Management of immobilization and its complication for elderly.

Increased life expectancy have an effect on the rising percentage of elderly population in Indonesia and health problem associated with the elderly, particularly immobilization. Immobilization may cause various complications, especially when it has been overlooked without any appropriate and proper medical care in keeping with the procedures. High incidence of immobilization in elderly and the life-threatening complication call for an agreement on management of immobilization and its complication. Management of immobilization needs interdisciplinary team-work cooperation, the patients and their family. The management may be commenced through a complete geriatric review, formulating functional goals and constructing therapeutic plan. Various medical conditions and external factors that may act as risk factors of immobilization as well as drugs intake that may exaggerate the immobilization should be evaluated and optimally managed. Any complication due to immobilization and other concomitant disease/condition should be recognized and managed comprehensively in order to reduce morbidity and mortality. Management of immobilization and its complications include pharmacological and non-pharmacological treatment, i.e. various mobility exercises, utilization of ambulatory device and supporting appliance for assisting patients in stand-up position, as well as the management of urinary voiding and defecation.

Vitamin D status among Indonesian elderly women living in institutionalized care units.

AIM: to obtain the profile of vitamin D deficiency in Indonesian elderly women. METHODS: it is a cross-sectional study in 74 elderly women from 4 randomly chosen institutionalized care units in two cities, Jakarta and Bekasi. Data collection included characteristics of subjects, 25(OH)D and PTH, concentration,skin type, nutrient intake including protein, calcium, and vitamin D, and use of sun screen. RESULTS: the prevalence of 25(OH)D deficiency among Indonesian elderly women in institutionalized care is about 35.1%. Most of deficient subjects went out-door only once a week (38.5%). Veil was the most sun protection worn by the subjects and most subjects had length of sun exposure 30-60 minutes a week. The mean daily intake of vitamin D was 0.6 IU, protein was 33.9 gr/day and calcium was 239.9 mg/day,and cut-off of serum 25(OH)D in Indonesian elderly women is (suspected) to be 75.9 nmol/L. CONCLUSION: we conclude that the prevalence of 25(OH)D deficiency among Indonesian elderly women in institutionalized care is about 35.1% and cut-off of serum 25(OH)Din Indonesian elderly women is (suspected) to be 75.9 nmol/L. Population based study in Indonesia is needed to determine the normal value of 25(OH)D in Indonesian elderly women.

Oral anticoagulant treatment in management of elderly patients with atrial fibrillation [corrected]: is it beneficial or detrimental?

Atrial fibrillation (AF) is supraventricular tachyarrhythmia characterized by uncontrolled atrial activation, and deteriorates atrial function. In AF patients, increasing of age is related with enlarge left atrium (LA), diminished flow velocity of left atrial appendage (LAA), and spontaneously contrast echo, with other factors which are predisposition for LA thrombus. In AF patients, thromboemboli after cardioversion without anticoagulant administration is 1.5-3.0%. Elderly patient is not contraindication for anticoagulant, although higher risk for bleeding. For stroke prevention in >65 years of age whilst the patient is candidate for oral anticoagulant warfarin, it should be prescribed to reach INR 2.0-3.0. Some reports on anticoagulant evaluation (INR) and bleeding as complication of warfarin prescribed for AF treatment are not significantly different in elderly and younger patients.

Perioperative assessment and management of the elderly.

Around half of people aged 65 years and above will undergo surgery due to various indications. Several common types of surgery in the elderly are cataract extraction, joint replacement, cholecystectomy, and revascularization procedures. Elderly patients planned for surgery are at risk of having substandard or even terrible outcome due to decreased ability to maintain or recover physiologic homeostasis during surgery. Thorough preoperative assessment is important for the elderly. Preoperative assessment should be stressed on identification of risk factors or bad predictors after the surgery. Common comorbidities in the elderly need comprehensive assessment. Special attention should be given for postoperative management in the elderly. The elderly might need longer time to recover compared to young patients, and management programs might be needed such as sub acute management, rehabilitation unit, or home-care treatment. In general the postoperative treatments consists of the use of analgesic agents, early mobilization, proper use of urine catheter, prevention and management of delirium, and use of anticoagulants.

Vitamin D and autoimmune disease.

Vitamin D as a part of the endocrine system is an important component in the interaction between the kidney, bone, parathyroid hormone, and the intestine, which maintains extracellular calcium level within normal limits, in order to keep the vital physiologic process and skeletal integrity. Vitamin D is also associated with hypertension, muscular function, immunity, and ability to encounter infection, autoimmune disease, and cancer. The role of vitamin D in immunity is a feedback reaction of paracrine to eliminate inflammation or to influence CD4 T-cell differentiation and or to increase the function of T suppressor cell or combination between both. The active form of vitamin D produces and maintains self immunologic tolerance, some studies show that 1,25(OH)2D inhibits induction of disease in autoimmune encephalomyelitis, thyroiditis, type-1 diabetes mellitus, inflammatory bowel disease (IBD), systemic lupus erythematosus, and collagen-induced arthritis and Lyme arthritis.

Correlation between serum vitamin D (25(OH)D) concentration and quadriceps femoris muscle strength in Indonesian elderly women living in three nursing homes.

AIM: to investigate the correlation between serum vitamin D (25(OH)D) concentration and quadriceps femoris muscle strength. METHODS: this was a cross-sectional correlative study, conducted at three nursing homes in Jakarta and one nursing home in Bekasi in January 2005. The subjects were women aged 60 years or above. Those selected study subjects underwent quadriceps femoris muscle strength examination with Cybex dynamometer with 150 degrees/second speed, twice (three repetitions with 30 second rest time). The 25 (OH)D concentration was measured by ELISA. RESULTS: out of 67 subjects who met the required criteria for this study, five subjects withdrew from the study during muscle strength examination. The mean age was 71.1 (SD 7.2) years old while the mean serum vitamin D concentration was 68.2 (SD 21.6) nmol/l. Vitamin D deficiency (<or= 50 nmol/l) was found in 22.6% of subjects. It was also found that the median (minimum-maximum) quadriceps femoris muscle strength was 40.00 (11-116) N.m. Approximately 82.3% of the subjects were of generalized muscle weakness. Correlation was found between serum 25 (OH)D concentration and quadriceps femoris muscle strength (r = 0.327; P = 0.009). CONCLUSION: this study reveals that serum 25 (OH) D concentrations in Indonesian elderly women is correlated with quadriceps femoris muscle strength. The proportion of elderly women with muscle weakness is higher than the normal ones. The group with older age shows higher proportion of muscle weakness. Most subjects have normal serum vitamin D concentration.

Survey on appropriateness of drug administration in elderly patients at The Internal Medicine Ward dr. Cipto Mangunkusumo Hospital.

AIM: to evaluate the appropriateness of drug administration in elderly patients hospitalized at the Internal Medicine Ward dr. Cipto Mangunkusumo Hospital based on indication, dosage, duration of treatment, potential adverse events, contraindication, and potential drug interactions. METHODS: a cross sectional observational study was performed in patients aged over >or= 60 years old staying at the Internal Medicine Ward. Appropriateness of drug administration was evaluated based on the support from literature. The supporting references being used were guidelines at the Internal Medicine Department, reference textbooks, and drug brochures for newly approved drugs but had not been listed in references nor guidelines. RESULTS: from 347 drug administrations in 43 patients, 228 of the drug administrations (67.71%) were considered appropriate for indication, 15.85% slightly inappropriate for indication, and 18.44% with inappropriate indication. From 228 drug administrations, 206 (90.35%) were administered with adequate dosage, 2.63% subtherapeutic dosage, 3.95% overdosage, and 3.07% undefined dosage. From 126 drug administration evaluated for duration of therapy, there were 77.78% administered with appropriate duration of therapy, 18.25% with inappropriate duration, and 3.97% undefined duration. Out of 347 drug administration there were 2 possibilities of adverse drug events, 5 drugs were actually contraindicated and 25 potential drug interaction. CONCLUSION: there were 67% of drugs appropriately administered for indication. From this number, 90% were using accurate dosage, of all drug administration there were 2 possibilities of adverse drug events, 5 drugs were contraindicated and 25 potentially interacted drugs. From 126 drugs evaluated for duration of therapy, 77.78% received the right duration of therapy.

Correlation between vitamin D concentration and basic functional mobility in elderly women.

AIM: to determine vitamin D serum concentration, the timed up and go (TUG) test score, and the correlation between vitamin D serum concentration and TUG test score of elderly women. METHODS: a correlative cross-sectional study of elderly women aged 60 years old or above was carried out in three nursing homes in DKI Jakarta and one elderly nursing home in Bekasi, in January 2005. TUG test was performed to evaluate basic functional mobility by measuring the time in seconds to stand from 46 cm height armchair, walk three meters, turn around, and return to full sitting in chair. Vitamin D serum concentration was measured by ELISA method. Calcium ion serum concentration that was measured by NOVA method, age and body mass index (BMI) were confounding variables. RESULTS: of forty-two elderly women who met the inclusion and exclusion criteria, thirty subjects which proportional randomly assigned participated in this study. Mean (+SD) vitamin D serum concentration was 68.0 (21.1) nmol/L, with concentration < 50 nmol/L was 23.3%, TUG score was 10.7 (2.1) seconds, BMI was 22.3 (3.7) kg/m2, age was 70.2 (6.4) years, and median (minimum-maximum) ionized calcium serum concentration was 1.095 (1.030-1.230) mmol/L. Vitamin D serum concentration did not show significant correlation with TUG (r = -0.008; P = 0.968). There were also no significant correlations among the confounding variables and TUG. The correlation with TUG for BMI r = 0.014; P = 0.942, ionized calcium serum concentration r = 0.287; P = 0.124, and age r = 0.315; P = 0.09. CONCLUSION: vitamin D serum concentration has not show significant correlation with basic functional mobility of elderly women, the higher vitamin D serum concentration was not followed by lesser time to perform TUG test; the proportion of subjects with TUG score < 10 seconds (freely mobile in functional mobility) were lesser in vitamin D deficiency respondents.

C-reactive protein levels and decrease of albumin levels in hospitalized elderly patients with community-acquired pneumonia.

AIM: To obtain: (1) the correlation between initial CRP level on admission with the decrease of albumin level during hospitalization, (2) the mean difference in initial CRP level between the groups of patients with and without decrease of albumin level during hospitalization, and (3) the risk difference of decreasing albumin level in patients with high CRP levels on the admission compared to whom with low CRP level on the admission, in hospitalized elderly patients with CAP. METHODS: A prospective cohort study were conducted on 23 hospitalized elderly patients with CAP. Subjects with diseases and conditions that could interfere with CRP and albumin level besides pneumonia infection were excluded. The patient's CRP level was measured upon the initiation of the study, while the patient's albumin level was measured on the first and fifth day of hospitalization to observe changes that took place during 5 days of hospitalization. Pearson's correlation test, independent t-test, and chi-square test were used to answer the objectives of the study. RESULTS: We found that there were negative correlation between the initial CRP level and the percentage of albumin level decrease during 5 days of hospitalization (r=-0.442, p= 0.035) and significance difference in the mean initial CRP level between patients with and without decreasing albumin level (mean difference 99.69 mg/L, 95%CI 13.25 to 186.13 mg/L; P 0.026). The risk difference of decreasing albumin level during hospitalization between patients with high and low initial CRP levels did not attained statistical significance (RR 2.12. 95%CI 0.26 to 29.07; p=0.621). CONCLUSION: In hospitalized elderly patients with community-acquired pneumonia with high initial CRP levels tend to experience a decrease in albumin level during hospitalization.

Writing for scientific medical manuscript: a guide for preparing manuscript submitted to biomedical journals.

Publishing a manuscript of study results in a medical or biomedical journal is not as easy as we imagine. There are some components that should be noticed in publishing a medical scientific journal. Although every journal has different manuscript format, in general, a manuscript contain some components, which consist of: introduction, methods, results, and discussion. Before submitting the manuscript, be sure that it has been consistent with instructions to authors of the desired journal. Submitted manuscript should be enclosed by a cover letter, a statement about any sponsor or other potential relationship that may cause conflict of interest, a statement that the manuscript has been read and agreed by the author(s), and any information about a corresponding author. Writing skills is very important to obtain a good manuscript of study result, in order to achieve greater possibility for publication. Writing skills can be learned through various books or electronic sources such as internet which discuss about writing techniques.

Estimating the annual cost of overactive bladder in Indonesia.

AIM: to estimate the annual economic cost and quality of life related to OAB in Indonesia population by taking into account the direct cost, value of lost productivity and cost consequences associated with OAB. METHODS: cross sectional study was done in Geriatric Clinic and Urogynaecology Clinic in Dr. Cipto Mangunkusumo Hospital Jakarta from July 2005 to March 2006. Primary outcome of this study was annual cost of OAB, symptom and quality of life of OAB patients. Cost data related to personal routine care of OAB and transportation expenditures were obtained by using questionnaires modified from Dowell Bryant incontinence cost index validated questioner. Data related to quality of life were obtained by OAB-q questioner. Subjects included 30 male and female OAB patients aged 18-100 years. RESULTS: most of patients were female (96.7%). Median of age was 62.5 (30-93) years old, 56.7% patients were elderly (age more than 60 years). Median of total annual cost of OAB was Rp. 2,850,000,-. Median of total personal cost which consist of routine personal care costs and treatment costs were Rp. 2,850,000. Median of total cost which is expended by government for routine personal and treatment of OAB was Rp.2,500,000,- . Median score of symptom severity was 62.5. Quality of life score was divided into coping, concern, sleep, and social item. Median of coping score was 50.0, concern score was 43.1, sleep score was 50.8, and social score was 38.8. Median of total quality of life score was 44.7. Maximum score of symptom severity and quality of life should be 98.8. The higher the score, the more severe the symptom, but the better is the quality of life. CONCLUSION: total annual cost of OAB was Rp. 2,850,000, Quality of life of OAB patient was somewhat poor.

Insulin resistance and metabolic syndrome in elderly women living in nursing homes.

AIM: To obtain a depiction of insulin resistance and to determine the correlation between age, body mass index, and insulin resistance, and the prevalence of metabolic syndrome in elderly women living in nursing homes. METHODS: Ninety two elderly females with an average age of 71.4 (SD 7.45) who did not suffer from chronic renal disease or chronic liver disease and were not taking corticosteroids, beta blockers, thiazides, or anti-dyslipidemic drugs, participated as research subjects. Investigated variables, comprising blood pressure, body mass index, waist circumference, laboratory measurements, lipid profile, fasting blood glucose level, and fasting insulin level, were used to determine insulin resistance according to HOMA-IR > 75 percentile. The NCEP ATP III criteria Asia Pacific modification was used to determine metabolic syndrome. RESULTS: There were twenty three subjects with insulin resistance (HOMA-IR > 2.67) for the 75th percentile. Seventeen of them (73.9%) had metabolic syndrome. However, out of the 6 subjects (26.1%) without metabolic syndrome, 5 subjects had at least one component of metabolic syndrome. There was no correlation between age and insulin resistance. However, there was a correlation between BMI and insulin resistance (p<0.017). There were 53 elderly females (57.6%) with metabolic syndrome; the most common metabolic syndrome component being hypertension (79.3%), followed by HDL hypocholesterolemia (55.4%), and central obesity (53%). As many as 32.1% of subjects with metabolic syndrome also demonstrated insulin resistance. CONCLUSION: The value of insulin resistance was 2.67 (HOMA-IR cut-off > 75 percentile). Subjects with insulin resistance had at least one component of metabolic syndrome. A high prevalence (57.6%) of metabolic syndrome in elderly females living in a nursing home was found.

Prevalence of hypertension without anti-hypertensive medications and its association with social demographic characteristics among 40 years and above adult population in Indonesia.

AIM: To find out the prevalence of hypertension without anti-hypertensive medication and its social demographic risk factors among adult population in Indonesia. METHODS: Random samples of 3080 subjects aged 40-94 years were obtained from various districts in every big island in Indonesia. Blood pressure measurements, as well as assessment on history of hypertension, use of anti-hypertensive medications, and social demographic characteristics were performed. Blood pressure measurements were obtained by trained doctors with the subjects in supine position. Stepwise multiple logistic regression was used to determine variables which were most associated with treatment without anti-hypertensive medication in hypertensive subjects. RESULTS: The prevalence of hypertension without anti-hypertensive medication among 40 years and above adult population in Indonesia was 37.32% (677 our of 1814 hypertensive subjects). From bivariate analysis, we found that male sex, older age, informal education and unemployment were associated with the use of anti-hypertensive medication. Multivariate analysis shows that male sex (OR=1.33), education level of elementary school (OR=1.50), and government employment (OR=1.24) are significantly as risk factors for not taking anti-hypertensive medication. Age more than 60 years old (OR=0.49) and unemployment (OR=0.70) are protective factors for not taking anti-hypertensive medication. CONCLUSION: The prevalence of hypertension without anti-hypertensive medication in this study is higher than the prevalence found in some other studies, and due to several social demographic risk factors, such as low level education, male sex, and being government employees. On the other hand, older people and those who have no formal occupation are protective factors.

The prevalence of orthostatic hypotension and its risk factors among 40 years and above adult population in Indonesia.

Factors associated with orthostatic hypotension such as age, drug induced hypotension, hypertension and diabetes mellitus have still been debatable. Most of previous studies were conducted in subjects 65 years or older, only a few were done in subjects from younger to older adults. The purpose of this study is to find the prevalence and predictor factors of orthostatic hypotension among adult population aged 40 years and above in Indonesia. This study is a part of Indonesian Hypertension Epidemiologic Survey. A random sample of 4436 subjects aged 40–94 years was obtained from various municipalities in every big island in Indonesia. Orthostatic testing, assesment of history of medical conditions (diabetes mellitus, stroke, and hypertension), blood pressure measurement and use of anti-hypertensive medications were performed. A stepwise logistic regression was used to determine the significant predictor of orthostatic hypotension. A total of 561 persons (12.6%) experienced orthostatic hypotension. Central α2-agonist and other centrally acting drug is the only anti hypertension medicine which influences orthostatic hypotension. Multivariate analysis showed that high systolic and diastolic blood pressures were predictor factors of orthostatic hypotension. The use of anti-hypertensive medicine was a protective factor for orthostatic hypotension. This study confirms the conclusion that age is not a predictor factor for orthostatic hypotension. In fact, the existence of comorbidities in the subjects such as hypertension (high systolic and diastolic blood pressure) is a predictor factor, while the use of anti-hypertensive medication is a protective factor.