x 23 cm
ISBN: 978-979-19931-6-6
Hak Cipta Dilindungi Undang-undang
Dilarang memperbanyak, mencetak, dan menerbitkan se
bagian atau seluruh isi buku ini dengan cara dan bentuk apa pun juga tanpa seizin penulis dan penerbit.
Diterbitkan pertama kali oleh
Perhimpunan Gerontologi Medik Indonesia Cabang Jakarta
Jakarta, September 2016
email: [email protected]
Redaktur pelaksana: Sri Herawati
AuliaRizka
Dewa Pu tu Pramantara
Edy Rizal Wachyudi
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I Nyoman Astika
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Nina Kemala Sari
Noto Dwimartutie
Novira Widajanti
Siti Setiati
Penulis
Divisi Geriatri
Departemen Ilmu Penyakit Dalam
FKUI/RS. Dr. Cipto Mangunkusumo Jakarta Divisi Geriatri
Departemen Ilmu Penyakit Dalam FK UGM/RSUP Dr. Sardjito Yogyakarta Divisi Geriatri
Departemen Ilmu Penyakit Dalam FK UGM/RSUP Dr. Sardjito Yogyakarta Divisi Geriatri
Bagian Ilmu Penyakit Dalam FK UNUD/RSUP Sanglah Denpasar Divisi Geriatri
Bagian Ilmu Penyakit Dalam FK UNUD/RSUP Sanglah Denpasar
Departemen Ilmu Kesehatan Kulit dan Kelarnin FKUI/RS. Dr. Cipto Mangunkusumo Jakarta Departemen Psikiatri
FKUI/RS. Dr. Cipto Man
gUnk
usumo Jakarta Divisi GeriatriDepartemen Ilmu Penyakit Dalam
FKUI/RS. Dr. Cipto Mangunkusumo Jakarta Divisi Geriatri
Departemen Ilmu Penyakit Dalam
FKUI/RS. Dr. Cipto Mangunkusumo Jakarta Divisi Geriatri
Departemen Ilmu Penyakit Dalam FKUnair /RSU Dr. Soetomo Surabaya Divisi Geriatri
Departemen Ilmu Penyakit Dalam
FKUI/RS. Dr. Cipto Mangunkusumo Jakarta
Kata Pengantar
Pasien usia lanjut membutuhkan pendekatan khusus baik dari aspek diagnosis dan terapi, karena karakteristiknya yang khusus pula, seperti multipatologi, malnutrisi dan tampilan klinisnya yang atipikal. Pendekatan khusus ini yang secara umum dinamakan Pengkajian Paripurna Pasien Geriatri, menganalisis seorang pasien usia lanjut dari berbagai aspek tidak terbatas pada aspek medik saja. Kemampuan untuk melakukan pendekatan yang berbeda ini merupakan suatu hal yang hams dipelajari dan dilatih oleh para klinisi yang melayani pasien usia lanjut pada praktek sehari-hari.
Buku ini memuat kumpulan tulisan ilmiah para pembicara terkait Temu Ilmiah Geriatri yang mengusung tema "Tips Praktis Menangani Masalah Kesehatan Pasien Geriatri" . Tulisan tersebut diharapkan dapat menjadi bekal pengetahuan masyarakat profesi kesehatan dalam menjawab tantangan pelayanan kesehatan bagi kaum usia lanjut di Indonesia. Selain itu, abstrak penelitian pada orang usia lanjut di Indonesia juga ditampilkan· agar dapat mem
berikan wawasan data lokal terkait penelitian orang usia lanjut dan diharapkan dapat menjadi acuan bagi perkembangan penelitian selanjutnya di Indonesia.
Semoga bermanfaat Jakarta, September 2016 Tim Editor
Daftar Isi
The Iceberg Phenomenon of Malnutrition in Elderly ... 1
Keselamatan Pasien Geriatri: Panggilan untuk Bertindak... 14 Guideline for Dyslipidemia Management:
Focus on Adults and Elderly ... 26 Peranan Obat Herbal pada Insomnia Usia Lanjut ... . . . . .. . ... . 38 Update Herpes Zoster dan Neuralgia Pasca-Herpes... 52 Masalah Berkemih Spesifik pada Perempuan Usia Lanjut.... 59
Stratifikasi Pasien Usia Lanjut Risiko Tinggi di
Instalasi Gawat Darurat . . . 69
Pengembangan Pelayanan Rawat Rumah Pasien Geriatri:
Pengalaman RSUP Dr. Sardjito Yogyakarta. .. ... .. . ... ... . ... 90
Peranan Nutrisi pada Perbaikan Komplikasi yang Um um
pada Pasien Geriatri: Fokus pada Frailty. . . . .. . . 102 Peran Protein dan Suplementasinya pada Usia Lanjut ... 119 Diagnosis dan Terapi Demensia pada Usia Lanjut... 1 24
Demensi - Perawatan Pasca Diagnosis
dan Dukungan Lingkungan ... .. . . .. . . .. . . .. . . .. . . 133 Vaksinasi Influenza Quadrivalent pada Usia Lanjut... 1 39
The Iceberg Phenomenon of Malnutrition in Elderly
Siti Setiati, Robby Pratomo Putra
Introduction
The elderly population is growing rapidly in various parts of the world including in Indonesia. This phenomenon is due to the decrease of birth rates and increase of life span.
The life expectancy in Indonesia is expected to increase from 67.8 years in 2000-2005 to 73.6 years in 2020-2025. According to World Health Organization (WHO), the proportion of elderly people will rise to 22% of the world population, and in 2050 there will be 2 billion people aged 60 years and older. In 2002, Indonesia was ranked 6th as the most populous elderly people, and expected to raise to rank 5th in 2025. The increase of elderly people will be followed by the emergence of various problems in health care and services, with malnutrition as one of the problems.
Nutrition is an important aspect for health, physical function, age longevity, and quality of life. When the nutritional needs of an individual is not adequate, it will cause a condition called malnutrition. Malnutrition is often undiagnosed in the elderly, which results in failure to meet nutritional needs of this population. One of the risk factors is health workers do not care for malnutrition screening in the elderly. Several diseases in the elderly including chronic degenerative diseases are associated with malnutrition such as: hypertension, stroke, cardiovascular diseases, demensia, diabetes, etc.
The elderly are prone to malnutrition due to several causes of aging process such as: decrease of physical activity, decrease of lean body mass, decrease of protein turnover, decrease of taste sensation, decrease of stomach compliance, etc. Therefore,
early screening of nutritional status in elderly is important for better outcomes of malnutrition treatment in the elderly.
However, attempts to provide the elderly with adequate nutrition encounter many problems such as: nutritional requirements are not well defined, inconsistent nutrient needs due to aging with some components increasing while some components decreasing.
Malnutrition is classified into two types which are:
undernutrition and overnutrition, but sometimes the term malnutrition is often referred to undernutrition only. The undernutrition type consists of: protein energy malnutrition (PEM), low BMI, and wasting syndrome. The overnutrition type, on the other hand, consists of: obesity, dyslipidemia, and hypervitaminosis. However, there is a certain time while the component of undernutrition is also found in overnutrition patients. Such as when the elderly with obesity has an unbalanced diet, comorbid disease, or low physical activity, may also becomes lack of protein.
One of the main effects of malnutrition is a condition/
d isease called sarcopenia. This disease has several factors that has association of causal effect with each other such as:
immobilization, decrease in protein reserves due to anorexia or normal aging, falls, hospitalization, in which all of these will cause decrease in capacity of protein synthesis to fight other diseases or traumas and may cause death in the individual.
Indonesia is an archipelago country consists of more than 1 7,000 islands. There are 33 provinces, 440 districts, and 72,000 villlages currently. There are more than 250 million people from 300 ethnic groups to date. The elderly population comprises more than half of the population, and the proportion of elderly increases while children decreases. Despite the general improvements in health and social services, health and nutrition problems still exist in various forms due to geographic, demographic, and cultural variations. We will present several data about nutrition problems in the elderly from various
researches in Indonesia compared with other countries, in various aspects such as: epidemiology of undernutrition and overnutrition, etiology and risk factors, and prognostic factors/
predictors related to nutritional status. The modified version of systematic review steps were conducted to search for the data, such as: defining the scope, gathering evidence, selecting evidence, and presenting the data results. We also describe the diagnosis, prevention, and management of malnutrition in the elderly, and the role of protein supplementation in this article.
Epidemiology of Undernutrition
Prevalence of undernutrition in community setting in other country was found in a study conducted by Schilp J, et al., which is a cross sectional study in Netherlands with 3959 elderly aged 65 years and alders as participants, differed into three groups: com unity dwelling individuals, home care residents, and GP clinic patients. They found out that the prevalence of undernutrition was high in Dutch community elderly, with the highest in home care residents (34.8 % ) compared to community (10.7%) and GP clinic (11.8%).
Prevalence of undernutrition in hospital setting in other country was found in a study conducted by Cerri AP, et al., which is a prospective observational study in S. Gerardo Hospital Italy with 103 elderly inpatients as participants.
They found out that the prevalence of undernutrition was high (43.6% ), while the rest of the participants was in the risk of undernutrition (56.4 % ), and none of them was in normal nutritional status.
The prevalence of undernutrition in Indonesian elderly was found in three studies conducted by Setiati S, et al.
Two studies reported that the prevalence of undernutrition was 2.14 % and 2.50 % respectively in hospital setting. The third study measured nutritional status in community setting using geriatric nutritional risk index other than mini
nutritional assessment, so there is no malnutrition category in the prevalence of the participants but only normal and risk of undernutrition. Nonetheless, the prevalence of risk of undernutrition was high (9.8% ).
For the prevalence of overnutrition in Indonesian elderly, we found the data from two studies which was conducted by Setiati S, et al. and Sari K, et al. The former found that the prevalence of overnutrition was high in hospital setting, with the prevalence of overweight was 22.51 % and obesity was 22.08% . While study conducted by Sari K, et al. reported that the prevalence of overnutrition was also high in community setting (19.7% ), but this number is still lower when compared to hospital setting.
Etiology and Risk Factors of Undernutrition
A systematic review conducted by Tamura BK, et al.
reported that the most associated factors with poor nutrition in the nursing home patients were: impaired function, demensia, swallowing difficulties, poor oral intake, and older age. The most associated factors with weight loss were: depression, poor oral intake, etc. The most associated factors with low BMI were:
immobility, female gender, etc.
Another systematic review conducted by Pols-Vijlbrief R, et al. found out that there were 37 determinants that can cause protein energy malnutrition in community dwelling older adults. The strongest evidence for association with protein energy malnutrition was poor appetite while moderate evidece were edentulousness, no diabetes, hospitalization, and poor self reported health.
We found three studies in Indonesia about the risk factors of undernutrition and overnutrition in elderly. A study conducted by Kusumayanti IGA, et al. found that the significant risk factors for undernutrition in hospital setting were: energy
On the other hand, a study conducted by Wijaya AM, et al.
found that in community setting, the significant risk factor for having undernutrition in elderly was oral health status, where bad oral health status will increase the risk by 1 .797 times of having undernutrition. The risk factors for overnutrition were found by Sari K, et al. in a study in community setting, such as:
female gender, living in urban area, and living with caregiver.
Prognostic Factors/Predictors Related to Nutritional Status
A study conducted by Budiningsari RD, et al. in hospitalized elderly found that there was a relationship between the effect of nutritional status changes in length of hospital stay and costs of hospital care. The decreasing nutritional status from better status to poorer one was found to be the highest risk to the increase in length of hospital stay and hospital care costs, compared to increasing from poorer to better nutritional status.
Setiati S, et al. in their study found that there is an increased risk of having poor quality of life in subjects with risk of undernutrition. Another risk factors of having poor quality of life were found to be gender and number of chronic diseases.
In another study, Setiati S, et al. found that subjects with undernutrition increased the risk of having frailty, falls, and hospitalization with the highest risk score was for frailty (OR/
RR: 3.75, 1 .51, and 2.02 respectively).
Diagnosis of Malnutrition in Elderly
Diagnosis of nutritional problem must be determined by history taking, physical examination, and adjunctive examinations (such as scoring form, laboratory examination, or others). In order to prevent underdiagnosis of nutritional problem in an elderly, a comprehensive geriatric assessment must be conducted, in w hich the components consist of
screening, assessment, and monitoring of nutritional status.
Screening of nutritional status consists of: mini nutritional assessment (MNA) complete and short form, malnutrition screening tool (MST), and subjective global assessment (SGA).
Assessment of nutritional status consists of: evaluation of nutrition, anthropometry, biochemical, and clinical status to find the cause and mechanism of malnutrition. Finally, monitoring of nutritional status consists of: reassessment of the nutritional status and planning nutritional care for the patient.
History taking and risk identification was aimed to evaluate the problems in mouth cavity, change in skin condition, pain or bone fractures. Physical examination was conducted to find loss of subcutaneous fat, loss of muscle mass, and the presence of edema in ankle, sacrum, or ascites. After taking history and doing physical examination, an assessment of nutritional status with MNA should be conducted which comprises of four aspects: anthropometric measurements (BMI, upper arm circumference, calf circumference), food intake, global assessment (lifestyle, medications, mobility, acute stress, etc.), and subjective assessment (patient perception about health and nutrition).
Prevention
There are several ways to prevent malnutrition in the elderly including: measuring body weight and screening of nutritional status in every v isits; administer balanced and variable diet with texture based on patient's ability; give solid food with low portion when in low appetite; screening for muscle mass loss, increase of fat, edema, even when in stable weight; screening for cognitive and mental impairment, fall risk, and polypharmacy; be cautious for probability of specific nutrition deficiency; check for vitamin Bl2, vitamin D, folic acid, and blood glucose if needed.
Management
The management of malnutrition in an elderly patient is inseparable from the adequate assessment of the patient. An elderly with a weight loss of more than 5% in 1 month must be confirmed whether or not the calorie intake is adequate, the adequacy of accessibility to food, and is there a malabsorption syndrome or not. Accessing the food accessibility must be accounted for several factors such as: social factors, needs for caregiver, problems in oral or swallowing ability (dental problem, anorexia, depression, drugs, etc.). If in the assessment we found malabsorption, then we must treat the specific diseases causing the malabsorption (e.g. metabolism disorder, endocrinopathy, malignancy, etc.) .
The selection of nutritional administration support is based on the ability to have oral intake. If the patient is able to have oral intake, then give nutritional support orally and monitor.
But if the patient is not able to have oral intake, evaluate the gastrointestinal tract function. If the function is good, then give enteral nutrition for the patient for long term (more than 6 weeks) or short term (less than 6 weeks) depending on the tools that are going to be used. On the other hand if the gastrointestinal function is not good, give parenteral nutrition for long term or short term depending on peripheral or central venous access.
Monitoring of enteral nutrition in elderly patient could be done by various indicators such as: any distended or discomfort feeling in the abdomen, input and output of fluid volume every day, gastric residual every 4 hours if needed, signs and symptoms of edema or dehydration every day, output and consistency of feces every day, body weight 3 times a week, nutritional status adequacy 2 times a week, serum electrolyte, BUN, creatinine 2 times a week, blood glucose, magnesium, phosphorus every week or as needed.
The Role of Protein Supplementation in Elderly
Reduction of muscle mass and functional capacity is an inevitable consequence of aging. This puts the elderly for the risk of sarcopenia and frailty condition. Several consensus states minimum protein intake is: 1-1.5 g/kg/ day to gain health benefits. However, about 33% of older adults fail to meet this requirement. Therefore, increasing and optimizing protein intake is essential for this population, especially for the elderly with catabolic stressors (illness, physical inactivity, injury).
When exercise ability is limited, protein could be one of the few options to preserve muscle mass and function.
An article created by Paddon-Jones D, et al. about protein and healthy aging stated that throughout adult life, consuming adequate amount of high quality protein at each meal, in combination with physical activity, may prevent onset or slow progression of sarcopenia. The recommendations are as follows: consuming 25-30 g protein at breakfast, lunch, dinner may provide sufficient protein for effective muscle protein anabolism, including variety of high quality proteins at each meal improves post prandial muscle protein synthesis, and performing physical activity in close to temporal proximity to a protein-rich meal may enhance muscle anabolism.
A review article from Landi F, et al. about protein intake and muscle health in old age recommend the elderly to consume high proportion of essential amino acids (e.g.
lean meat, dairy products, leucine rich foods like: soybeans, peanuts, etc.) to overcome anabolic resistances found in older age. The protein dosage recommendation is: 1-1.2 g/ kg/ day to preserve healthy aging muscles, 1 .2-1.5 g/kg/ day to combat acute or chronic diseases, and 2 g/ kg/ day for elderly with severe illness or malnutrition. They also found that consuming meat 4-5 times a week is recommended to prevent sarcopenia.
Another result they found is that nutritional supplementation with leucine and P-hydroxy P-methylbutyrate has been shown
to improve muscle strength and body composition in elderly with inadequate intake of proteins.
Rondanelli M, et al. conducted an RCT study with 130 sarcopenic elderly inpatient at St. Margherita Hospital, Italy.
They used whey protein, essential amino acids, and vitamin D combined with regular and controlled physical activity for the intervention group compared to placebo group in 12 weeks period. They found that in intervention group, there was an increase in fat free mass and strength, as well as other aspects contributed in sarcopenic elderly compared to placebo group.
A similar result was also found in an RCT study conducted by Zdzieblik D, et al. in 53 sarcopenic elderly men in community setting. They administered collagen peptides for intervention group compared to placebo in control group, while both of the groups had 12 weeks guided resistance training program. The result was all subjects showed higher levels of fat free mass (FFM), bone mass (BM), isokinetic quadriceps strength (IQS), sensory motor control (SMC), and lower fat mass (FM) after 12 weeks training, but with significantly more pronounced effect in intervention group.
In Indonesia, the study about protein supplementation in specific elderly subjects was still lacking. We only found several studies about snakehead fish supplementation in chronic diseases such as: HIV/ AIDS, TB, and ischemic stroke.
A study by Pattiha A, which was an RCT in 36 subjects with HIV/ AIDS patients showed that there was a higher pre albumin and albumin levels in intervention group with snakehead fish extract 3x4 capsules each day compared to placebo group after 21 days follow up, but no significant difference in CD4 levels.
Therefore, snakehead fish extract can be given early in HIV/
AIDS patients to prevent further declining albumin levels which could lead to further malnutrition status.
A study by Paliliewu N, et al. about snakehead fish supplementation capsules did not influence nutrition status, but showed a promising future for accelerated beneficial
therapeutic effect of TB drugs by improving cytokine response after 12 weeks period in 36 pulmonary TB patients.
Finally, a study by Retnaningsih, which was an RCT in 61 acute ischemic stroke conscious patients, showed a significant increase in albumin, transthyretin, transferrin, total antioxidant status, and decrease in malondialdehyd and National Institute of Health Stroke Scale (NIHSS) in 1 week period in intervention group compared to placebo group. With the improvement of protein status, snakehead fish extract could be recommended as a part of management in early attacks of ischemic stroke to prevent malnutrition as well as for better clinical outcome.
Conclusions
M alnutrition in the elderly remains one of the health problems that is associated with several communicable and non-communicable diseases. Malnutrition is often undiagnosed properly by health care workers due to lack of cautiousness.
Epidemiology of malnutrition in Indonesia is similar with other countries, where the prevalence of malnourished or the risk of malnutrition is higher in hospital than community. Several risk factors for malnutrition: cognitive and functional impairment, swallowing difficulties, older age, etc . The screening, assessment, and monitoring of nutritional status is inseperable from CGA. Optimizing protein intake and regular exercise are fundamental components to ensure adequate nutritional status in elderly. The role of protein supplementation in elderly warrants further research in Indonesia.
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Keselamatan Pasien Geriatri:
Panggilan untuk Bertindak
Ni na Kemala Sari
Pendahuluan
Usia lanjut memiliki kerentanan yang unik terhadap medical error yang harus menjadi perhatian, Rekomendasi yang mencakup implementasi pendekatan sistemik untuk memperbaiki keselamatan pasien-pasien geriatri sangat kritis. Karena itu pemahaman terperinci gerakan keselamatan pasien sangat krusial jika para geriatrisien terns meningkatkan pelayanan bagi usia lanjut.
Tulisan ini mayoritas merupakan saduran dari sebuah review article oleh Dionyssios Tsilimingras, Amy K. Rosen, serta Dan R. Berlowitz yang bertajuk Patient SafehJ in Geriatrics: A Call for Action yang dimuat dalam Journal of Gerontology: MEDICAL SCIENCES tahun 2003.
Mengingat hubungan erat antara keselamatan pasien dan geriatri, penting sekali agar geriatrisien mendapatkan cara yang diperlukan untuk meningkatkan pengetahuan tentang keselamatan pasien dan memulai upaya-upaya penerapan praktek-praktek yang aman saat memberikan perawatan usia lanjut. Perlu dilakukan evaluasi terhadap 3 isu utama. Pertama, hubungan antara penuaan dengan medical error. Kedua, perlu dipertimbangkan bahwa berbagai Sindrom Geriatri adalah medical error. Ketiga, pengembangan laporan berbasis bukti dari IOM dan AHRQ (AgenctJ for Healthcare Research and Qualiti;) tentang praktek-praktek keselamatan dengan menampilkan rekomendasi spesifik untuk perbaikan perawatan pasien geriatri.
1. Penuaan dan Medical error
Usia lanjut m e r u p a k a n kelompok y a n g berisiko mengalami medical error. Medical error didefinisikan sebagai kegagalan melakukan tindakan yang direncanakan atau menggunakan rencana yang salah untuk mencapai tujuan. Error tidak selalu menyebabkan cedera. Error yang menyebabkan cedera pada pasien sering disebut sebagai kejadian tidak diharapkan yang dapat dicegah. Kejadian tidak diharapkan adalah cedera yang lebih disebabkan oleh manajemen medik daripada penyakit atau kondisi yang mendasari. Kejadian tidak diharapkan tidak selalu dapat dicegah seperti reaksi obat yang tidak diketahui pada pasien yang menerima obat yang sesuai untuk pertama kalinya. Jika reaksi obat terjadi pada pasien yang telah diketahui memiliki reaksi alergi pada obat tertentu, kejadian tidak diharapkan dalam hal ini disebut kelalaian.
Kelalaian didefinisikan sebagai kegagalan pemberi layanan memenuhi standar pelayanan yang secara masuk akal diharapkan dari dokter rata-rata.
Kejadian tidak diharapkan yang berhubungan dengan usia lanjut telah didokumentasikan dengan baik dalam literatur oleh berbagai peneliti hingga Harvard Medical Practice Study (HMPS) .
HMPS meneliti secara acak lebih dari 30.000 pasien yang dirawat di rumah sakit pada tahun 1984 pada 51 rumah sakit di New York. Kejadian tidak diharapkan yang berhubungan dengan terapi terjadi pada 3,7% pasien dengan 27,6% kejadian tidak diharapkan yang disebabkan oleh kelalaian. Lebih dari 70% kejadian tidak diharapkan menyebabkan disabilitas yang terjadi kurang dari 6 bulan dimana 2,6 % menyebabkan disabilitas permanen dan 13,6% menyebabkan kematian.
HMPS menyampaikan bahwa pasien-pasien berusia 65 tahun ke atas mengisi 27% populasi yang dirawat di rumah sakit ta pi 47% dari yang mengalami kejadian yang tidak diharapkan.
Angka kejadian tidak diharapkan meningkat dengan bertambahnya usia, menempatkan pasien berusia 65 tahun ke atas memiliki risiko 2 kali lipat mengalami kejadian tidak diharapkan dibandingkan pasien yang berusia di antara 16 hingga 44 tahun.
Stu di yang dilakukan oleh AHRQ menunjukkan bahwa insiden keselamatan pasien tertinggi yang berhubungan dengan error ditemukan pada usia 65 sampai dengan 74 tahun. Sebuah studi peningkatan mutu di antara pasien
pasien usia lanjut berisiko tinggi di rumah sakit pendidikan menemukan lebih dari separuh komplikasi kejadian tidak diharapkan sebenarnya secara potensial dapat dicegah dan perawatan di bawah standar berhubungan dengan komplikasi yang lebih banyak.
Errors of omission juga sering terjadi pada usia lanjut.
Sebagai contoh: kurangnya utilisasi obat-obat pada pasien dengan penyakit jantung koroner terjadi pada berbagai setting pelayanan. Alasan mengapa usia lanjut sering mengalami kjadian tidak diharapkan masih belum jelas. Ada dua kemungkinan mekanisme yang harus dipertimbangkan. Pertama, usia lanjut memiliki lebih banyak penyakit yang berkontribusi pada lama rawat yang lebih panjang di rumah sakit dan meningkatnya pajanan terhadap berbagai obat dan prosedur. Kedua, orang usia lanjut kerap rapuh. Kerapu han (frailty) merupakan sindrom biologis penurunan cadangan faali dan daya tahan terhadap stresor yang menyebabkan penurunan kumulatif berbagai sistem fisiologi tubuh dan menyebabkan kerentanan terhadap kejadian tidak diharapkan. Akibatnya, stres dari berbagai macam pro
sedur dan terapi medik membuat usia Ian jut lebih mungkin mengalami kejadian tidak diharapkan. Meningkatnya predileksi terhadap medical error dan kejadian tidak diharapkan m ungkin merupakan satu mekanisme dimana frailhj menjadi prediktor mortalitas.
2. Sindrom Geriatri sebagai Medical error
Isu sentral dalam perawatan pasien geriatri adalah manajemen berbagai kondisi medik yang umum terjadi yang disebut sebagai Sindrom Geriatri seperti jatuh, delirium, ulkus dekubitus, dan intake kurang. Sindrom Geriatri ini cenderung terjadi bila kemampuan kompensasi usia lanjut terganggu oleh efek akumulasi berbagai gangguan sistem organ. Dinyatakan oleh Tsilimingras dan kawan-kawan bahwa seringkali Sindrom Geriatri ini harus dipandang sebagai medical error untuk 3 alasan berikut. Pertama, Sindrom Geriatri berhubungan dengan meningkatnya mortalitas. Sebagai contoh, insiden cedera yang tidak diharapkan dimana paling sering disebabkan oleh jatuh, menempati urutan keenam teratas penyebab kematian pada usia 65 tahun ke atas. Terjadinya delirium pada pasien usia lanjut yang dirawat di rumah sakit dihubungkan dengan tingkat mortalitas 25% hingga 33 % . Tingkat mortalitas penghuni perawatan kronik dengan ulkus dekubitus sebesar 26% selama periode follow up 6 bulan. Intake kurang juga berhubungan dengan buruknya outcome klinik dan merupakan indikator risiko peningkatan mortalitas. Tingkat mortalitas berhubungan dengan intake kurang pada penghuni panti rawat werda sebesar 48% selama periode follow up 6 bulan.
Kedua, literatur memperlihatkan bahwa Sindrom Geriatri ini di ban yak kasus dapat dicegah. Contoh, sebuah riset pencegahan jatuh menyimpulkan bahwa jatuh secara potensial dapat dicegah jika dilakukan strategi pencegahan yang optimal.
Strategi pencegahan optimal intake kurang mencakup adanya panduan klinik yang dapat membantu pencegahan malnutrisi di perawatan kronik atau pemberian megestrol asetat untuk mencegah kehilangan berat badan lebih jauh dan meningkatkan selera, asupan kalori, kenikmatan makan, dan berat badan pada pasien-pasien panti rawat
werda. Studi lainnya menyarankan bahwa insiden Sindrom Geriatri dapat diturunkan dengan menerapkan kebijakan sistemik di level lokal dan nasional. Sindrom Geriatri juga dapat diturunkan atau dicegah dengan strategi edukasi staf dan intervensi multikomponen.
Ketiga, pencegahan Sindrom Geriatri sering mem
bu tuhkan pendekatan s is tem . Pendekatan sistem menerapkan seperangkat elemen yang saling tergantung (termasuk manusia dan non manusia) yang berinteraksi untuk mencapai tujuan bersama. Berbagai studi pada perawatan geriatri menggunakan pendekatan sistem dan menunjukkan perbaikan hasil perawatan melalui perubahan pemberian layanan. Contoh yang menonjol dalam perawatan geriatri adalah implementasi Acute Care for the Elderly Units (ACE Units). ACE Units mempromosikan fungsi kemandirian pasien geriatri dengan mencegah kontribusi lingkungan fisik dan proses-proses perawatan dalam menurunkan status fungsional pasien. Jadi, dengan cara ini, dapat mengurangi efek prediktor penurunan status fungsional seperti usia, komorbiditas, status fungsional dasar, dan gangguan kognitif. Elemen-elemen kunci dari ACE Unit adalah pengkondisian lingkungan, perawatan berpusat pada pasien (patient centered care) yang menekankan kemandirian, discharge-planning yang menyiapkan lingkungan rumah saat pulang, dan evaluasi perawatan secara intensif untuk meminimalisir efek samping prosedur dan obat-obatan.
Pengkondisian lingkungan di A CE Unit ini mencakup disain struktur seperti karpet, handrails, lorong yang kosong dari benda dan sekat-sekat, jam dan kelender yang besar, kursi toilet yang dapat dinaikturunkan, dan handle pintu untuk fungsi kemandirian usia lanjut. Tanpa perubahan sistemik spesifik tersebut, seorang klinisi tidak dapat berbuat banyak untuk meningkatkan kualitas perawatan usia lanjut.
Inisiatif-inisiatif sistemik lainnya adalah penerapan program kehidupan usia lanjut di rumah sakit dan inter
vensi multikomponen untuk menurunkan deliriu m . Pendekatan sistemik ini memiliki target faktor-faktor risiko spesifik seperti gangguan kognitif untuk menurunkan kejadian delirium.
Program intervensi multifaktor yang mencakup eva
luasi obat-obatan, edukasi, latihan gaya berjalan dan kete
rampilan transfer, perubahan bahaya lingkungan, latihan pengua tan, dan modifikasi perilaku menurunkan kejadian jatuh di rumah sebesar 31 % .
Program reduksi risiko jatuh multifaktor yang men
cakup edukasi risiko jatuh, program latihan di rumah, konseling nutrisi, dan edukasi bahaya lingkungan mem
perbaiki hasil perawatan pada usia lanjut di masyarakat.
Intervensi gizi kurang berupa pemberian makan selama 2 hari atau 6 porsi makanan dengan bantuan makan one-on-one di panti rawat werda secara signifikan meningkatkan asupan makan per oral dan asupan cairan selama waktu makan pada 50 % peserta.
Upaya lainnya memperlihatkan bahwa program edukasi staf dapat menurunkan kejadian ulkus dekubitus.
Program edukasi yang melibatkan tim dokter dan perawat menurunkan kejadian ulkus decubitus sebesar 63% dengan memperhatikan pengkajian dini dan melakukan teknik
teknik preventif sederhana.
Stud i-studi ini menekankan bahwa hanya upaya seorang klinisi saja jarang untuk dapat mencegah kejadian Sindrom Geriatri. Instruksi mengubah posisi tiap 2 jam untuk prevensi ulkus dekubitus, atau mem
promosikan pasien tidur dalam lingkungan yang tenang untuk mencegah delirium, tidak akan efektif jika tidak didukung oleh sistem di rumah sakit tersebut. Karena itu, keberhasilan reduksi Sindrom Geriatri membutuhkan konstruksi lingkungan yang mendukung praktek-praktek
terbaik guna rnewujudkan setting perawatan yang lebih aman dan lebih sehat untuk usia lanjut.
Rekomendasi untuk Peningkatan Keselamatan Perawatan Geriatri
Berbagai rekornendasi untuk praktek yang efektif dan arnan diusulkan oleh IOM dan AHRQ. Rekornendasi
rekornendasi ini fokus pada disain sistern perawatan kesehatan yang lebih aman dengan integrasi rnetode-rnetode keselamatan yang telah terbukti untuk mencegah dan meminimalkan medical error. Tentunya rekomendasi-rekomendasi ini dapat dan harus diterapkan bagi pasien geriatri. Selain itu, Tsilimingras dkk telah mengidentifikasi dan mengembangkan enam rekomendasi spesifik yang diyakini akan meningkatkan keselamatan perawatan geriatri. Keenam rekomendasi spesifik tersebut rnencakup deteksi dan pelaporan Sindrorn Geriatri, identifikasi kegagalan sistem bila terjadi Sindrom Geriatri, dibuatnya unit perawatan khusus geriatric, rnemperbaiki kontinuitas perawatan, rnenurunkan kejadian efek samping obat yang idak diharapkan, dan rneningkatkan prograrn
program pelatihan geriatri.
Deteksi dan Pelaporan Sindrom Geriatri
Deteksi dan pelaporan medical error sangat vital yang harus diaposi di pelayanan geriatri. Geriatrisien harus mendeteksi dan rnelaporkan Sindrorn Geriatri yang telah ada sebelumnya dan yang baru yang akan rnernarnpukan rnereka untuk memberikan rencana terapi segera. Praktek ini kemudian akan membantu geriatrisien untuk memeriksa kegagalan sistemik yang rnendasari yang menirnbulkan Sindrom Geriatri yang baru. Jika Sindrom Geriatri tidak terdeteksi atau tidak dilaporkan, identifikasi kegagalan sistemik dan
identifikasi kegagalan sistemik dan inisiasi perhatian medis segera akan menyebabkan terhindarnya bahaya bagi usia lanjut.
ldentifikasi Kegagalan Sistem Bila Terjadi Sindrom Geriatri
Sekali geriatrisien mendeteksi dan melaporkan Sindrom Geriatri, penting untuk mengidentifikasi kegagalan sistem yang mendasarinya. Pada artikel terbaru, komite keselamatan pasien menangkap adanya kegagalan proses dan pengambilan keputusan setelah memeriksa error dalam rantai kejadian klinik yang dimulai dengan keputusan perawatan aw al hingga ke kejadian tidak diharapkan yang menyebabkan error.
Rantai peristiwa klinik beruntun bisa mencakup faktor manusia seperti alasan bahwa dokter tidak mengenali adanya Sindrom Geriatri dan mengapa instruksi dokter tidak dilakukan tepat waktu oleh staf non dokter untuk mencegah Sindrom Geriatri.
Faktor-faktor lainnya adalah faktor-faktor teknis yang mencakup sistem komputer dan faktor-faktor organisasi.
Dengan menggarisbawahi sekuens kegiatan klinis yang menimbulkan Sindrom Geriatri, geriatrisien akan dapat mengidentifikasi kegagalan sistemik dan mengembangkan solusi untuk perbaikan outcome perawatan.
Menyiapkan Unit Khusus Geriatri
Berbagai studi memperlihatkan bahwa outcome pasien
pasien usia lanjut lebih baik di lingkungan yang disesuaikan dengan kebutuhan spesifik mereka.
Lingkungan ini telah berhasil mengurangi penurunan status fungsional dan Sindrom Geriatri dengan membuat perubahan spesifik di rumah sakit. Lingkungan ini unik karena diarahkan untuk intervensi spesifik tidak hanya untuk
pasien yang status fungsionalnya sudah turun ta pi juga untuk mencegah penurunan status fungsional karena hospitalisasi.
Gillick mengambil konsep ini lebih jauh dengan menya
rankan kreasi rumah sakit geriatri untuk terapi berbagai problem medik dan bedah dan untuk perawatan rehabilitasi.
Karena itu, para geriatrisien perlu mendorong upaya-upaya penetapan adanya unit khusus geriatri untuk perawatan usia lanjut.
Memperbaiki Kontinuitas Perawatan
Diskontinuitas perawatan sering terjadi bila informasi medik seperti alergi obat atau kegagalan obat terapi sebelum
nya tidak terkomunikasikan dari farmasi rawat jalan ke raw at inap saat pasien dirawat di rumah sakit.
Perbaikan informas i antara rawat j alan dan rawat inap adalah praktek keselamatan yang penting yang akan menurunkan kejadian tidak diharapkan.
Diskontinuitas perawatan sering akibat serah terima pasien antar dokter yang tidak terstruktur. Sebuah studi menemukan bahwa kejadian tidak diharapkan yang dapat dicegah 6 kali lebih mungkin terjadi saat serah terima tidak terstruktur. Sebuah studi lainnya menyimpulkan bahwa terdapat lebih sedikit kejadian tidak diharapkan setelah menerapkan intervensi yang mencakup program sign out dengan komputer secara terstruktur
Petersen dkk menyarankan serah terima terstruktur dengan komputer yang mencakup resume kondisi medi, data laboratorium terbaru, status resusitasi, daftar masalah, alergi obat, dan follow-up untuk transfer informasi yang efisien.
Tidak adekuatnya transfer informasi juga disebabkan oleh resume discharge yang tidak terstruktur dan waktu yang dibutuhkan untuk ditransfer dari pemberi layanan rawat inap ke rawat jalan. Studi-studi menunjukkan bahwa penerapan resume pulang terstandar dan penggunaan resume pulang
yang dihasilkan dari data dasar daripada resume pulang yang didiktekan meningkatkan mutu kandungan informasi clan menurunkan waktu yang dibutuhkan untuk transfer inf ormasi ini.
In-efisiensi lainnya dalam transfer informasi medik juga terlihat pada proses perencanaan pulang. Proses discharge planning terstruktur merupakan elemen kunci Unit ACE.
Proses discharge planning ini fokus pada kepulangan awal, penilaian rencana clan kebutuhan pulang oleh perawat pada saat masuk, clan keterlibatan dini pekerja social clan perawat pasien di rumah.
Tsilimingras menyarankan bahwa proses perencanaan pulang komprehensif juga harus mencakup adanya manajer discharge terlatih pada semua kepulangan dari ruma sakit.
Manajer discharge akan bertanggung jawab untuk mentransfer semua informasi discharge ke pasien atau keluarga pasien, seperti daftar obat-obatan clan jadwal kontrol ke dokter, tes laboratorium, clan prosedur medik. Selain itu, manajer discharge akan membuat transisi perawatan yang seamless ke pusat rehabilitasi. Karena itu, proses discharge komprehensif akan menjamin bahwa semua informasi yang diperlukan rumah sakit clan pasien tersedia clan dipahami dengan baik sebelum pasien pulang.
Penelitian retrospektif di Boston, Massachuset pada 10.371 pasien memperlihatkan bahwa penyebab readmisi dalam 30 hari mayoritas tidak berhubungan dengan diagnosis primer pada perawatan sebelumnya namun berkaitan dengan penyakit-penyakit komorbid itasnya . Tiga komorbiditas tersering yang menyebabkan rehospitalisasi adalah neoplasma, penyakit ginjal kronik, clan gaga! jantung kronik. Oleh karena itu, discharge planning juga harus mempersiapkan program
program tatalaksana penyakit-penyakit komorbid secara detil clan spesifik.
Reduksi Kejadian Akibat Obat yang Tidak Diharapkan
Diperkirakan 1 juta pasien yang dirawat di rumah sakit mengalami kejadian akibat obat yang tidak diharapkan. Upaya segera yang dapat dilakukan adalah menerapkan computerized physician order entry (CPOE) dan computerized medication alert monitors.
Sis tern ini dapat menurunkan kesalahan peresepan hingga lebih dari 50 % . Implementasi CPOE dan compu terized alert monitors secara khusus akan memberikan manfaat bagi usia lanjut dimana kejadian akibat obat yang tidak diharapkan paling sering terjadi.
Pencegahan kejadian akibat obat yang tidak diharapkan juga untuk pasien yang tinggal di rumah yang berisiko karena polifarmasi. Sebuah studi menunjukkan bahwa polifarmasi harus dipertimbangkan sebagai penanda risiko hospitalisasi.
Perbaikan Program Pelatihan Geriatri
Seperti disampaikan di atas, seorang dokter paling ahli pun tidak akan dapat memberikan perawatan geriatric optimal bila struktur sistem tidak dibuat sesuai kebutuhan. Advokasi sistem tersebut tidak mudah dan membutuhkan advokasi serta keahlian manajemen yang bukan merupakan bagian dari program pelatihan geriatri saat ini.
Instruksi dalam program pelatihan geriatri harus menekankan rekomendasi yang disebutkan di sini dan terns menekankan keterampilan perawatan berfokus pada pasien dan praktek berbasis bukti. Integrasi rekomendasi baru ini dan keterampilan geriatri pada program pendidikan geriatri saat ini akan meningkatkan implementasi praktek-praktek keselamatan dan menghindari timbulnya Sindrom Geriatri.
Kesimpulan
Keyakinan Tsilimingras bahwa geriatri harus diingat sebagai sebuah spesialisasi keselamatan pasien. Telah diperlihatkan hubungan kuat antara geriatri dan keselamatan pasien dan telah jelas di definisikan kebutuhan untuk memperbaiki perawatan pasien geriatri. Perbaikan perawatan dapat dicapai dengan mengambil rekomendasi keselamatan pasien yang telah diterima secara luas seperti satu yang disebutkan di sini, menurunkan kej adian medical error.
Sekali rekomendasi keselamatan ini diambil dan digunakan secara efektif, kejadian Sindrom Geriatri dapat diturunkan.
Geriatrisien hams menyadari bahwa rekomendasi keselamatan sangat kritis untuk meningkatkan mu tu perawatan geriatri.
Selain terhadap penyakit primer saat perawatan, discharge planning juga harus mempersiapkan secara khusus komorbiditas yang mendasari sehingga readmisi dapat dicegah.
Daftar Pustaka:
1 . Tsilimingras D , Rosen AK, Berlowitz DR. Patient Safety in Geriatrics: A Call for Action. Journal of Gerontology: MEDICAL SCIENCES. 2003;.58A(9): 813-819
2. Causes and pattens of readmissions in patients with common· comorbidities: a retrospective cohort study. Harvard Medical School. BMJ. 2014.
Guideline for Dyslipidemia Management:
Focus on Adults and Elderly
Siti Setiati, Robby Pratomo Putra
Introduction
Dyslipidemia is defined as a disorder of lipoprotein metabol is m including l ipoprotein overprod uction or deficiency. The disorder may be manifested as elevation of total cholesterol (TC), the "bad" low density lipoprotein cholesterol (LDL-C), and triglyceride (TG) concentrations, while decrease in the " good" high density lipoprotein cholesterol (HDL-C) in the blood.
The prevalence of dyslipidemia is still high in China, as reported in a study that was conducted by Sun GZ, et al.
involving 11,956 subjects aged more than 35 years. They found that among the study population, 16.4% had high TC, 13.8%
had low HDL-C, 7.6% had high LDL-C, and 17.3 % had high TG concentrations. Further analysis showed that 36.9% of the population had at least one type of dyslipidemia. On the other hand, Indonesia had higher numbers in terms of dyslipidemia prevalence. According to Basic National Health Research (Riskesdas) in 2013, there were 35.9% of adults with high TC, 22.9% with low HDL-C, 15.9% with high LDL-C, and 11 .9%
with high TG concentrations.
Dyslipidemia remains one of the important modifiable risk factors for the development of atherosclerosis and cardiovascular disease (CVD) besides diabetes mellitus (DM), hypertension, peripheral arterial disease, physical inactivity, heavy smoking, and older age.
Cardiovascular disease is a major cause of morbidity
With rapid socioeconomic development, CVD has reached epidemic proportions in developing countries in recent years.
Indonesia, as one of the developing countries, had CVD in its top 10 most prevalent death causing diseases, especially in the elderly who contributed for more than 80% deaths caused by CVD. Therefore, due to the reason that dyslipidemia and CVD are causally related, the effort to decrease the prevalence and burden from CVD can be done by treating dyslipidemia. An effective management of dyslipidemia, by pharmacological treatment or lifestyle changes is known to reduce the rate of CVD morbidity and mortality. This article will combine several of the most used guidelines for d yslipidemia management with focus on adults and elderly population.
Dyslipidemia Screening
Screening of dyslipidemia is indicated for these patients:
1. All adults men (;;::: 40 years) and women (;;::: 50 years or post menopause).
2. Patients with clinical signs or increased risk of CVD [DM, chronic kidney disease (CKD), peripheral arterial disease (PAD), hypertension (HT)].
3. Patients w i th autoimmune chronic infl a m m atory conditions [rheumatoid arthritis (RA), systemic lupus erytematosus (SLE), and psoriasis].
4. Patients with clinical signs of genetic dyslipidemias (xanthoma, xanthelasma, and, premature arcus cornealis).
5. Patients consuming antiretroviral therapies.
6. Children came from severe dyslipidemia patients.
7. Patients with history of premature CVD in family members.
The suggested analysis used for baseline lipid evaluation include: TC, TG, HDL-C, LDL-C (calculated with Friedewald Formula unless TG are elevated > 400 mg/ dL or with a direct method), and non HDL-C. When avaialble, apoB can be considered as an equivalent to non HDL-C. Additional lipid
evaluation that may be considered include: Lp(a), apoB:apoAl ratio, and non HDL-C:HDL-C ratio.
The direct methods for HDL-C and LDL-C evaluation are widely used and reliable in patients with normal lipid levels.
However, these methods are not reliable in hypertriglyceridemia condition. The use of non HDL-C may overcome the problem, but still dependent on the correct analysis of HDL-C. ApoB, on the other hand, may be an alternative to non HDL-C analysis.
It is accurate with small variations and it is recommended when available.
Conventionally, blood samples for lipid analysis have been drawn in fasting state of the patient. However, recently a data has been shown that fasting and non fasting state blood sampling gave similar results for TC, LDL-C, and HDL-C.
Only TG that had higher plasma level in non fasting state because its level is affected by food consumed. Nonetheless, to further characterize severe dyslipidemias and for follow up patients with hypertriglicerydemia, fasting state sampling is recommended.
Dyslipidemia Management
B o t h r e c e n t g u i d el i n e s p r o d u c e d by E u r opean Atherosclerosis Society (EAS) with European Society of Cardiology (ESC) and American College of Cardiology (ACC) with American Heart Association (AHA) emphasized the importance of lowering LDL-C to prevent CVD in the treatment of dyslipidemia. This is supported by the data from a trial called Atherosclerosis Risk in Communities (ARIC), which involved 15,792 residents aged 45-64 years in USA and found that relative coronary heart disease (CHD) risk increased progressively with LDL-C levels.
As with most kinds of diseases, there are two types of management in dyslipidemia, which are: non-pharmacological therapies (lifestyle modification) and pharmacological
therapies (drugs). The regiment for administering dyslipidemia therapies includes these four steps:
1 . Determine the goal for dyslipidemia treatment (primary
or secondary prevention).
2. Conduct lifestyle modifications for primary and secondary prevention.
3. Give pharmacological treatment for primary prevention.
4. Give pharmacological treatment for secondary prevention.
Determine The Goal
There are several criterias of patients to be categorized to have primary prevention, which are:
1 . Patients with LDL-C levels � 190 mg/ dL.
2. Patients with DM, aged 40-75 years, and LDL-C levels between 70-189 mg/ dL, or
3. Patients without DM, aged 40-75 years, LDL-C levels between 70-1 89 mg/ dL, but the es timated 10 year atherosclerotic cardiovascular disease (ASCVD) risk is � 7.5%.
ACC/ AHA has developed a calculator to estimate the absolute risk of cardiovascular events in 10 years based from data of representative population samples, which is called
"10 years ASCVD risk" . The calculator includes various important parameters such as: gender, age, race, HDL-C, TC, DM, treatment of hypertension, systolic blood pressure, and smoker. If a 10 years ASCVD risk is 10%, it means that among 100 patients with the entered risk factor profile, then 10 people would be expected to have heart attack or stroke in the next 10 years. The calculator can be accessed on the internet via http:/ / tools.acc.org/ ASCVD-Risk-Estimator/ .
The secondary prevention, on the other hand, also has several criterias as follows:
1 . Patients with confirmed coronary heart disease (CHD) including: myocardial infarction and prior coronary revascularization.
2. Pa tients with other cardiovascular d isease (CVD) including: stroke, transient ischemic attack, and peripheral artery disease.
3. Patients with combinations of risk factors, resulting a 10 year ASCVD risk more than 20% .
4. Patients with CKD (estimated GFR < 45 ml/ min/1 .73m2 5. Patients with DM, who are risk equivalent of having CVD.
Lifestyle Modification
Lifestyle modification is the foundation of ASCVD risk reduction, both prior to or in combination with drug therapies.
The lifestyle modification steps consist of:
1 . Maintain healthy normal weight by decreasing weight for overweight patients.
o Adhere to a heart healthy diet
o Consume dietary pattern that emphasizes intake of vegetables, fruits, whole grains, low fat dairy products, poultry, fish, legumes, and limits intake of sweets, sugar sweetened beverages, red meats.
o Aim for dietary pattern that achieves 5-6% of calories from saturated fat.
o Reduce percent of calories from saturated fat.
o Reduce percent of calories from trans fat.
o Limit sodium intake to less than 2400 mg/ day to lower blood pressure.
2. Increase physical activity by aerobic exercise.
o Recommended frequency is 3-5 days every week.
o Recommended intensity is between 50-80% exercise capacity.
o Minimum exercise duration is 20-60 minutes.
o Examples of aerobic exercises are: walking, treadmill, cycling, rowing, and stair climbing.
3. Stop smoking completely.
4. Limits alcohol consumption to moderate level (20 g/ day
or 2 units for men and 10 g/ day or 1 unit for women).
5. Consume dietary supplements (phytosterols, red yeast rice, dietary fiber, soy protein, n-3 unsaturated fatty acids).
Pharmacological Treatment for Primary Prevention
When a pharmacologic agent is required for the treatment in primary prevention, a statin is the preferred medication. If statin is not tolerated or a particular LDL-C goal is not achieved on a statin alone, it is recommended not to add a nonstatin lipid lowering drug first before intensifying. Statin is beneficial to these four group of patients:
1 . Patients with clinical ASCVD (ACS, history of MCI, stable, or unstable angina).
2. Patients with primary elevation of LDL-C 2'. 190 mg/ dL.
3. Patients with DM, aged 40-75 years, LDL-C 70-189 mg/
dL, and without clinical ASCVD.
4. Patients without DM or clinical ASCVD, LDL-C 70-189 mg/ dL, but 10 years ASCVD risk 2'. 7.5 % .
Statin i s differed into three levels based o n its potency to lower LDL-C, which is: high intensity, moderate intensity, and low intensity statin therapy (see Table 1).
The American College of Cardiology and American Heart Association (ACC/ AHA) has made the following recommendations about statin therapy, as follows:
1. Adults 2'. 21 years with primary LDL-C 2'. 190 mg/ dL should be treated with high intensity statin therapy unless contraindicated. Use maximum tolerated statin intensity if not tolerated.
2. If LDL-C is still 2'. 190 mg/ dL, intensify statin therapy to achieve 2'. 50% of LDL-C reduction.
3. If LDL-C is still 2'. 190 mg/ dL after maximum intensity of statin, consider addition of non-statin drugs such as:
fibrates, nicotinic acid, cholesterol absorption inhibitors, bile acid sequestrants, or PCSK9 inhibitors.
Table 1. Three levels of statin therapy and their example drugs.
High Intensity Statin Therapy
Moderate Intensity Statin Therapy
Low Intensity Statin Therapy
Daily dose Daily dose Daily dose
lowers LDL-C by approximately � 50%
lowers LDL-C by approximately 30- 50%
lowers LDL-C by approximately < 30%
Atorvastatin 40-80 mg
Atorvastatin 10-20 mg
Simvastatin 10 mg
Rosuvastatin 20-40 mg
Rosuvastatin 5-10 mg Pravastatin 10-20 mg
Simvastatin 20-40 mg Lovastatin 20 mg Pravastatin 40-80 mg Fluvastatin 20-40 mg Lovastatin 40 mg Pitavastatin 1 mg Fluvastatin 80 mg
Pitavastatin 2-4 mg
Another recommendations have been made for adults aged 40-75 years, without known CVD, and LDL-C 70-189 mg/ dL, which comprise of:
1 . Patients without DM:
• Treat patients with 10 years ASCVD risk � 7.5% with moderate to high intensity statin therapy.
• Treat patients with 10 years ASCVD risk 5-7.5 % with moderate intensity statin therapy.
2. Patients with DM:
• Treat patients with moderate to high intensity statin therapy.
• Consider treating patients with 10 years ASCVD risk
� 7.5 % with high intensity statin therapy.
• For adults > 75 years, evaluate potential statin therapy for ASCVD benefits and adverse effects, as well as drug to drug interactions and patient preferences when initiate, continue, or intensify statin therapy.
Pharmacological Treatment for Secondary Prevention
The secondary prevention used the same drug as primary prevention, which is statin therapy. The high intensity statin therapy is recommended to be used in patients aged � 75 years and no safety concerns regarding the use of therapy. In addition, patients with known CVD or at similar risk of having CVD, should be treated with high intensity statin therapy regardless of baseline LDL-C levels. A data has shown that atorvastatin 80 mg daily reduced mortality in acute coronary syndrome patients and it is recommended as an initial therapy.
On the contrary, patients aged > 75 years or there are safety concerns regarding the use of statin therapy, should be treated with moderate intensity statin therapy.
Treatments are also given based on the risk of having CVD events, whether it has high risk or low risk (stable CVD). The
recommendations are as follows:
1. Patients with very high risk of having CVD events (e.g.
established coronary heart disease; multiple major risk factors especially DM; severe and poorly controlled risk factors especially heavy smoking; multiple risk factors of the metabolic syndrome especially TG � 200 mg/ dL, non HDL-C � 130 mg/ dL, and HDL-C < 40 mg/ dL; or acute coronary syndrome) should be treated with maximum intensity of statin therapy, if patients do not achieve � 50% reduction in LDL-C, until LDL-C below 70 mg/ dL.
Additional non statin drug is rational if LDL-C remains above goals.
2. Patients with low risk of having CVD events (stable CVD) should also be treated with maximum intensity of statin therapy, if patients do not achieve � 50% reduction in LDL-C, until LDL-C below 100 mg/ dL. The addition of non statin drug is recommended if LDL-C remains above goals.
Monitoring Statin Therapy
Monitoring statin therapy response and adverse effects is recommended to be done in 4-12 weeks after initiation of statin, then 3-12 months as indicated. Adherence to medication and lifestyle regimens are required for ASCVD risk reduction and need to be reemphasized before addition of non statin drug in statin intolerant and unresponsive patients. When initiating statin therapy, also remember to always consider the possibility that patients might experience adverse effects. After association of adverse effects with statin therapy has been established and they have been resolved, patients should be given lower dose of the same statin or other alternative appropriate statin until statin and dose that have no adverse effects identified.
The risk of statin adverse effects might increase in these populations:
• Patients with multiple or serious comorbidities (e.g.
impaired renal or hepatic function).
• Patients with history of previous statin intolerance or muscle disorders.
• Patients with unexplained ALT levels elevation more than 3 times the normal value.
• Patients' characteristics or concomitant use of drugs affecting statin metabolism.
• Patients more than 75 years.
Management of Statin Adverse Effects
The most common adverse effects in statin therapy are:
muscle symptoms and hepatotoxicity. Muscle symptoms comprise of: pain, tenderness, stiffness, cramping, weakness, or fatigue, and it is recommended to evaluate and treat them in patients taking statin therapy. If the muscle symptoms are unexplained, severe, and develop during statin therapy, it is recommended to promptly discontinue the statin and evaluate
