BRAINs IMSTC

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Month Day Year

Introduction

Bundle Regular of AMSA-Indonesia National Competitions (BRAINs) is a full compilation of all works submitted in every national competitions held by Asian Medical Students’ Association (AMSA) Indonesia. The previous bundle is named AMSA Indonesia National Competition Bundle (AINCB).

Each year, AMSA Indonesia held three national competition events entitled Pre-conference competition for East Asian Medical Students’ Conference (PCC for EAMSC), National Paper Poster Training, and also Pre-conference competition for Asian Medical Students’ Conference (PCC for AMSC).

This bundle compile all works participated in IMSTC 2013. The theme for this competition is “Community Medicine: Geriatic Medicine as Multidisciplinary Approach to Elder Care”.

In this competition, all members of AMSAIndonesia may send Scientific Papers, Scientific Posters, Public Posters, and Public Videos consist of 1 Film and1 Public Poster.

Once compiled, Bundle of AMSA will be both distributed to all local AMSA and published via the AMSA-Indonesia web so that all members could easily access and obtain useful information gather in this bundle.

Enjoy and keep involved in academics!

Regional Chairperson Garda Widhi Nurraga Universitas Diponegoro

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Contributors:

Secretary of Academics Fabianto Santoso Universitas 2 Indonesia

A-Team AMSA-Indonesia

Cardiac Rehabilitation: Beneficial but Underutilized among Elderly People in Indonesia Callista Beatrice, Elisa, Ria Pitasari Atma Jaya Catholic University, Indonesia

ABSTRACT Introduction: While the burden increases with age, heart disease is the leading cause of morbidity and mortality in most countries, including Indonesia. Participation in cardiac rehabilitation (CR), has been reported to have beneficial effects in elderly.It successfully addresses cardiac risk and has been shown to reduce mortality by 25%. Nevertheless, as in other countries, the implementation of supervised CR program at the hospital in general is still considered to be underutilized.

Methods: A study is done to demonstrate the effectiveness of CR by analyzing and reviewing several researches showing beneficence of CR participation in the elderly and also barriers towards it in the elderly. Some points of view are given to overcome the barriers into solutions for a better CR program for elderly in Indonesia.

Results: CR reduces mortality rate and prevents the long-term risks of death. It also increases exercise capacity and reduces psycological stress among elderly. On the other hand, there is an inverse relationship between age and attendance rate. Fewer older patients are reffered to CR. The underlying reasons are mostly: already exercising at home, confidence in ability to self-manage their condition, patients’ perception about CR, not knowing about CR, lack of physician encouragement, and comorbidities.

Discussion: There are some main barriers related to current condition in Indonesia such as lack of transportation, health insurance regulation, less physician referral, and the CR program itself which is not always well-distributed in every healthcare center.

Conclusion: Regardless of the barriers less likely to be overcome, CR can be more utilized if physicians place more attention in referring, educating, and encouraging the elderly to participate and attend the program. However, the future idea could be considered, too. It lies with acknowledging that some patients rehabilitate themselves without formal program support, providing an economical service, and tailored to the perceived needs of the patients who seek support. Therefore, this would make CR more relevant to older patient.

Introduction At the beginning of the 20th century, cardiovascular diseases (CVDs) were responsible for 10% of all deaths worldwide; today, that figure has risen to 30%, with 80% occurring in low- and middle-income countries1. It is the number one cause of death globally: more people died annually from CVDs than from any other cause.

World Health Organization (WHO) estimated that 17.3 million people died from CVDs in 2008. Of these deaths, an estimated 7.3 million was due to CVDs and 6.2 million was due to stroke. It was predicted that by 2030, almost 25 million people will die from CVDs. These are projected to remain the

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single leading cause of death.2According to the latest WHO data published in April 2011, Coronary Heart Disease (CHD) deaths in Indonesia reached 243,048 or 17.05% of total deaths. The age adjusted death rate is 150.77 per 100,000 of population with greater distributions in older people.

Heart disease is one of leading causes of death in the elderly.3Elderly group ≼60 ( years4) is a high-risk group to cardiovascular disease. Along with the increasing in human life expectancy, the number of elderly population is also getting bigger and so is the population at high risk of CVDs. Cardiovascular disease which is common in causing sudden death is

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coronary artery disease (CAD), which then manifests as myocardial infarction (MI).

While the burden increases with age, CAD is the leading cause of morbidity and mortality in most countries. Cardiac rehabilitation (CR) successfully addresses cardiac risk and has been shown to reduce mortality by 25%.5 Survivors of these disorders constitute an additional reservoir of CV disease morbidity.6 The morbidity and subsequent disability incurred from CAD alone have far-reaching medical and socioeconomic implications. Continued major efforts in primary prevention are critical to reduce overall incidence of CAD. Nonetheless, continued advances in medical and surgical techniques combined with effective and focused programs in cardiac rehabilitation are needed to manage the burgeoning manifestations and sequences of overt CAD. When compared to younger counterparts, elderly patients are typically at a higher risk of complications from MI and myocardial revascularization procedures, leading to prolonged hospital stays and subsequent deconditioning.7 Among patients with coronary heart disease, participation in cardiac rehabilitation, compared with nonparticipation, has been reported to have beneficial effects.8 The importance of a rehabilitation program is characterized by the historical WHO definition, as: “sum of activity required to ensure cardiac patients the best possible physical, mental, and social conditions so that they may, by their own efforts, regain as normal as possible a place in the community and lead an active life.�

During the development of cardiac care, further objectives have been added, including opportunistic health promotion and secondary prevention. Observational studies in the new millennium consistently conclude that cardiac rehabilitation does significantly reduce mortality even in the context of improved medical and revascularization strategies and, therefore, it could be argued that its relevance is more apparent than ever before.9 In the implementation of cardiac rehabilitation, the program is grouped into

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several phases: Phase I is the effort to be done while the patient is still in its care, the main goal of this phase is to reduce or eliminate the adverse effects of 'decondition' due to prolonged bed rest, to educate early and so patients are able to perform daily activities independently and safely. Phase II, conducted immediately after the patient is out of the hospital, an intervention program for patients to restore function optimally, immediate control of risk factors, education and additional counseling on healthy lifestyle. Both phase I and phase II usually take place in the hospital. Phase III and IV are the maintenance phases, in which the patient is expected to have been able to undertake a rehabilitation program independently, safely, and maintain a healthy lifestyle for all, or jointly assisted families and surrounding communities. Since 1994, the American Heart Association (AHA) declared that cardiac rehabilitation is not limited to physical exercise program alone, but should include a multidisciplinary effort that aims to reduce or control the risk factors that can be modified. Currently in Indonesia, cardiac rehabilitation carried out either in the hospital or outside the hospital. Cardiac rehabilitation programs conducted in hospitals have been implemented in several cities such as Jakarta, including RS Jantung Harapan Kita, RS Cipto Mangunkusumo, and RS Fatmawati. It is also conducted in other cities, such as RSHS in Bandung, RS Dr. Sardjito in Yogyakarta, and also in Padang. As in other countries, the implementation of supervised cardiovascular rehabilitation program at the hospital in general is still considered to be underutilized.10 Methods This study aims to demonstrate cardiac rehabilitation beneficence in the elderly and to investigate and overcome the barriers into solutions for a better cardiac rehabilitation implemented in Indonesia.

This study is done by some major steps:

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• •

• •

reduces mortality rate and prevents the longterm risks of death and MI among elderly. A study in 2010 also indicates that there are linear relationship between CR attendance rate and more beneficence effect postrehabilitation. Attending more sessions was assosiated with lower risk of MI compared with attending lower number of sessions.

Attending 36 sessions was associated with a 15% lower risk of death compared with attending 24 sessions (HR, 0.85; 95% CI, 0.81 to 0.90), a 28% lower risk compared with attending 12 sessions (HR, 0.72; 95% CI, 0.64 to 0.80), and a 38% lower risk compared with attending 1 session (HR, 0.62; 95% CI, 0.52 to 0.73).13 In fact, in older patients, it has been observed that exercise improves functional capacity and reduces myocardial work at standardized exercise workloads, demonstrating expected outcomes similar to those in younger patients.6 Another study shows that Cardiac Rehabilitation and Exercise Training (CRET) program are very beneficial for older patients. One of the most significant benefits of formal CRET within all participating age groups is the improvement of aerobic exercise capacity.

Aerobic exercise capacity is the maximum amount of physical exertion an individual can sustain. And in this context, elderly patients has a greater improvements in exercise capacity compared to younger patients after CRET (Table 1).14

Searching the worldwide websites, articles, and journals about certain keywords.

Reviewing the second analysis from researches resultingthe association between cardiac rehabilitation program and participation barriers and age.

Comparing the research results with the situation and problem in Indonesia.

Finding some possible solutions about the problems.

Results The main components of cardiac rehabilitation comprise cardiac education, physical training, social and occupational support, counselling or psychological therapy and support for the transfer of medical care from hospital to general practice.11 Among patients with coronary heart disease, participation in cardiac rehabilitation, compared with nonparticipation, has been reported to have beneficial effects. Cardiac rehabilitation in elderly patients have shown its effectiveness in many studies with multidisciplinary outcomes.

Exercised-based cardiac rehabilitation which is emphasized in CR, is an important part of the long-term management of patients with chronic stable angina and of patients who have had a MI or undergone coronary artery bypass grafting (CABG) surgery.12 It has been proven that CR Table 1. Benefit of CRET programs in elderly CHD patients.

Improvements in Exercise Capacity Estimated METs Maximal oxygen consumption (peak VO2) Anabolic threshold Improvements in Lipids Total cholesterol HDL-C LDL-C Triglycerides Total cholesterol/HDL-C LDL-C/HDL-C Reduction in Obesity Indices Weight % Body fat Body mass index Improvements in Blood Rheology

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Changes +34% +13% +11% −1% +3% 0% −5% −4% −3% −1% −6% −1%

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Reduction in homocysteine levels * Improvement in viscosity * Major Morbidity and Mortality Reduction in overall mortality * Reduction in congestive heart failure * Reduction in hospital costs * Reduction in non-fatal MI * Improvement in Psychological Factors Depression score −12.6% Anxiety score −4.3% Hostility score −2.3% CRET: Cardiac rehabilitation and exercise training; CHD: Coronary heart disease; METs: Metabolic equivalent of task; HDL-C: High density lipoprotein cholesterol; LDL-C: Low density lipoprotein cholesterol; QoL: Quality of life. Adapted from Lavie et al(16)

It is becoming increasingly evident that psychological conditions such as anxiety, hostility, and depression among CVD patients are negatively impact CV health.

Depression has been shown to be independently associated with CV morbidity and mortality. Elderly patients with hostility have higher level of anxiety and depression compared to those who don’t.15 Cardiac rehabilition also plays a role in reducing psychological stress as shown in this figure below. In this figure, it is clear that psychological stress are declining postrehabilitation.

Figure 1.Prevalence of psychological risk factors in elderly coronary heart disease (CHD) patients before and after cardiac rehabilitation and exercise therapy (CRET). (n = 260, mean age 75 ± 3 years). Adapted from Lavie CJ & Milani RV.16 Ironically, with all those benefits, fewer older patients are reffered to cardiac rehabilitation. There is also an inverse

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relationship between age and attandance rate. Older people are less likely to attend, when invited, and more likely to drop out.

The underlying reasons include complications of heart disease such as heart failure, comorbidity, physical and mental frailty, and perceptions by both health professional and patients that rehabilitation is less relevant and too late anyway.11 Grace et al.17 published a study investigating age differences in barriers to cardiac rehabilitation enrollment and participation. This study was participated by 1.273 outpatients with CAD, some of which had undergone percutaneous coronary interventions or acute coronary bypass (ACB), diagnosis heart failure, and arrhytmia. Respondents were asked to rate the reasons for not attending CR or for missing sessions if they did attend.

Responses were made on a 5-point Likerttype scale from "strongly disagree" to "strongly agree," with higher scores indicating stronger agreement that a particular item was a barrier. The result of the study shows that total CR barriers to enrollment and participation were significantly related to age, with older patients endorsing more barriers than younger patients. Older age was positively related to total CR barriers (P < .001). Older patients more strongly endorsed the following CR barriers: already exercising at home (P = .001), confidence in ability to selfmanage their condition (P = .003), perception of exercise as tiring or painful (P = .001), not knowing about CR (P = .001), lack of physician encouragement (P < .001),

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comorbidities (P < .001), and perception that CR would not improve their health (P

<.001). 17 (Table 2)

Table 2. Pearson’s correlation of the association between cardiac rehabilitation enrollment and participation barriers and age. 17 the rate of older patients being much lower.

However, both older and younger people do Discussion have barriers in CR. The Pearson Cardiovascular rehabilitation presents Correlation reveals that older people have specific objectives aiming essentially to various barriers, such as already exercising improve the patients’ autonomy and quality at home, confidence in ability to selfof life by exercise reconditioning, taking manage disease, perception of exercise as into account frequent concomitant diseases tiring or painful, and not knowing about CR, and lifestyle. Unfortunately, the utilization while younger people’s barriers are most of cardiac rehabilitation by older patients about lack of time. The clinical and with CHD has been poor, given the benefits functional evaluation of elderly cardiac associated with cardiac rehabilitation and patient has to include psychosocial exercise training in the elderly. The reason assessment and the weight of the behind this is the involvement of several comorbidity also. factors, such as poor referral and Older cardiac patients are less likely to encouragement by physicians, be aware of CR. Most of them don’t know inconvenience, a lack of importance placed what CR is and what to expect from it. Lack on preventative medicine, etc. of information and encouragements from There are so many barriers especially for physician are also proved to be the barriers. older people in cardiac rehabilitation. In In the current study, older patients are less United States and Canada, only 15% to 30% likely to be referred to CR. That leads older of eligible patients participate in CR, with

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people to think that CR would not improve their health or their quality of life.

Physicians and other health care workers should be encouraged to prescribe CR to elderly patients following coronary events and procedures, provide written information about CR and actively encourage patient participation.17 Besides that, the experience of pain and fatigue from exercising in rehabilitation could also becomes the obstacles. Older patients who suffer from comorbidities such as diabetes, angina, and heart failure, which can all serve as deterrents to exercise in CR programs due to pain, shortness of breath and disability.

There is a need to consider older patients’ lower exercise capacity and greater comorbidities. Before initiating an exercise program, older patients should undergo a history and physical examination directed at indentifying cardiac risk factors, exertional signs or symptoms, and physical limitations. we should consider some useful parameters in training program: 1) reducing intensity, considering that a benefit is achievable with an activity at 50% of maximal functional capacity; 2) increasing the total duration of the training program; 3) simplifying the exercise to help with familiarity in execution; 4) selecting exercises appropriate to musculoskeletal conditions in the older patients; 5) avoiding exercises that require rapid postural variations for orthostatic hypotension risk; and 6) shortening the duration of single sessions, considering the early appearance of fatigue.6 The other barriers are transportation problem and cost. Lack of transportation leads to isolation. This condition causes the elderly people to depend on their family due to transports. Indeed, government’s ride services through programs and social service agencies offer some help, but it still considers ineffective. Moreover, facilities for elderly have not well-distributed. And also, CR programs have not spread evenly in every hospital and healthcare center.

Therefore, many patients, especially older people find it difficult to reach, not to mention patients who live far from the city, where the health center is still very few,

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including its facility. Socioeconomic status also plays an important role. Health insurance (ASKES) only funds the second phase of CR, out of four, and it is only for post-operative cardiovascular patients.10Afterwards, patients have to pay the rest of CR programs. This barrier is determining the number of participants in CR programs. However, regardless this insurance’ help in paying phase II, the patients who participate are still very few.

For example, in Harapan Kita hospital, only 2% patients of post Percutaneous Transluminal Coronary Angioplasty (PTCA) participate in rehabilitation programs, more less for patients of post MI and heart failure.

Even though the patients of post operation Coronary Bypass Artery Grafting (CABG) are dominant in CR programs, actually, only 58% of them participate in rehabilitation programs. The rest follow this programs not formally in the hospital because they have to go back to their hometown or the hospital is too far to reach.

Indonesian government is expected to be more assertive in managing implementation of social security system, especially in terms of transportation, also in providing more alternative for elderly in order to reach healthcare center easily. Recognizing how important cardiac rehabilitation is, the government should cover phase II CR program through health insurance, even if they are not post-surgery patients. If it is not possible, providing remission price from the hospital to attract patients to participate in CR is also a good way.

Despite the possible solutions shown previously, another solution can be considered as a future implementation: home-based rehabilitation program (HBRP).

The physician can control patients’ health status by phone and home visiting. While, risk stratification, education, counselling, and programs evaluation still could be done at hospital or at home by internet, if possible.

Home Based Rehabilitation Program is an individualized rehabilitation program for clients who require rehabilitation in the context of their own home to facilitate

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learning and their return to previous activities and lifestyle.19 A home-based service model for cardiac rehabilitation based on mobile phones and web services.

This technology potentially offers increased access to cardiac rehabilitation. The program does not replace standard rehabilitation programs but offers a more flexible option for eligible patients and greatly minimizes reliance on healthcare center visits.

Conclusion Cardiac rehabilitation has been proved to be beneficial among elderly people. It improves elderly’s physical activity, control of risk factors and quality of life. However, older cardiac patients have a greater burden of CR barriers which makes it underutilized.

These barriers in elderly include: already exercising at home, confidence in ability to self-manage their condition, perception of exercise as tiring or painful, not knowing about CR, lack of physician encouragement, comorbidities, and perception that CR would not improve their health. Future research to overcome these barriers is needed.

Physicians should place more attention on referring and encouraging elderly patients to participate and attend the program. The future lies with acknowledging that some patients rehabilitate themselves without formal program support, accepting high nonattendance and early dropout rates and providing an economical service, tailored to the perceived needs of the patients who seek support. This would make cardiac rehabilitation more relevant to older patient.

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Gaziano TA. Cardiovascular disease in the developing world and its cost-effective management. Circulation. 2005;112:3547– 3553.

World Health Organization. [homepage on the Internet] Cardiovascular diseases. 2012 [cited 2013 Jan 15]. Available from: http://www.who.int/mediacentre/factsheets/f s317/en/index.html.

Sahyoun NR, Lentzner H, Hoyert D, Robinson KN. Trends in Causes of Death Among the Elderly. Aging Trends; No.1.

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15.

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BPS. Statistik Penduduk Lanjut Usia, Survei Sosial Ekonomi Nasional, Badan Pusat Statistik Indonesia,2004.

Canadian Association of Cardiac Rehabilitation. Canadian Guidelines for Cardiac Rehahilitation and Cardiovascular Disease Prevention: Enhancing the Science, Refining the Art. Winnipeg, Manitoba: Canadian Association of Cardiac Rehabilitation; 2004.

Ferrara N, Corbi G, Bosimini E, Cobelli F, Furgi G, Giannuzzi P, et al. Cardiac rehabilitation in the elderly: patient selection and outcomes. The American Journal Of Geriatric Cardiology. 2006 ;15:22–7.

Wenger NK. Current Status of Cardiac Rehabilitation. J Am Coll Cardiol 2008 2008;51:1619-31.

Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63–70.

Obson LE, Lewin RJ, Doherty P, Batin P, Megarry S, and Gale C. (2012) Is cardiac rehabilitation still relevant in the new millennium? J Cardiovasc Med 2012; 13(1), p 32-7.

Radi B, Joesoef A, Kusmana D. Rehabilitasi Kardiovaskular di Indonesia. 2009;3:43-45 West R. Cardiac rehabilitation of older patients. Reviews in Clinical Gerontology.

2003;13(3):241–55.

Drury NE, Nashef SA. Outcomes of cardiac surgery in the elderly. Expert Review of Cardiovascular Therapy. 2006 ;4(4):535–42.

Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63–70.

Lavie CJ, Milani RV, Arena RA. Particular utility of cardiac rehabilitation in relation to age. Curr Cardiovasc Risk Rep2011; 5: 432– 439.

Lavie CJ, Milani RV. Impact of aging on hostility in coronary patients and effects of cardiac rehabilitation and exercise training in elderly persons. Am J Geriatr Cardiol 2004; 13:125–130.

Milani RV, Lavie CJ. Reducing psychosocial stress: a novel mechanism of improving survival from exercise training.

Am J Med 2009; 122: 931–938.

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17. Grace, S. L., Shanmugasegaram, S., Gravely-Witte, S., Brual, J., Suskin, N., & Stewart, D. E. (2009). Barriers to cardiac rehabilitation: does age make a difference? J Cardiopulm Rehabil Prev, 29, 183-7.

18. Lee S, Naimark B, Porter MM, Ready AE. Effects of a long-term, community-based cardiac rehabilitation program on middle-

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aged and elderly cardiac patients. The American Journal Of Geriatric Cardiology.

2004;13:293â&#x20AC;&#x201C;8.

19. Barwon Health [homepage on the Internet].

Home based rehabilitation. 2012 [cited 2013 Feb 1].

Available from: http://www.barwonhealth.org.au/homebased-rehabilitation.

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Ecological Model of Geriatric Behaviour as Prevention of Diabetes Mellitus Type 2 Steven Philip, Eunika Kosasih

AMSA-Unika Atma Jaya Introduction Indonesia, as a country which economically supported by agrarian sector, now gradiently shifting into industrial sector because of improvement of technology.

Armida Alisjahbana, the head chef of national planning and development (BAPPENAS) said economic growth in Indonesia was 6,4% in 2011 and also Indonesia was nominated as the second country with greatest financial improvement in the world after China.(1) One of the indicator of socio – economic caused by financial improvement is an increasing of life expectation. According to CIA world factbook in 2011, life expectation in Indonesia rosely increasing to 70,76 years old. Based on prediction from UN in 2003, Indonesia is one of the country with the most increasing of old people, from 1990 until 2020 it will rise up to 414%. (2) On the other hand, huge explosive number of old people brought new serious issue in our nation, degenerative diseases. In 1990, around 49% of disease group in developing countries is communicable diseases, maternal and perinatal conditions and nutritional deficiences. Meanwhile, noncommunicable conditions or degenerative disease only 27%. But fortunately, with baseline scenario in 2020 noncommunicable disease climb up until 43% and it will be prime concern for physicians in the future. Based on the statistic, the most common degenerative disease found in Indonesia are osteo artritis, osteoporosis, hypertension, cardio vascular diseases (CVD), cancerand diabetes melitus.

Until 2011, approximately 24 million people with age more than 60 years live in Indonesia and more than 30% of them had diabetes melitus type 2.

Diabetes melitus type 2 (DM type 2) is a group of metabolic diseases in which a person has high blood sugar that caused by mutation or insulin’s receptor called insulin

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resistance. DM type 2 has become a serious issue around the world because it’s a distraction for people to achieve good qualities of life. Often, DM type 2 also bring another complication diseases such as microvascular, macrovascular, and other diseases that distract people’s qualities of life.

There are some complications happened to older patients with diabetes and often they present with these complications in the time of diagnosis. In elderly patients who have cognitive impairment, limitations to daily activities, deficiency in social communities and unstable emotion can contribute in the development of diabetes’ complications.

Method After searching and intergrating information that collected, there are some ecological behavior that help people to preventing DM type 2. The new model of behavior purpose to change multiple levels to encourage healthier community especially group of old people. The reason we give this method is not just for a mere work, but because older people need more care than other levels of age. As with all persons with diabetes, self-education or training for older people should be adapted with their medical, cultural, and social situation. That’s why people around them are important to help those older people to maintain their health.

This method is basically using ecological model of behavior in any level of human interaction especially interaction of older adults. Ecological model of behavior method as prevention for DM type to 2 in older people not only for avoiding long term and side effect of medicine itself, but also because out come of method shown more effective result in the end than pharmacologies methods. Prevention using ecological model of behavior divided into 3 levels: individual, group and community. (3)

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In individual level, one-on-one pasienphysician apply using flexibel manner.

Flexibel manner itself used for careproviders to make good relationship with older adult patients.Besides flexibel manner, shared decision making also important for prevention for elderly. Sometimes healthy lifestyle doesn’t match with patient goals. It happens because the main focus of healthy lifestyle is health care, older people focus most on their functional status and independence. So shared decision making also important to makes a good relationship.After building a good relationship, reduction fat intake also implemented but through health care settings. Beside flexibel manner, human in individual level also a social being and family is one of the best way to help high risk DM type 2 people to change their life style. Family behavioral approach using diabetes self management education/training (DSME/T) such as self monitoring problem solving, relapse prevention needed for pasien care and providing easy-to-read handouts lifestyle.

When communicating with them, even patients with complications, educators near them such as family, friends, and caregivers should address the patient with names so the older people will not confuse. Calling old patient especially with high risk of glycemic problem or even with DM type 2, that tends more sensitive, with their own name will help older patients feel close and comfortable with their physician. Maybe at first they felt insecure but with such caring, older patients will not feel the gap again.

The other ones are speaking in simple terms, using signals that aid memories (hands signal, demonstrations, or verbal analogies), and it’s important also to visit often to build information and education.(4) Screening for diabetes and prediabetes patient also important for prevention for midle-age and old-age patients. Overweight adults with high risk factors and all adults aged more than 45 years must be screened every 1-3 years for early diagnostic. For healthy 66 year old individual should be

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encouraged by their family to have routine control of glucose level.

Second, intervention through group either school environment or work site.

Intervention through school environment also important to build a healthy habit since early age that continuous until becoming an old adult. In school environment, they could adapt to life intervention such as classroom instruction by teachers, cafetaria food choice, homework related to dietary and activity packages. Meanwhile in work site, life intervention could use some ways like rules for employee more than 55 years old to have screening, nutrition classes and goal setting for detecting diabetes symptoms.

Employee advisory board could help them by making plan intervention for their worker’s heatlh like physical activity and fitness regulation. Although old adult employees conspire to reduce fitness and strength, physical activity interventions improve functional status in older adults with and without diabetes. They need to be encouraged with mandatory regulation in office to maintain their healthiness.

After intervention in group level, intervention through community also needed to achieve good results beside individual and group intervention. In community group could be started with intervention in supermarket that selling healthy food, community based classes to educated people to change their life style to healthy one and encourage people by using news letters. As a person being old, their need for nutrition also changing. In vulnerable resident (resident with most eldery population or senior citizen house), it could be a routine mini-nutritional assesssment. The routine mini nutritional assessment is simple to perform and may be determined whether referral to a registered dietitian for medical nutrition therapy (MNT). This method is intergrating eldery’s nutrition needs and diet intake.

Last but not least, outside home long term care (LTC) facilities help elder people preventing in communities level. Keeping elder people inside home without supervision that taking care of them also

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becoming one high risk factor for them get DM type 2. Nursing homes which provides 24-hours nursing care for elder people in either residential care or rehabilitative care are helping elder people preventing DM type 2 with providing proper diet and fluid intake based on nutrition needed. It also could help eldery to manage their physical activity also to preventing from DM type 2.

Result As the result, lifestyle intervention has a big role for prevention of DM type 2. The ecological model of geriatric behavior mainly focusing in lifestyle changes by losing 7% of body weight and also achieving 150 activities each week.

Behavioral management procedures identification of palms for coping with temptation for relapse, identification to concrete change goals, all implemented in a highly individualized manner.

From ecological behavior could reduce incidence of DM type 2 from 58 to 4,8% in general age and reduce 71% among 60 years old people.

These results are quite encouraging to apply in daily life prevention for geriatrics compare with drugs intervention using metformin by Diabetes Prevention Program (DPP), which shows lesser improvement from 31% to 7,8%. The Finnish Diabetes Prevention Study also found a 58% reduction among high risk diabetes indication with focusing in 5 changes: fiber consumption, fruit and vegetables consumption, reduced dietary fat, exercise, and weight loss.

Diabetes also brings economical burden for treatment cost especially for geriatrics, who should cosume different type of medicine and 25% more expensive than other group of peopleâ&#x20AC;&#x2122;s medication. In 2007, diabetes melitus approximately cost $174 billion including direct treament and inefficiency because of their absence in work days. Medical expenditures, that is, cost for treating diabetes melitus could be pressed down by preventing the diabetes itself mainly in elder people group which has more vulnerable and expesive treatment

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cost. DPP and the Stop-Non-IsulinDependent Diabetes Melitus (NIDDM) study suggest that lifestyle intervention is safe.

On the same side, a prospective economic analysis conducted by DPP Research Group estimated that life style interfention only costing $1.400 per person in its first year and approximately $700 per person per year after. Elder people who preventing diabetes could save around more than $10.000 per year if they can keep their body healthy. (5) Idea of prevention of DM type 2 focusing on weight loss, dietary changes, and physical activities also supported by early repot from many organization such as National Heart, Lung and Blood Institute (NHLBI), NIDDK, Task Force on Community Preventive Services organization for DPP and Agency for Healthcare Research and Quality (AHRQ).

Discussion Ecological model of geriatric behavior as prevention of DM type 2 is more effectively compare than drugs intervention, metformin, to reduce incident of DM type 2. Ecological method combining multilevel approach instead of single level intervention.Lifestyle changing also need care-providers or supervision from reliable and competent people to help older adults for preventing DM type 2. People with DM 2 have a high risk of getting more complications and even could cause death. That is why it is also required also for those patients to receive several medical classes and education to control their own body. It really needs a great attention to encourage and control the older peopleâ&#x20AC;&#x2122;s health care.

Participation from government also important to create supporting environment for old people preventing from DM type 2.

This is one of preventive ways so that patients with diabetes could get good intervention in their health care. Highly dicipline behavior also needed to maintain healthy condition in eldery. Moreover, ecological model of behavior achieved by long term practicing to get proper result. It

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doesn’t take a short time to make this method happen.

lifestyle interventions for older patients with diabetes.

Conclusion As the time goes by, global economic changes and bring its advanatages and disadvantages as well. One of the indicator is socia-economic factor, life expectation that also increasing. Meanwhile, good financial bring changes in people’s lifestyle and move over from communicable into non-communicable diseases.

Diabetes melitus is a metabolism disorder that affect blood plasma glycemical as one of the dangerous non-communicable diseases especially for older adult.

Diabetes melitus, same like HIV, doens’t have cure. Low quality of healthiness lifestyle brings a big number of old people with Diabetes Melitus. As non-curable disease, diabetes melitus only could be delayed or prevented, by changing the root of the problem, lifestyle.

Lifestyle intervention as one of the best way to prevent diabetes melitus which using multilevel approach in individual, group and community level. It is important for all educators, families, and also care-givers, who are taking good care of the old people, to know how to control and educate them in maintain their health care. The reason why is because this level of age need more attention, patience and tolerance when facing the elder. Besides that, the result of lifestyle intervention is more efficient than pharmachologies approach, ecological model of geriatric behavior as prevention of diabetes melitus type 2 also cost friendly for high risk people.

Seeing the result, we can conclude that ideal geriatric care requires a multidisciplinary approach. Like any other patients with diabetes, we must try to minimalize the complications and impairments by stop the diabetes’ risk from early onset. Older patients should realize the physiology and recognition of some serious complications that could happen anytime.

Moreover we also need exploration in lower cost of treatment but efficient and safe

Table and figure

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Figure 1 – Ecological model of health behavior

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Managementofdiabetes Encouragephysicalactivity,evenifnottooptimallevels,andimplementMNTusingsimpleteachingstr ategiesandcommunityresourceswhileconsideringpatient safetyandpreferences.

DSME/Tinolderadultsshouldtakeintoaccountsensorydeficits,cognitiveimpairment,anddifferentl earningstylesandteachingstrategiesandshouldincludecaregivers.

Managementofolderadultswith diabetesinsettingsoutsidethehome Theglycemicgoalsforhospitalizedolderadultswith diabetesareusuallysimilartothoseforthegeneralpopulation.

TheuseofSSIaloneforchronicglycemicmanagementisdiscouragedininpatient settingsaswellasinLTCfacilities.

Transitionsofolderadultswithdiabetes(e.g.,fromhomeorLTCfacilitytohospitaltopostdischargesetti ng)areperiodsofhighrisk.Careful medicationreconciliationandwritteninformationregardingmedicationdosingandtiminghel p tominimizeriskforhyper-and hypoglycemia.Earlytransitionofdiabetescaretoanoutpatientproviderisimportanttomodifyd rugtherapyaccordingtochangesin clinicalstatus.

Table 1 – additional consensus recommendation for care of older adults

Table 2 – Cost effectiveness of intervention for the primary prevention of diabetes melitus type 2. n+Tahunan/Laporan+Perekonomian+Indone sia/lpi_2011.htm References 2.

CIA - The World Factbook 1.

Laporan Perekonomian Indonesia [Internet]. [cited 2013 Feb 6]. Available 2011 - Bank Sentral Republik Indonesia from: [Internet]. [cited 2013 Feb 6]. Available https://www.cia.gov/library/publications/the from: -world-factbook/rankorder/2102rank.html http://www.bi.go.id/web/id/Publikasi/Lapora

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3.

Fisher EB, Walker EA, Bostrom A, Fischhoff B, Haire-Joshu D, Johnson SB. Behavioral Science Research in the Prevention of Diabetes Status and opportunities. Dia Care. 2002 Mar 1;25(3):599–606.

4.

Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, et al.

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Diabetes in Older Adults. Dia Care. 2012 Dec 1;35(12):2650–64.

5. CHARLOTTESVILLEV, HERMAN WH. Cost-effectiveness Issues ofDiabetes Prevention and Treatment. [cited 2013 feb 6]; available from: https://dpgstorage.s3.amazonaws.com/dce/resource/cos t_effectiveness.pdf

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The function of Geriatric Medicine on Elderly Population with Hypertension in Ambon Auldrich Huka, Widya Ambari Universitas Pattimura, Ambon ABSTRACT Based on projections of Bappenas, the elderly population 60 years or olderis expected to increasefrom 18.1million(2010) to 29.1 million (2020) and 36million (2025). With the increasing number of elderly, would be followed by an increase in health problems in the elderly. Every elderly with that change requires more attention. Every stage of change that happen to their body must receive special management. In this case, related with the management of their health care.

To increase of the quality of elderly health care, it require corporation between every element of health profession, including geriatric medicine. One of the health problem in elderly is hypertension. The number of elderly with hypertension in Ambon reach 631 people.

Aging process requires special attention from the stakeholder in Ambon city because it can be a health challenge in the future. Geriatric medicine is a specialty of medicine concern with physical, mental, function social condition in acute, chronic, rehabilitative, preventive and end of life care in older patients. Furthermore, elderly health problem including hypertension more handle by internist and nurse not specialized by geriatric medicine. Because of that, the government of Ambon city should maximize the function of geriatric medicine in elderly health service.

Keywords: Geriatric medicine, hypertension in elderly Introduction When someone entering to the elderly stage of life, they might be worried about their productivity in life. Some people worried of decreasing the ability to hearing, visualization, wrinkle on the skin, gray hair, and many changes that could happen to them. Life is always going on, human will growth up until the time when they must receive the situation of decreasing of their body function.

Constantinides(1994)says thatthe aging processisa processgradualdisappearance ofthe ability ofthe tissue toimproveor replace andmaintainnormal functionand therefore can notsurviveagainstinfection andrepairthe damage suffered. (1) Ageis used asa benchmarkas theelderlyvary,generally ranging from60-65 years. According toWHO, there are four stages ofmiddleage limitisage(middleage)between45-59yearsold, age (Elderly) between 60-74years,

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andolderage(old) between75-90years old, andvery oldage(veryold)over90 years.(1) According to Ministry of Health Republic of Indonesiaelderlylimitsare divided intofouragegroups: the middleage(virility) thegestationagethatmightrevealthe physical andmentalmaturitybetween45-54 years, earlyage(prasenium) that the groupbegan to enter theagebetween 55-64yearold agegroup(senium) aged65 yearsandolderwitha high risk ofthegroupover the age of70 yearsorthe elderlywho live alone, isolated, living ina nursing home,suffering fromserious illness, ordisability. (1) The results ofthe Population Censusof 2010, Indonesiais nowincluded in thetop fivecountries withthe highestnumber of elderly peoplein theworld, the18.1million people or9.6%of the population. Based onprojections ofBappenas, the elderly population60 years or olderis expected to increasefrom

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18.1million(2010)to29.1million(2020)and 36million(2025).(2) Physiological aging refers to the changes in structure and functioning of the body that occur over a lifespan. Many of these changes are involuntary and occur very gradually while others occur over a short period.

Following are the descriptions of some of the physiological changes that normally occur.

Some changes that may occur in the cardiovascular system are a decrease in the elasticity of the blood vessels and heart valves, restricted blood flow due to the thickening of the vessel walls and because of the fatty deposits lining the vessels, and a decrease in the ability of the heart to pump out as much blood with each beat. As a result, the elderly may feel fatigued, become short of breath more easily and have less capacity for physical exertion(2) Decreased elasticity of the lungs may occur with aging. This may affect lung's ability to utilize oxygen, as well as the ability to cough and take deep breaths. Geriatric may be more prone to fatigue and shortness of breath on exertion, and become more susceptible to infections.

There tends to be a gradual loss of muscle tone, elasticity and strength. In some areas, the muscle is often replaced with fatty tissue with little rolls or soft, flabby spots. More significant is that the endurance or strength to perform certain tasks may also decrease. (2) The digestive tract is a very resilient system, but there are some changes that occur which may cause some distress. There is a gradual slowing of the system as well as a decrease in the secretion of saliva and enzymes which are necessary for digestion. As a result, there may be problems with indigestion, elimination and adequate absorption of nutrients. (2) The effects on Neurological system are the messages take a slightly longer time to pass from the nerves to the muscles, and the muscles take a slightly longer time to react

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to these messages. In the other words the geriatric have loss their ability to make a quick response. Also, there may be a decrease in the perception of pain and an increase in the time to react to it. (2) The ability of the kidneys to filter and reabsorb may also decrease. Also, men show a tendency towards prostate enlargement while women have hormonal changes that may cause vaginal itching and burning, making intercourse uncomfortable. (2) From the explanation above we can concluded that aging process is an inevitable part of life and every part of changes must be receive in every people. In Elderly occurs decreasing function of cells because of aging process it can influence to decreasing of function organ, physic insufficiency and appearance of various diseases particularly degenerative diseases. Some of the elderly has a disability in their life so that some of them quit from the social community, depressed and decreasing of their passion to making productive activity even some of them wishing to end their life. It is veryburdensomeon theeconomy ofbothindividuals andthe governmentbecause of the diseaserequires long-treatmentandneeds a lot offundingfortreatmentand rehabilitation. (4) With the increasingnumber of elderly, would be followed by anincrease inhealthproblemsin the elderly. Every man with that change requires more attention.

Every stage of change that happen to their body must get correct management. In this case, related with the management of their health care. In years 2012, The Ministry of Health of Republic Indonesian make a program with the main theme â&#x20AC;&#x153;Sehat dan Aktif di Usia Lanjutâ&#x20AC;? (Healthy and Active in Elderly) has a purpose to approach elderly care so that they can life healthy, independently, without discrimination. (1) Every province in Indonesian expected to

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perform this program seriously to reach that main purpose.

Ambon is the capital city of Molucas province that located on East of Indonesia.

Based on population census on 2011 the number of population in Ambon city was 340.427 people. Elderly population in Ambon city was 59.140 people. (3)Increase inthe elderly populationwill lead to variousproblemsincludetechnicalmedical problems, mental psychological, social andeconomic. Thirty-eight percent ofthe problemsin the elderlyis a health issue. One of the health problem that often occurs in elderly population in Ambon is Hypertension.

Hypertension defined as a blood pressure over 140/90 mm Hg. Arterial stiffness and endothelial dysfunction also increase with age. The complication of hypertension are stroke, myocardial infraction, renal failure, heart failure, cognitive impairement.

Hypertension also increase risk of vascular death 3 times (Final Report, 11th ASEAN Gerontology Course,2010). (4) Hypertension is an important risk factor for cardiovascular morbidity and mortality, particularly in the elderly. It is a significant and often asymptomatic chronic disease, which requires optimal control and persistent adherence to prescribed medication to reduce the risks of cardiovascular, cerebrovascular and renal disease. Hypertension in the elderly patients represents a management dilemma to cardiovascular (CV) specialists and other practioners.(5) Either diastolic (>90 mmHg) or systolic (>140mmHg) hypertension occurs in one half to two thirds of people older than 65 years and in 75% of people older than 80 years. A large number of older people are unware that they have hypertension. Even when it is recognized, hypertension is not controlled in many older patients, and older age is considered one of the strongest risk

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factors for resistant hypertension (Braunwald). (6) Aging process requires special attention from the stakeholder in Ambon city because it can be a health challenge in the future. The purpose of the paper is to explain about the now condition of older population with Hypertension in Ambon, program that held by health department of the city and the involved of geriatric medicine in effort to increased the level of elderly health care.

Methods Preparation ofthis papercarried outin the city ofAmbon, Malukuprovince. Writingthis paperusesthe methodof observation(observation), interviews, and data collection. The datarequired inthis studyinvolvesseveral things, as follows; • The number ofelderly population in Ambon City • Health problems of the elderlyin Ambon city, specially the number of elderly with hypertension.

• Health service for elderly with hypertension in Public Health center (Puskesmas) • The function of Geriatric medicine to elderly with hypertension.

Data gathering andinterviewsconducted on25 to 28 January2013 in the office ofHealth Departement of Ambon city andthefour Public Health Centers.To determine theeffectivenessof health careinelderlyposyanduin Ambon, authorstook samplesfrom four Public Health Centersin the city ofAmbon. Four Public Health Centers, among others; Health Center of Belakang Soya, Public health center of Aer Salobar, Public Health Center of Benteng, and Public Health Centers of Waihaong. The interviews was held with the chief of the Puskesmas and the coordinator in field that has a duty to manner the program.

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Result Aging is an inevitable part of life and brings along two inconvenient events: physiologic decline and disease state. Hypertension is an important risk factor for cardiovascular morbidity and mortality, particularly in the elderly.

After makingobservations andcollecting datafromAmbonCity Health Department, AerSalobarhealth center, health centerWaihaong, Betenghealth centers, andhealth centersRearSoya, the data obtainedare follows: According to recent data(year 2010) number ofelderlyin the Ambon city reach 59.140 people. The number of elderly visitor in health center reached 6049people.

From the observation,eachhealth center monitor anyposyandulocated inits jurisdiction.

According tohealth departmentof Ambon city, the number of elderlyvisitorsin theclinicarea ofthe ofAmboncity in 2012reached6049people.Hypertensionin the first place that occursin theelderly populationin 2012. Number of patients withhypertension is693people. In thesecond tohypertensionis obesitythenumberreached313 peoplefrom 22centersin the city ofAmbon. The other diseases withsmallnumber of casesincludingdiabetes, anemia, kidney disorders, mentaldisorders, andanother diseases.

Ofthese diseases, visitors aretreatedamounted to3973andthecounselingtotaled831people.

According to dataandinterviews that conductedat fourhealth centers,the resultsshown thatattention to thehealth care of the elderlyis veryregularly performedby theclinic.

Eachclinicis working withposyandu of elderlytolaunch acommunity-managedhealth servicesfor the elderly. Eachclinicroutinely monitoringon eachposyandu based on the the posyanduâ&#x20AC;&#x2122;sscheduleineach area.

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Since theprogramwas declared about â&#x20AC;&#x153;health, indepedentand productivein old ageâ&#x20AC;?, the effort of elderlycare in Ambon city being intensified.According to data health department of Ambon city,thenumber of elderly visitorsincreased fromprevious years.

Based on theclassification ofelderlyage, thehighestnumber of visitorswereaged >60 (or classified as elderly age) yearsuntilveryold age,>80 years.

Based on the interview and observation health service for elderly held by health center of each area in Ambon city, performed by general doctors, nurse, and public health agent. This is explain that there is no geriactric medicine service on Ambon.

Furthermore, management health problem of elderly managed by general doctors, internal medicine and nurse in the hospital or in the puclic health center.

Discussion Hypertension in elderly The increasingnumber of elderly, would be followed by anincrease inhealthproblemsin the elderly, one of which is Hypertension.

Thirty-eight percent ofthe problemsin the elderlyis a health issue, as well as otherissuessuch asfinances, loneliness, feeling useless andunproductive.Staying healthyin old agewouldbe great achievement of government program. So theefforts ofhealthinold ageand understand thevariety of possiblediseases thatcouldariseare important to know.

Old ageisan inevitableprocess, whichoccurs changes in body functionssuchas changes in thecardiovascular system thatcan causehypertension. Hypertension is also known as high blood pressure is a medical condition in which continuous high blood pressure or according to JNC-7 (Joint National Committee) hypertension is an increase in arterial blood pressure that remains. Based on recommendations of the JNC 7, the classification of BP (expressed in

A.

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mm Hg) for adults aged 18 years or older is as follows(7) • Normal: systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg • Prehypertension: systolic 120-139 mm Hg, diastolic 80-89 mm Hg • Stage 1: systolic 140-159 mm Hg, diastolic 90-99 mm Hg • Stage 2: systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater Hypertension in the elderly is associated with increased occurrence rates of sodium sensitivity, isolated systolic hypertension, and 'white coat effect'. Arterial stiffness and endothelial dysfunction also increase with age. (7) Sodium sensitivity, defined as the extent of the rise in arterial blood pressure with an increase in sodium chloride intake, is heightened with age. In the elderly, limitation of dietary sodium intake and the use of diuretic agents show more effectiveness in controlling hypertension than in the young. (7) Isolated systolic hypertension (ISH) is characterized by systolic blood pressure ≥ 140 mm Hg with diastolic blood pressure <90 mm Hg, and (consequently) high pulse pressure. (7) ISH is characterized by decreased arterial compliance, usually expressed as increase in arterial stiffness. There is controversy over the mechanism of the increased stiffness.

Some attribute the effect to age-related loss of distensibility in the major central arteries as elastic tissue is progressively replaced with collagen. Other investigators attribute the increased arterial stiffness to endothelial dysfunction. Although both factors probably contribute, the effect of endothelial dysfunction is potentially the more correctable pharmacologically. (7) Endothelial dysfunction is caused by free oxygen radicals in the arterial wall and by the upstream effects of reduced distal vascular flow reserve. Accumulation of free

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oxygen radicals results from age-associated cardiovascular risk factors, including atherosclerosis, diabetes mellitus, and renal impairment as well as hypertension itself.

Endothelial dysfunction manifests clinically as impairment in acetylcholine-stimulated, endothelium-dependent, NO-mediated vasodilatation: the depressor response to antihypertensive agents which operate through endothelium-dependent mechanisms is decreased, but the response to exogenous nitrates is preserved. (7) The 'white coat effect' occurs when blood pressure is increased temporarily through an autonomic neural reaction triggered by the process of measurement. This effect increases with age. As the systolic component often rises more than the diastolic, the type of hypertension due to a 'white coat effect' could be mistaken for ISH. How ever, a ‘white coat’ effect can be confirmed by finding a major discrepancy between automated blood pressure values in the normal range) and observer readings (high). (7)

B.

G

eriatric Medicine for management elderly with hypertension Geriatric medicine is a specialty of medicine concered with physical, mental, function social condition in acute, chronic, rehabilitative, preventive and end of life care in older patients. This group of patients are considered to have high degree of frailty and active multiple pathology, requiring a holistic approach. Disease may present differently in older age, are often very difficulty to diagnode, the respone to treatment is often delayed and there is frequently a need for social support.(8) Geriatric Medicine therefore exceeds organ orientated medicine offering additional therapy in a multidiscipliranary team setting, the main aim of which is to optimise the

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functional status of the older person and improve the quality of life and autonomy. (8) Geriatric medicine is not specifically age defined but will deal with the typical morbidity found in older patients. Most patients will be over 65 years of age but problems best dealt with by the speciality of geriatric Medicine become much more common in the 80+ age group. (8) The program of the health ministers focuseson, first, enhancementand stabilization oftheElderlyhealth effortsinprimary health care,particularlyhealth centersand groupsthrough the conceptElderlySeniorsHealth CenterCourteous.

Second, increased effortsforthe Elderlyhealth referralthrough the development ofGeriatric Medicineat thePolyclinicHospital.Third, increased outreachand information disseminationof health and nutritionfor the elderly. (9) This programmustbe anational programthatshould be pursuedby everyprovince. Implementation requiresthe cooperationofthe variousprofessionsin the health sectorincludinggeriatric medicine.

In Ambon elderly health problems that often happens is hypertension. described in the previous section, hypertension can lead to various complications that can be dangerous. according to the observations of many parents who do not know about it, causing the higher incidence of hypertension elderly. where the role of geriatric medicine.

This situation should be of particular concern for the city health department to be more focused aim towards elderly care and proper treatment for hypertension. Our suggestion to this issue is the focus of geriatric medicine in dealing with elderly hypertensive population in the city of Ambon. â&#x20AC;˘ Increasing effective treatment in accordance with the appropriate

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combination of drugs and dosage according to patients with comorbidities.

The hypertension pandemic has driven extensive pharmaceutical research, and new drugs continue to be introduced. The major classes of drugs commonly used for treating hypertension are diuretics, calcium channel blockers, and renin-angiotensin system blockers. Each class has specific benefits and adverse-effect profiles.

It is appropriate to start antihypertensive drug therapy with the lowest dose and to monitor for adverse effects, including orthostatic hypotension. The choice of drug should be guided by the patientâ&#x20AC;&#x2122;s comorbid condition and the other drugs the patient is taking.If the blood pressure response is inadequate, a second drug from a different class should be added. In the same manner, a third drug from a different class should be added if the blood pressure remains outside the optimal range on two drugs.(10) Most elderly hypertensive patients have multiple comorbidities, which tremendously affect the management of their hypertension.

They are also more likely than younger patients to have resistant hypertension and to need multiple drugs to control their blood pressure. In the process, these frail patients are exposed to a host of drug-related adverse effects. Many studies have indeed shown that treating hypertension reduces the risk of stroke and other adverse cardiovascular events. A decade ago, Staessen et al, in a meta-analysis of more than 15,000 patients between ages 62 and 76, showed that treating isolated systolic hypertension substantially reduced morbidity and mortality rates. Moreover, a 2011 metaanalysis of randomized controlled trials in hypertensive patients age 75 and over also concluded that treatment reduced cardiovascular morbidity and mortality rates and the incidence of heart failure, even though the total mortality rate was not affected. Opinion on treating the very elderly

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(â&#x2030;Ľ 80 years of age) was divided until the results of the Hypertension in the Very Elderly trial (HYVET)came out in 2008.

This study documented major benefits of treatment in the very elderly age group as well. .(10) â&#x20AC;˘ Geriatricmedicinestudy thepathophysiology ofaging process and its change and elderly hypertension, socould well explain theconsequences caused byhypertensionand how tocontrol it to public.

In this case, Geriatric medicine get involve to spread the information to public, such as making socializing about aging process and the consequences. The target of this socializing is not for people with aged >60 years old but must initially from aged 45 years old as the population pre-elderly.

Moreover, it is unclear if the same target should apply to octogenarians. According to a 2011 American College of Cardiology/American Heart Association (ACC/AHA) expert consensus report,an achieved systolic blood pressure of 140 to 145 mm Hg, if tolerated, can be acceptable in this age group. Socializing the effect of aging and its impact must concentrated to this population so its easily to control elderly population that can develop in the future.(10) The function of geriatric medicine to this population is reaches the goals that can explain in the following strategies; The goals and strategies for treating hypertension in the elderly population are different from, and more challenging than, in younger patients. Lifestyle modification is effective in this population, but it is difficult to maintain. The American College of Cardiology (ACC) and the American Heart Association (AHA) recently released the first expert consensus statement to help clinicians effectively manage hypertension in the elderly population. Like JNC 7, the

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ACC/AHA document recommends BP measurement of <140/90 mm Hg for those aged 65 to 79 years. For patients aged â&#x2030;Ľ80 years, most experts, including the ACC/AHA statement, recommend a lessstringent systolic BP goal of 140 to 145 mm Hg, to minimize side effects.

This ACC/AHA document further recommends starting the evaluation of the elderly patient with known or suspected hypertension with 3 measurements of BP, including in the standing position, to obtain an accurate BP value. If BP is elevated, the cause should be isolated. Any organ damage should be assessed. Other CV disease (CVD) risk factors or comorbid conditions should be identified, along with any potential barriers to treatment adherence. According to this ACC/AHA statement, lifestyle modifications may be all that is necessary to treat milder forms of hypertension in elderly patients. In patients with resistant hypertension, drug therapy is recommended and should be started at the lowest dose possible, with gradual increases depending on response.

Diuretics, angiotensinconverting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs) are effective in lowering BP and reducing CV outcomes in the elderly. Beta-blockers are inferior in benefits compared with these drug classes, but they may be used in selected cases in the elderly population.(11) Lifestyle modification is recommended as the first-line treatment for all patients with hypertension, especially in the elderly population, where polypharmacy, potential drug interactions, and nonadherence to treatment regimens are serious concerns.

Weight control, adoption of the Dietary Approaches to Stop Hypertension (DASH), dietary sodium restriction, increasing activity level, and limiting alcohol intake are effective tools in the treatment of hypertension.(11)

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years old but must initially from aged 45 years old as the population pre-elderly.

Socializing the effect of aging and its impact must concentrated to this population so it is easily to control population of elderly with hypertension that can develop in the future.

Conclusion Old ageisan inevitableprocess, whichoccurs changes in body functions.With the increasing number of elderly, would be followed by an increase in health problems in the elderly. Every men with that change requires more attention. Every stage of change that happen to their body must get correct management. In this case, related with the management of their health care.

To achieve Healthy and active in elderly of Ambon city, the government must collaborating with health profession specially geriatric medicine. The program must concern to effectiveness health care with correct treating for Hypertension of elderly. Geriatric medicine get involve to spread the information to public, such as making socializing about aging process and the consequences. The target of this socializing is not for people with aged >60 Table and Figure

Number of Elder with age

26%

29% 49 - 59 60-69 > 70 45%

Source: Health Departement of Ambon City, 2012th

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3500 3000 2500 2000 1500 1000 500 0 Hipertension Hipotension

Obesitas

Thin

Other desease

Diabetes

Source: Health Departement of Ambon City, 2012th References 1.

Kementrian Kesehatan RI.Sehat dan aktif di usia lanjut. [Online]. 2012 November 21 [cited 2013 January 28]; [3screens].

Available from:URL: http://depkes.go.id/index.php/berita/pressrelease/2143-sehat-dan-aktif-di-usialanjut.html 2. http://www.myseniorhealthcare.com /Signs-of -Aging.html 3.

Regional Report Health Departement of Ambon City 2012 4. http://sg.88db.com/HealthMedical/geriatric-Medicine/q-TTS/1/search/ 5.

Lionakis Nikolaos, Dimitrios Mendrinos, Elias S, G Favatas and Maria G. Hypertension in the elderly. [Online] 2012 May 26 [cited 2013 January 28].[20 screens].

Available from: URL: http://www.wjgnet.com/19498462/journal/v4/i5/index.htm 6.

Bonow O R, Douglas L M,Douglas P Z, Petter L. Braunwaldâ&#x20AC;&#x2122;s heart diseases: a testbook of cardiovascular Medicine Volume I. Ninth edition. Philadelphia: Elsevier Saunders; 2012. p.1735

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7.

Stokes Gordon S. Management of hypertension in the elderly patient.[Online].

2009 October 2012 [cited 2013 January 28].

[23 screens]. Available from URL: http://www.ncbi.nlm.nih.gov/portal/utils/pag eresolver.fcgi?recordid=1359303959993979 8. http://www.geriatrics.org.sg/Defintio ns/Entries/2009/7/15_Geriatric_Medicine.ht ml 9.

IZN â&#x20AC;&#x201C; pdpersi. Komitmen Para Menkes Asia Tenggara untuk Lansia.[Online]. 2012 September 5. [cited 2013 January 28]. [3 screens]. Available from: URL: http://www.pdpersi.co.id/content/news.php? catid=23&mid=5&nid=910 10.

Chaundry Kashif N, Patricia Chavez, Jerzy Gasowski, Tomasz Grodzicki, Franz H. Messerli. Hypertension in the elderly: Some practical considerations.[Online]. [cited 2013 Januari 30] Available from URL: http://www.ccjm.org/content/79/10/694.full Nguyen T Quang, Scott R. Anderson, Lindsay Sanders, Loida D. Nguyen.

Managing Hypertension in the Elderly: A Common Chronic Disease with Increasing Age.[Online]. [cited 2013 January 30].[10

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screens].

Available from: URL: http://www.ahdbonline.com/feature/managin

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The Important of Geriatric Medicine in Indonesia Rio Alexsandro, Monica Djaja Saputera Universitas Tarumanagara, Jakarta

ABSTRACT Old age is the age of a person who has reached 60 years of age or above. In the next few years, an estimated population of elderly will continue to increase, both in the world as well as in Indonesia. A surge in elderly population that will occur will be giving effect to the state, such as health and economic problems.

Geriatric services that are holistic is one effort that can be done to tackle health problems in the future. One goal of this ministry is to improve geriatric quality of life of the elderly. See the importance of the existence of geriatric services in the future, the role of physicians as well as much-needed supporting facilities in Indonesia.

Keywords: Elderly, Health Workforce, Facilities Introduction Population datafromthe United Nations(UN) said that in 10years,the number of elderlyin theworldtoreachthe 1 billion. An increasing number ofpeople inthe world each year, the populationis dominatedby theelderlyover the age of60 yearsormore.

Totalelderly populationin 2000amounted to605million,and is expectedin 2025will reach1.2 billion people.1, 2

One of thedeveloping countries inthe world are experiencingan increase inthe elderly populationisIndonesiabasedcharts.

In2011 inIndonesia, the number of elderlyreached8.2%of thetotalpopulation of Indonesia, with an estimatednumberof19.5million people.This figure isexpected toincrease to13.2%and25.5%in 2025andin 2050.1,3,4,5

Figure 1 Percentage of People 60 years old and over in selected Developing Countries5

One of the factors caused the increasing of elderly every year in Indonesia is the increasing of life expectancy figure. BPS

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(central statistic biro) says that life expectancy figure in 2010 is 67.4 year with the number of 23,992,552 million of people.

And, it is predicted by 2020, life expectancy

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figure will increase to 71.1 year with the number of 28,882,879 million people. 3,4 The increase of elderly from years to years will cause a lot of problems in medical and economy sectors. Minister of health of Indonesia, Nafsiah Mboi, told that impact of the increasing of elderly is the appearance of a lot of chronic diseases. More over, the explosion of elderly can cause the increasing of non communicable disease. In 1990, in developing countries, non communicable diseases is in second rank with 27%,

neuropsychiatric disorder with 9%, and injuries with 15%. While in 2020 it is predicted that all of them will be increase, non communicable diseases will be the first rank with 43%, neuropsychiatric disorders with 14%, and injuries with 21%. 4, 6

Figure 2 Global Burden of Disease 1990-2020

by Disease Group in Developing Countries6

The increasing of elderly will be a challenge to the world and to every country in improving the needs to accommodate and to maintain the status of health to elderly.

Survey that has been done to 26 countries, give a result that health program system in developing countries not ready yet to guarantee the elderly health status. 6 In Indonesia, medical care to elderly by institution of social service in medication will be started in 2014. Not only medical care to elderly which a priority to the nation, empowering human resources is also a priority of the nation in 2014. So far medical care workers are also needed in implementing the medical cares to elderly. 4 In addition to the health workforce, health care is one of supporting the country's health

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status. Countries with an increasing number of elderly would have to start thinking about the availability of medical support facilities lansia. 7 From the data mentioned above, it can be concluded that the number of elderly people in Indonesia will continue to increase each year, while the health workforce to perform geriatric care are lacking. Writing this paper has the purpose to inform the reader about the importance of elderly care in Indonesia in order to identify and improve the quality of the health system, both in terms of the health workforce and support facilities in the future.

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Methods The method usedin writing ofthispaperis the study ofliterature. In this method, a team of writerswritea reviewof theaspects that willbe reviewedby way ofrewritingtheoriesor opinionsofa particular party. Theoriesor opinionsofcertain partiesis obtainedfrom textbooksor journalsthat are considerednewby theteam of writers, so thatthe information submittedisupdate.8 Results a. Geriatric i. Definition Definition of geriatrics base of Encylopedia of Public Health is the branch of clinical medicine focusing on health promotion among older people and the prevention and treatment of disease and disability in late life.9 Definition of geriatric according to the book Know Your Elderly and Care is a branch of medical science that studies gerontology and health in the elderly in many aspects, promotive, preventive, curative, and rehabilitative.10 So, geriatric is a study that is a branch of the science of gerontology who specializes in health issues elderly patients, both in the business promotive, preventive, curative, and rehabilitative. b. Elderly i. Definition and Classification According to Shaban M I, the elderly are older people is a biological process experienced by all creatures. It starts early in age and lasts for the rest of life and accompanied by changes in vital body organs and tissues. 11 Elderly according to the WHO classification divides into middle age (middle age) and elderly (Elderly),

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elderly parents (old) and the elderly are very old (very old). A middle-aged man with an age range 45-59 years, 60-74 years elderly, elderly 75-89 years old, and very old elderly above 90 years. 12 According to the Law of the Republic of Indonesia Number 13 Year 1998 on Elderly Welfare, advanced age is a person who has reached the age of 60 years. 13 From some of the definitions and classifications in the elderly, it can be concluded that when the elderly person is 60 years old. ii. Elderly Statistics in the World Health information that can accurately describe the actual state, as well as having an influence on planning in dealing with health problems in the world and in those countries. Based on population data conducted by the UN, the data obtained that the number of elderly in the world in the next 10 years, to reach the 1 billion mark. 1,14 In 2010, the population of the world is 6.9 billion people. Where 11% of the total population is resident over the age of 60 years and 80 years and over. The number of elderly people aged over 60 years in the year 2010 was 759 million, whereas the elderly over the age of 80 years amounted to 105 million people. 15 From these data, the United Nations estimates that by 2050 the number of elderly in the world population will reach 2 billion people.

Estimated number of people in the world will rise to 9.1 billion people, and 22% of the total population is the population over the age of 60 years and 80 years. If in the year 2010, the elderly population aged over 60 years

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is 759 million people, in 2050 is expected to reach 2 billion people.

While the elderly population aged 80 years and over 400 million people.

1,15 iii. Elderly Statistics in Indonesia According to the Ministry of Social Affairs of the Republic of Indonesia, the number of elderly people in Indonesia from year to year continues to increase. This is evidenced by data from the Central Bureau of Statistics reported that in 1980, the number of elderly is 7.9 million or 5.45% of the total population of Indonesia. In 1990 increased to 6:29% of the total population of Indonesia is 12.7 million people, in 2000 to 14.4 million people, in 2003 to 16.1 million in 2004 to 17.7 million people, in 2006 to 19 million, and in 2010 there were 23.9 million elderly or 9.77% of the total population of Indonesia. The increase continues to occur each year is expected to continue rising to reach 30 million by 2020. 12,16 Table 1 Total of Elderly in Indonesia 12,16

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The increasing number of the elderly population, the rate of life expectancy also increased from year to year. In 1980 the average life expectancy is 52.2 years older, was 59.8 years in 1990, the year 2000 was 64.5 years in 2006 was 66.2 years, and in 2010 was 67.4 years. Estimated that in 2020 life expectancy elderly will increase to 71.1 years. Life expectancy increasingly higher every year this will be a problem for the world or a country. The higher the life expectancy, the burden borne by the state even more severe. In addition, high life expectancy can also increase the rate of chronic diseases in the country. 12,16 Table 2 Angka Usia Harapan Hidup 12,16

H e a l t h Problems In Elderly WHO estimates of infectious diseases in the country in 1990 around 50% and it will turn into a non-disease comunicable disease about 40%.

According to Kane & Ouslander, health problems that often occur in the elderly is often referred to as the 14 I Immobility (less mobile), instability (standing and walking is unstable or easily fall), Incontinence (beser pissing urinate and or defecate),

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Intellectual impairment (intellectual impairment / dementia), Infection (infection), impairment of vision and hearing, taste, smell, communication, convalescence, skin integrity (impaired sensory perception, communication, healing, and skin), Impaction (difficult bowel movements), Isolation (depression), Inanition (malnutrition), Impecunity (no money), Iatrogenesis (disease caused by drugs), insomnia (trouble sleeping), Immune deficiency (decreased endurance), and Impotence (impotence). 17 Naturally elderly will decline, physical, biological, and mental development. Decreased function of the various organs of the body will make the elderly are susceptible to the disease is acute or chronic. In addition it is also common in the elderly physical dependence, it can no longer perform daily activities because of the disease itself. There is an increasing number of elderly will also create health problems facing the more complex problems especially relating to degenerative.18 According to Mc. Kenzie, many people believe that the health status of the elderly has improved over the past few years because many elderly people are living longer, but on the other hand according Darmojo elderly population particularly vulnerable to infection, susceptible to disease. The most consistent risk factors of illness and death for the entire population is age, and in general, the health status of the elderly is not as good as when they were younger. As already stated above by Nugroho2 that the elderly will be many setbacks organs.19, 20 So which is expected in the elderly despite advanced age, should keep

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health with respect to lifestyle such as diet, physical activity, break habits, not smoking and other others.21 c. Health Workforce i. Kinds of Health Workforce Estimated in the 21st century health workforce will be needed to handle the high volume of elderly patients. No matter what the specialization will be taken for treatment of elderly patients is not too different from the handling of basic medical sciences. However, doctors in the future requires a debriefing in handling geriatric patients.

There are approximately 30 'geriatric syndrome' including physical, mental, and social. 22 This includes nurses,doctors, social workers, caregivers and policy makers acting at all levels starting from primary health care to the specialized unit at a tertiary hospital, rehabilitation and long-term care facilities, as well as in the office of the local or national health care authorities.23 In the geriatric clinic, there are some doctors who were involved in it, such as general practitioners such as specialist doctors geriatric medicine, eye doctor, dermatologist, dentist, psychiatry, etc. 24 Specialist science of medicine is a branch of medical science that plays a role in addressing health problems and disease, both in children and in the elderly. The development of science specialists in internal medicine toward a more in-depth on a particular organ made in this pathology has another subspecialty. Though divided into several subspecialty, but actually they are all inter-related and connected.

Subspecialist the field of allergy

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immunology clinic is, gastroenterohepatology, geriatrics, kidneyhypertension, hematology-oncologymedical, cardiology, metabolic, psychosomatic, pulmonology, rheumatology, tropical infections, and medical emergencies.25,26 Subspesialis geriatrics is the study of a variety of health problems and diseases in the elderly. Treatment of the elderly can be given to elderly patients who are treated or ongoing treatment, such as the treatment of cognitive disorders such as dementia and delirium, malnutri, infection, dehydration, electrolyte disorders, psychological disorders such as depression, urinary incontinence or Alvi, impaired balance, falls, immobility or limitation of motion, decubitus ulcers, and sensory disorders such as hearing and vision.

25,26 Apart from giving treatment to the elderly, geriatric medicine specialists also need the skills to care for patients.

Required skills such as how to install the stomach sonde (flocare), put a urinary catheter, decubitus ulcer patient care, and the skills to assess cognitive function, mental status, and functional status in patients. 25

Indonesia. According PAPDI current number of medical specialists in internal medicine in Indonesia is 2556 people. This figure is still less than many of the targets set by the Papdi 20,000 specialists in internal medicine.

Still the shortage of specialists and specialists in internal medicine distribution uneven contributed to a new problem in Indonesia. If you see the current spread of the disease in most specialists in the capital Jakarta.

While in other areas such as in Maluku, West Nusa Tenggara of specialists in internal medicine is so few. 25 Figure 3 Distribution of internist in Indonesia

ii. Health Labor Statistics in Indonesia Ration of medical care workers per 100,000 residents in 2008 is categories below the target. In 2008, ratio of specialist doctors is 7.73, general practitioners are 26.3, and nurses are 1567.75. Meanwhile, target of specialist doctors is 9, general practitioners are 30, and nurse is 158.27 Medical specialist in internal medicine or called an internist is one of the specialists who are needed in

Source: Halo internist25 Not only is still lacks a specialist in internal medicine, Indonesia is still shortage of doctors subspecialist. The ratio of specialists in internal medicine and subpesialis was 75% and 25%.

According to a survey conducted by Papdi, current interest subspesialis doctors against doctors is much higher than for specialists in internal medicine. However Papdi also mentioned that despite high interest subspesialis doctors and the numbers

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are still lacking, the addition should be regulated because Indonesia still needs a specialist for internal medicine in the area. 25 d. Elderly Medical Facilities Medical treatment to elderly has three kinds of applied treatment, medical treatment to elderly in society, medical treatment to old people in society based on hospital, and medical treatment to elderly based on hospital Elderly medical facilities The medical treatment to elderly in society is a medical treatment by puskesmas and practitioner as a leader. In this medical treatment, puskesmas has a role in collecting, building a group of elderly.28 Practitioner responsible for medical treatment or curative action to elderly.

Medical treatment to elderly in society based on hospital is a geriatric service as a leader. Hospital has a direct and indirect role to elderly. Indirect action is by giving a guidance to elderly to puskesmas (medical treatment to people) in his or her territory. 28 Besides,elderly based of hospital is a medical treatment that done by hospital which has a special treatment for elderly.

The treatment given by hospital to elderly based on hospital are: 28 1. Geriatric Polyclinic In this polyclinic, elderly has a curative treatment, also consultation regard to their diseases.

Doctor whom has a role in geriatric polyclinic is a subspecialist. So that, elderly whom has treatment in this clinic is a patient whose already has recommendation from other polyclinic.

2. Acute Geriatric Ward Is a ward or special room to elderly whom suffer chronic disease, such as stroke, pneumonia, diabetic, etc. To this treatment, geriatric team has a role in

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3.

4.

5.

6.

7.

doing assessment, curative, and rehabilitation to elderlys.

The team consists of general practitioner, nurse, social worker of medic, fisioterapis, speechterapis, internis, okupasi terapis, ortotis prostetis, rehabilitation of medic specialist (dokter spesialis rehabilitasi medik), psikolog, also geriatris.

Day-hospital day-hospital is a treatment of geriatric that implemented to on going patient, such as curative, assessment, ambulation, rehabilitation, and recreation.

Geriatric/internist, nurse, physiology, etc., take part in day hospital.

Chronic geriatric ward Chronic geriatric ward id a ward or a special room for elderly whom suffer of chronic disease, of which has to stay and has to have long term medication.

Nursing home Nursing home is an institution or bureau acts in handling elderly in medic or chronic disease which no longer needs of hospital medication.

Geriatric rehabilitation Geriatric rehabilitation is rehabilitation can apply to patient whom has acute and chronic disease.

Geriatric consultation The consultation is a consultation service to elderly. The aim of the consultation to give medication to patient, to recommend the patient to go to geriatric polyclinic.

e.

The Important of Elderly Health Care Geriatricservicesareservices performedspecifically forelderly patients.

In Indonesia, geriatricserviceshave existed sincethe 20th century, and is stillin the development stageto date. According to the MOH, geriatriccarehas a goal topursuea happyfuturefor the elderly, so

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thatthe elderlycan live independentlyandare nota burden onthe family. Another goalofgeriatriccareisto maintainthe health ofthe elderlyfromsicknessorhealth problems, the elderlymake early diagnosis, to treatmentof the elderlywho suffer froman illness, guiding the elderly tolive independently, as well as providingassistancein the form ofmoral andattention. 29 Besides that, The American Geriatric Society also identified five goals to increase and optimalizing the health of elderly, such as to give the older person good health care, to increase the number of health worker to caring the older people, to increase and recruit health care professional and phsyciatrics in geriatric medicine, and to influence the public policy about geriatric medicine.

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While theprinciplesofgeriatriccarealone there are4, namelyholistic approachorbiopsikososialspiritual, coordination, involving family membersin theimplementation of services, providingintegrateddiagnosis, and orientedto the needs ofelderlytersebut. 10 The main principleofhealth careisa holisticministrythatinvolvesvarious aspects.Variousaspects thatshould be present by doctor inholisticministryare: 10,28

1. Promotive Promotionis anattempt by themedical teamtoimprove the health ofthe elderlyin order toprevent theelderlyfromsickness.

Promotivecan bedone in several ways, one of which is tocreate an appropriate environmentfor theelderly, such as the flooris notslipperyto minimizethe incidence offalls.

2. Preventive

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Preventiveis aneffort madein threeways:primary prevention, secondary, andtertiary.

Primary preventionisthepreventionconducted inhealthy elderlyby way ofimmunization, counseling, etc..Secondary preventionisaway in whichtodetect thepresence ofdiseasein the elderlybeforeclinicalsymptoms appear.

Examplesofsecondarypreventionis early detectionof cancer,cervical cancer screeningin elderlywomen.As forthe tertiarypreventionis usuallyperformedon elderlywho have experiencedillness ordisability.The goal ofsecondarypreventionis to improveand maintainthe function ofthe body.

3. Earlydiagnosisandprompttreatment In doingearly diagnosis, not justmedical personnelareable to do, butseniorscan do ityourself. Anelderly canperformself-diagnosis to yourselfby filling out aself-test, orby looking at theCardTowards Healthy(KMS). While thediagnosismade by themedical officerisphysicalstatusexamination, physical examinationdiagnostic, psychiatricexamination, screening fora disease, etc..Aftermaking a diagnosis,themedical officerthatthe doctor willprovidetreatment according tothesymptomsof theelderly.

4. Disability limitation Handicap experienced by elderly may caused from several aspects, such as difficulties or limitation in activating skeletal, muscle, nerve.

5. Rehabilitative Is an effort done by medic officer to help elderly whom suffering dysfunctional or handicap so that they could do their activities. E.g. elderly whom has hearing problem and be given a hearing aid.

Discussion

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Ever-increasing numbers of age life expectancy in Indonesia caused the elderly population keeps increasing every year. This is certainly going to be a new challenge for the government of Indonesia in dealing with various problems in the elderly. The elderly who are in a state of healthy and active, of course will be slightly reduce the burden of the government in particular against the efforts of health workforce health management. While the elderly who suffered health problems and requires long-term treatment will certainly be an issue for the country.

Thus, the existence of services ranging from implementation of geriatric health of elderly in society, elderly health services in community-based hospitals, and elderly health services hospital based is indispensable in addressing this issue. While the elderly who suffered health problems and requires long-term treatment will certainly be an issue for the country. 31 However, there are some obstacles that occur in this geriatric services run as the lack of health workforce. Geriatric services will be made new by 2014, would have needed a special medical team, as a doctor specialist geriatric. Data from a number of PAPDI mentions that needed specialists is as much as 20,000 doctors, whereas there is at present only 2556 doctors. Lack of health workforce as a specialist in the disease course, have influence in treatment efforts against health problems faced by geriatric medicine. In fact, as we know that treatment efforts is one of the efforts that need to be done by the medical team of elderly patients suffering from certain diseases.

In addition promotif and preventive efforts also became a special concern for the doctor. This is because the purpose of the Ministry is making the elderly geriatric Indonesia can live actively and independently. physically, mentally, and socially. Promotif and preventive efforts are

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usually given on the elderly who are still active and independent, with the intention of distancing or avoiding the elderly from attack a disease that often strikes the elderly.

The existence of preventive efforts is expected to improve the quality of life of the elderly.

Conclusion From the above discussion, can be known that geriatric services are essential services in the future. Various aspects to enhance, maintain, and troubleshoot the health of geriatric service coverage for the sake of the survival of the elderly to remain active and independent. To achieve success, it is also a geriatric service roles as well as physicians and ancillary facilities.

References 1. bbc.co.uk[internet]. Jumlah manula satu miliar dalam 10 tahun[updated 2013 Jan 13;cited 2012 Oct 1]. Available from: http://www.bbc.co.uk/indonesia/majalah/ 2012/10/121001_unaging.shtml.

2. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 5 3. S Permanasari I[internet]. Saatnya negara-negara antisipasi ledakan[updated 2013 Jan 13;cited 2012 Sept 5]. Available from: http://nasional.kompas.com/read/2012/09 /05/17472153/Saatnya.Negara.Negara.An tisipasi.Ledakan.Lansia.

4. Anna LK[internet]. Fokus pada jumlah lansia[updated 2013 Jan 13;cited 2012 Sept 5].

Available from: http://health.kompas.com/read/2012/09/0 5/06533520/Fokus.pada.Jumlah.Lansia 5. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 5.

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6. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 8 7. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 13 8. Sastroasmoro S, Ismael S. Dasar - dasar metodologi penelitian klinis. Jakarta:CV Sagung Seto;2011.

9. Kirch W. Encyclopedia of Public Health.

Tucker B, editor. Germany:Springer; 2008.

10. Maryam RS, Ekasari MF, Rosidawati, Jubaedi A, Batubara I. Mengenal usia lanjut dan perawatannya. Jakarta: Salemba Medika;2008.

11. Shaban M I. Syrian Arab Republic (Country Profile). Ministry of Health, Primary Health Care Directorate. Elderly Health Department. Tahun 2003:vol 2: hal 27 12. Saragih RW, Supiana R[internet]. Hari senja yang indah di binjai [updated 2013 Jan 13;cited 2012]. Available from: http://www.kemsos.go.id/modules.php?n ame=Content&pa=showpage&pid=29.

13. Undang-undang Republik Indonesia nomor 13 tahun 1998 tentang kesejahteraan lanjut usia. Available from: http://www.dpr.go.id/uu/uu1998/UU_199 8_13.pdf 14. Kementrian Kesehatan Republik Indonesia. Data/Informasi Kesehatan Provinsi Jawa Barat. Bandung: Bakti Husada;2011.

15. menkoskera.go.id[internet]. Tahun 2050 akan ada dua miliar penduduk lanjut usia [updated 2013 Jan 13;cited Oct 17 2012].

Available from: http://www.menkokesra.go.id/content/tah un-2050-akan-ada-2-miliar-penduduklanjut-usia.

16. Hamid A[internet]. Penduduk lanjut usia di Indonesia dan masalah

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kesejahteraannya. [updated 2013 Jan 13;cited Oct 23 2007]. Available from: http://www.kemsos.go.id/modules.php?n ame=News&file=article&sid=522.

17. Kane R L, Ouslander J G, Abrass I B, Resnick B. Essentials of Clinical Geriatrics.McGraw-Hill Professional; 2008.

18. Nugroho, Wahyudi. Perawatan Lanjut Usia, Jakarta: EGC; 1995.

19. Mc. Kenzi F. Kesehatan Masyarakat, Jakarta: EGC; 2003.

20. Darmojo, Budhi. Dkk. Buku Ajar Geriatri. Jakarta: FKUI; 1999.

21. Djaeni SA. Ilmu Gizi. Jakarta Timur: Dian Rakyat; 2000.

22. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 50-53 23. World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 53-56 24. rscm.co.id[internet]. Poliklinik geriatri terpadu [updated 2013 Jan 13;cited 2011].

Available from: http://www.rscm.co.id/index.php?bhs=in &id=OUR1000014.

25. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia[internet]. Halo internis.

Available from:http://www.pbpapdi.org.

26. Pohan HT, Santoso M, Syam AF, Makmun LH, Atmakusuma D, Ujainah A, et al. Standar profesi dokter spesialis penyakit dalam. Jakarta:PAPDI;2009.

27. Rencana pengembangan tenaga kesehatan tahun 2011-2015. Jakarta:2011.

28. Darmojo B. Geriatri(ilmu kesehatan usia lanjut). 4nd ed. Martono HH, Pranarka K, editor. Jakarta:Balai Penerbit FKUI; 2010.

29. Solomon DH. Why geriatrics as a career choice?. New York:The American Geriatrics Society.

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30. American Geriatrics Society. Caring for older americans:the future of geriatric medicine. Journal of American Geriatrics Society. 2005;53(6):245-56.

31. Pranarka K. Penerapan geriatrik kedokteran menuju usia lanjut yang sehat.

Universa Medicina. 2006;25(4):187-97

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A Preventive Solution to Risk Factors of Hypertension that Affects Elderly Anastasia Limanto, Claresta, Ferdy Iskandar Unika Atma Jaya, Jakarta ABSTRACT Introduction:Hypertension is characterized by a blood pressure of more than 140/90 mmHg. The risk of having it increases with age, and it is in fact one of the geriatric problems in Indonesia.

This journal aims to probe the factors that affect hypertension incidence the most and find a way to solve it.

Methods:Internet sources are used to find journals and articles relevant to the theme in order to create a literature review about hypertension, its most prominent risk factors and find a solution.

Results:Results show that the amount of daily salt intake per person affects blood pressure directly, and that knowledge about hypertension affects the attitude of the population towards it.

Discussion:Although there are two factors affecting the incidence of hypertension the most, the solution could be integrated as one health campaign. In the health campaign, it is necessary to educate the population with recommended salt intake as well as about the disease and the complications. Legislatively, there should be regulations regarding food contents and the necessity to place labels on food packagings so that consumers are more aware of what they eat.

Lastly, we suggest a home-screening model of hypertension that is conducted in selected areas in order to prevent and control hypertension.

Keyword: hypertension, elderly, salt intake, knowledge, home-screening model, health promotions Introduction All beings who are part of the ecosystem living on Earth is bound to one same fate: aging. As we age, there are many changes we go through. Our wisdom expands, the wheel of fortune goes around, the people around us change, and many more. But what is easily noticeable, and at the same time most people pay attention to is physical health. The common paradigm associates being an elder with 10 Is: immobility, instability, incontinence, intellectual impairment, infection, impairment of vision and hearing, irritable colon, isolation, innanition, impecunity, iatrogenesis, insomnia, impotence and immune deficiency. In Indonesia, being an elder means being more than 60 years old. In 2010, 7.18% of the population are elderly, but it is likely that the numbers will increase1. The Center of Statistics Bureau predicted that 11.34% of Indonesian residents will be elders in 2020, or equivalent to 28.8 millions lives2. With those many problems and increasing amount of

elderly in Indonesia, it is important to learn more and practice the field of geriatric medicine. Yet, geriatric medicine has not been a widely known field in Indonesia. To say that geriatric medicine is important would be an understatement as the infectious disease trend is starting to shift to chronic non-communicable diseases. It also appears that the complications of chronic noncommunicable diseases struck elderly more often than it does to youth as it worsens over time.

In this paper, we want to concentrate especially on hypertension, as it is the second disease that affects elderly in Indonesia. Hypertension, by definition, is a condition where the arterial blood pressure of pumping blood exceeds 140/90 mmHg3.

Based on a research by WHO â&#x20AC;&#x201C; Community Study of Central Java, 15.2% of 1203 subjects are affected with hypertension4. The number one disease affecting elderly is actually arthritis â&#x20AC;&#x201C; then hypertension comes second. However we deliberately choose hypertension considering its fatality rate is

higher than that of arthritis. This is also consistent with the results obtained by Basic Health Research (Riset Kesehatan Dasar) 2007 that cardiovascular diseases including hypertension are the disease which kills most in Indonesia5. With hypertension, actually it is the complication of the disease that are fatal compared to the disease itself.

The Health Ministry of Indonesia also informed that developed countries are still trying to control hypertension as well as its complication6. The results have not been a satisfaction, so it is thought that it will be better to battle hypertension by preventing it instead of curing or controlling it. Therefore, we are going to search the risk factors for hypertension – that might put a person in a high possibility to acquire the complications – that affect a person the most, and try to find an applicable solution or ways we can do to help increase the awareness of hypertension in the community.

Most of the time, the symptoms of hypertension are easily overlooked as they do not present a major condition like myocardial infarct does. In fact, a patient often realizes that he has a hypertension when he visited the doctor’s office and has their blood pressure measured. The terminology ‘silent killer’ is understandably a suitable name for hypertension, recalling that it has high-risk complications, namely heart attack, aneurysm, heart failure, blood vessels changes involving their elasticity and diameter, and other complications inflicting other systems such as the kidney and memory loss. What could be done to prevent hypertension or not to nourish an existing hypertensive condition is to change the lifestyle and through prevention measures.

However, there are many factors determining how this could be executed, which makes it a new emerging task to think about an effective way of how to address the problem of preventing hypertension or maintaining it. Besides, the many variations of individualistic backgrounds in the Indonesian populations of elderly also need to be analysed so as to discover what factors that affect the incidence of hypertension the most. According to JNC VI, the first choice

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of drug for hypertension in elderly is a diuretic (bendrofluazid, hydrochlortiazid, indapamid, etc) or a beta blocker. Other diseases or conditions suffered by the patients would also contribute to the choice of drug. For example, a patient with coronary heart disease will receive more benefits of a beta blocker compared to other types of medicine. Age is also a factor that will affect the drug’s metabolism and distribution in a patient, so the dosage of the medicine should be given at low doses initially, then slowly raised7.

Currently, there are not many programs or specific organizations that handle the problem of hypertension in elderly. A society called ‘Indonesian Society of Hypertension’ has been built with a mission of increasing awareness towards hypertension8, but it is still trying to be on the rise. Any regulations that are meant to prevent hypertension have not been made or if any, have not been widely acknowledged by the public.

Methods Although hypertension is one of the most prominent silent killers among epidemiologists, there has not been a detailed, updated nation-wide research or data about hypertension. This is due to the fact that such research will require lots of time, economic resources and human resources. However, there are researches done in big cities that are consistent with an established trend among the population, so a study using these published journals and papers are conducted. Thus, our primary method to create this paper is literature review.

There are some major steps in the process of study:  Searching the World Wide Web about certain keywords.  Canvassing information, which is gathered to find the best information.  Reviewing materials in order to find possible references, and further study about the topic.  Brainstorm about possible solution, and assess the results to provide a final

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solution, or solutions.  Obtaining the best conclusion about the topic.

Data Hypertension in elderly usually starts when they are younger, and the two factors that contributes to its high incidence in Indonesia is daily diet and knowledge. The aspect of daily diet has a relationship with salt intake. A high amount of sodium and low amount of potassium will induce the inhibition of sodium pump, which increases the amount of intracellular sodium. This sequence of event will lead to drive calcium inside the cell, and induce the contraction of smooth muscle cells. Ultimately, it leads to increased peripheral vascular resistance, and an elevation of blood pressure. Although genetics played a role of how sensitive a person to salt is, the overall salt intake beyond the recommended value is still a cause of elevated blood pressure. Also, the sensitivity to salt increases with age, so elders are more susceptible to exceeding salt intake induced hypertension9. Based on FDA, the recommended value from of salt intake for older people is a maximum of 1.5 g/person/day, but in Indonesia the values exceeds the recommendation both in towns and villages alike. Data shows that in cities, the value of visible salt intake from the food cooked at home per person/day is 5.8 g, 5.0 g and 5.2 g for the year of 2002, 2007 and 2009 consecutively. This value is lower compared to the value obtained from rural areas, which are 6.7 g, 6.2 g and 6.2 g per person/day for 2002, 2007 and 2009 consecutively (table 2).

Actually, there are two kinds of value for salt intake, which are the visible salt and non-visible salt. Visible salt are measureable from direct usage or salt that is directly added, and non-visible salt is the amount of salt already in the food product. The values mentioned for visible salt intake is only an approximate value, as in reality sources of visible salt could also be coming from industrial food products or food that are not cooked at home10. But what is important to note is the value of visible salt alone is

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higher than the recommended value.

Lowering salt intake to 1.5 g/person/day gives a particularly beneficial effect to elderly, as it may lower the systolic blood pressure by 8.1 mmHg for a person aged 55 – 76 years. Another study worth noting is that a reduction of 3 g salt per day might lower the blood pressure by 3.6 – 5.6/1.9 – 3.2 mmHg. This shows that salt intake has a relationship with the incidence of hypertension, especially in elderly.

The second factor affecting high incidence of hypertension in elderly is knowledge, which is very closely related to education. A research done in Pandanaran public health center, Semarang, shows that of 70 hypertensive subjects, all of them an elder, 35 of the subjects (50%) has a primary school level of education, 20 subjects (28.6%) has a junior high school level of education, 10 subjects (14.3%) has a senior high school level of education, and 5 subjects(7.1%) has a college level of education. It shows that the more educated the subjects are, the more knowledge they posses. The level of education is also inversely related to the amount of hypertension patients. The same research revealed that knowledge is an important part about prevention and control of hypertension by giving a pre-test and post-test while conducting a public health education. Before the education was done, 3 subjects (4.3%) have a good pre-test results, while 64 subjects (91.4%) have good enough results and 3 subjects (4.3%) have poor results (table 1). After the education, 100% of the subjects, or all 70 of them, have a good posttest result. The delivery of information to subjects is critical in this aspect, as the research also tested the subject’s attitude towards their hypertensive condition before and after the education. The attitude is classified into 3 different levels: good, average and poor. Before the education, 62 0f 70 subjects (88.6%) have an average attitude in facing hypertension. After the education, the statistic shifted to 66 of 70 subjects (94.3%) have a good attitude towards hypertension. The conclusive result of the study is that there is a 0.000

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difference of probability value compared to the significant value of 5% (0.05), and that there is a significant change of knowledge before and after the education of hypertension was given11.

Another research done at the integrated health center services for elderly in Makamhaji village, Sukoharjo also gives similar results. There are less subjects, but a questionnaire was used to assess the level of knowledge possessed by the elderly, so it may give a deeper assessment about the subjects. Knowledge are assesed twice using scoring system, which are before and after an educational lecture about hypertension using handout and picturesque slides. The highest score is 20, and the score before the lecture is 4.46, while after lecture the score is 13.97. It shows significant increase, thrice as much. Similar to the previous study, the relationship between knowledge attitude is also a point being researched. This research gives a quantitative value of how attitude is related to knowledge. The highest score for attitude is 15, and before the lecture mean average of score is 3.49, while after the lecture was conducted the score increases to 9.9. The studies conducted at these 2 villages could represent the overall condition Indonesia is going through, as the Basic Health Research conducted on 2007 also indicated that most of the hypertension cases in Indonesia had not been diagnosed, or that the patient had not known yet they are having a hypertensive condition12. The prevalence of hypertension in Indonesia for individuals aged more than 18 years 31.7% years and of all, only 7.2% knows they have hypertension. It does not follow that all of them take hypertensive medications, as in fact only 0.4% take medications for their hypertension. That means if there are 200 millions lives in Indonesia at the time the research was conducted, only 64 millions are hypertensive, and amongst them 4.6 millions are aware of their condition, and only 18,400 take their medications13.

Analysis As had been mentioned before, the composition of daily diet consumption

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which affects blood pressure the most is salt intake. There may be other factors contributing to the high-salt diet, including economic status and geographical condition.

Food high in salt contain may be easier to obtain and less expensive in cost. An example is salted fish. Indonesia is practically a nation consisting of islands, so it is no wonder that maritime products are abundant. Naturally, it becomes part of the daily consumption, and it is frequently salted to preserve it. Aside of salt sources from preservation process, there is also exceeding amount of salt being added to the food manually while the food is being cooked14.

As a result, the food may contain very high amount of salt. If the routine repeats every day, then it would be a long-term exposure to high salt intake for the person.

What could be done to prevent exceeding salt intake primarily is related to health promotion campaigns. Through health campaigns that are locally held per subdistricts (kecamatan), the residents could be made more aware of the fact that too much salt intake may cause hypertension. Aside from the knowledge about the dangers of high salt intake, the health campaign itself may as well include ways to reduce the salt intake. This includes eating more fruit and vegetables, particularly those with high potassium content, in order to counter excessive sodium inside the body.

According to FDA, the recommended value of potassium intake is 4.7 g/day15. Leafy and green-coloured vegetables, as well as fruits originating from vines, like grapes, are examples of fruit and vegetables rich in potassium. Most of the time, salt is also used to flavor the food, and it depends on the tongue how salty a food would taste.

Unfortunately, human tongue could easily adapt to flavors, so those who are used to eat relatively very salty food might not be aware that they are eating too much salt. The good news is flavor could be created or modified using other spices and herbs, so it would be recommended to partially replace the salt until the recommended value is achieved.

Several species of spices and herbs also have favorable effect for hypertension patients.

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One of the examples is garlic, which contains allicin as a blood thinner agent. By adding garlic to a menu, the flavor could be enriched, and at the same time it helps to reduce the overall resistance, hence the blood pressure.

Secondly, it is also important that the government help to reduce the incidence of hypertension through legislations or regulations. Even nowadays there is still insufficient information about the ingredient of a food whether from food labels on the back or the side, nor attractive labels usually placed strategically in front telling consumers the main feature of the product, like ‘low sugar’ or ‘trans fat’. The creation of a new regulation regarding placements of food labels on food products would help to solve the problem of not knowing the ingredient of a food product. In the USA, the salt content would be indicated by the amount of sodium, and this could be a good example as consumers may feel easier to calculate their daily sodium needs based on the label. This is legally required, as the regulation stated: Code of Federal Regulations Title 21 (4) A statement of the number of milligrams of sodium in a specified serving of food expressed as zero when the serving contains less than 5 milligrams of sodium, to the nearest 5-milligram increment when the serving contains 5 to 140 milligrams of sodium, and to the nearest 10-milligram increment when the serving contains greater than 140 milligram There has not been a strict regulations regarding the contents of such specific nutrition presently. If the information provided on the label is sufficient, then the public could be educated to help them decide which type of food they are to buy: low salt or low sodium. The FDA also regulates this through the Code of Federal Regulations title 21, section 101.13 which mentions about the limit of sodium amount in the food product which qualifies certain ranges. A label bearing the name ‘sodiumfree’ should contain less than 5 mg of

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sodium, ‘very-low sodium’ should contain less than 35 mg sodium, ‘low in sodium’ have a maximum of 140 g sodium, and finally the label ‘less/reduced sodium’ should contain at least 25% lesser than the regular product16. This is a neat system, and an adoption with modifications on the dosage would remain beneficial to the population. Also importantly, as this is dealing with elderly, the labels should preferably be made in a bigger font, with an attractive style and easily noticeable at the front site of the product so that it is readable by an elder. Another governmental approach would involve making regulations of the salt content in food products using percentages.

It should be calculated that for every servings of food, the amount of sodium content should not exceed the recommended limit.

The first and most important step to do about hypertension is to actually prevent it before it gets chronic and life threatening. In order to achieve that, the public needs to know what they are facing, and one of the many ways to make it possible is through an educational health promotions. The simple purpose of educational health promotion is to increase public awareness of a disease, and in this case is hypertension. There are many ways to do educational health promotion, including lectures or seminars, as well as the use of mass media. To reach the public effectively, a health promotion needs to be attractive, and seeing that the mass media is now a very influential aspect of life, they could be used as an advantage to promote health.

According to the data that had been obtained, there are 3 different reactions to hypertension. The first is that the patient themselves have no idea that they have hypertension. This could be caused by the fact that hypertension is asymptomatic and the culture that still hangs about the society.

It is not uncommon to assume that headaches are caused by witchcraft as the belief started centuries ago when science has not yet shown its advance like of now. The second type follows that the patient knows, but chooses to ignore their disease. Again,

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this could be due to the disease being asymptomatic so the patient chooses to simply ignore it. Another scheme is that the patient does not know the danger of hypertension, so although they are aware, they might think the worse that can happen is daily headache. Besides, hypertension medications may have caused more noticeable effect than the disease, so patient feels that the intake of medicine is unsatisfying. The last reaction is a desirable one, that the patient is aware and care about themselves. What is lethally dangerous about elderly – and in fact most of the population – is they are actually aware about their disease, however, they lack of care and awareness about the complications.

Hypertension is asymptomatic until the point it is life-threatening, making it undetectable amongst many other symptoms usually experienced by an elder.

Health campaigns or promotions in Indonesian sub-districts about hypertension which targeted 30-60 years of age should be held annualy at a minimum. If it is targeted to be an annual program, it may have a chance to be integrated in the culture and drive the population subconciously to be more aware about hypertension. The target age is set so that the younger population could prevent themselves from acquiring hypertension and help those who are older in taking care their hypertensive issue. The health campaign itself should explain about the factor risks, prevention method, and the danger of hypertension. The materials need not be too deep, in fact it should be explained in a simple language containing non-medical terms using a multi-media tools to ensure.

Another of our proposed solution would involve the home-visit or home-care models adapted from health systems overseas. As it name suggests, patient centered medical home model follows that the patients are being visited at home by a team of medical staffs including doctors, nurses, therapists or social workers17. These are done in order to help the patient obtain a better care, especially if they are unable to go to hospitals by themselves. A system derived

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from the patient centered home care model suitable for hypertension prevention is a home-screening model. As part of the hypertension prevention measures, medical staffs visit every certain areas appointed to them, and measure blood pressure once every 6 months. In Indonesia, areas are grouped into districts and sub-districts.

Every districts has their own public health center (Puskesmas) provided by the government which is affordable and has been anticipated to reach as many people on the district. Medical staffs from the public health center could help do the rounds once every month. Home-screening would be beneficial, as measuring blood pressure per person takes about 1 minute, and that it has a preventive nature compared to waiting for the patient to visit a health center. Besides, home-screening could alleviate what is known as masked hypertension as well as white-coat hypertension because the patient is in a more relaxed condition, and not in a doctor’s office.

However, home-screening would take a lot of time and become ineffective because of that particular reason. What could be done in order to make it more applicable is to do area selection and increase the human resources. Population with better socioeconomic status and higher level of knowledge will be able to screen themselves, and become aware about the disease. For area selection, it is best to select an area which has the highest risk factor for hypertension. As much as it is important and fair to actually record everyone’s blood pressure, prioritizing the ones who have low socio-economic statuses would be a more sensible method, as the population who has a low socio-economic status – moreover, an elder – would have more barrier in accessing proper health care. Knowledge is also a rare aspect in those underprivileged, it is not unexpected to find them uncaring although they know they have very high blood pressure. So, choosing an area based on the population’s socio-economic and knowledge status may be an option to tackle the problem of wide area coverage. As for increasing human resources, medical

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students starting from the second or third year could be trained and being involved in the home-screening model according to the location of their university campus. Their help would be included as a form of social or charity act so that their knowledge will not go to waste. This would be an advantage both to the population being measured and the medical students themselves.

intake and lack of knowledge are related to the high incidence of hypertension.

Therefore, what is aimed to do involves increasing awareness about hypertension as well as recommended salt intake. This could be achieved through proper health promotion campaigns containing information about recommended salt intake as well as knowledge about the disease itself, and how to prevent it. The complications and dangers should also be publicized to give an understanding why it is important to prevent hypertension rather than controlling it. Lastly, we also proposed that there should be a home-screening model where medical staffs and medical students work together measuring the blood pressure of a population with low socio-economic and knowledge status in order to prevent and control hypertension.

Conclusion To conclude, one of the geriatric problems that is starting to rise is the high incidence of hypertension. The disease itself is asymptomatic so people may not be aware of it. Complications caused by hypertension might be life threatening, so it is important to not overlook the disease in elderly who already has a decrease of bodily function. As researches revealed, two factors that affect high blood pressure the most are knowledge and daily salt intake. High amount of salt Tables and Figures Table 1. Frequency distribution of respondent's knowledge about hypertension at Pandanaran public health center on Dec '11 - Jan '12(n=70) N um Pengetahuan Sebelum (%) Sesudah (%) 1 Baik 4.3 100 2 Cukup baik 91.4 0 3 Tidak baik 4.3 0 T otal 100 100 Table 2. Visible Salt Consumption at 2002, 2007, 2009 Num Areas 2002 2007 1 Urban 5.8 5 2 Rural 6.7 6.2

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References 1. Rahajeng E, Tuminah S. Prevalensi Hipertensi dan Determinannya di Indonesia.

Maj Kedokt Indon. 2009 Dec; 59(12): 580587.

Available from: http:// indonesia.digitaljournals.org 2. Hypertension [Internet].2011.[updated 2011 June 6; cited 2013 Jan 27]. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/ PMH0001502/ 3. Badan Pusat Statistik. Profil Kemiskinan di Indonesia Maret 2012.

Jakarta: Badan Pusat Statistik; 2012 July 2.8 p. Report No.: 45/07/Th. XV, 2 Juli 2012 4. Profil Kemiskinan di Indonesia Maret 2012 [Internet]. 2012 July 2 [cited 2013 Jan 24].

Available from: http://www.bps.go.id/brs_file/kemiskinan_0 2jul12.pdf 5.

InaSH Menyokong Penuh Penanggulangan Hipertensi [Internet]. 2012 [cited 2012 Jan 13]. Available from: http://www.depkes.go.id/index.php/berita/pr ess-release/896-inash-menyokong-penuhpenanggulangan-hipertensi.html 6. RA Kuswardhani. Penatalaksanaan Hipertensi Pada Lanjut Usia. J Peny Dalam.

2006 May; 7(2): 135-140. Available from: http://ojs.unud.ac.id/index.php/jim/article/vie w/3757/2755 7. Indonesian Society of Hypertension: Vision and Mission [Internet]. 2012 [cited 2012 Jan 14].

Available from: http://www.inash.or.id/about.html 8. Tiberio M, Roland E, Tomasz G, Franz H. Salt and Hypertension: Is Salt Dietary Reduction Worth the Effort?. Am J Med. 2012 May; 125(5): 433-439. doi:10.1016/j.amjmed.2011.10.023 9. Hardinsyah. Analisis Konsumsi Lemak, Gula dan Garam Penduduk Indonesia. Gizi Indon 2011, 34(2): 92-100.

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10. MT Susanti, M Suryani, Shobirun.

Pengaruh Pendidikan Kesehatan Tentang Hipertensi terhadap Pengetahuan dan Sikap Mengelola Hipertensi di Puskesmas Pandanaran Semarang.Jurnal Ilmu Keperawatan dan Kebidanan.Vol 1 Juni 2012.

11. DF Widyasari, A Candrasari.

Peningkatan Pengetahuan tentang Hipertensi pada Lansia di Posyandu Lansia Dukuh Gantungan Desa Makamhaji Kartasura Sukoharjo. WARTA, Vol. 13, No.1, Maret 2010: 28-36.

12. Masalah Hipertensi di Indonesia [Internet]. 2012 May 6 [cited 2013 Jan 13].

Available from: http://www.depkes.go.id/index.php/berita/pr ess-release/1909-masalah-hipertensi-diindonesia.html 13. Reducing Salt Intake in Populations: Report of a WHO Forum and Technical meeting [Internet]. 2006 Oct [cited 2013 Jan 24].

Available from: http://www.who.int/dietphysicalactivity/redu cingsaltintake_EN.pdf 14. Lowering Salt in Your Diet [Internet].

2010 May 18 [updated 2012 August 9; cited 2013 Jan 27].

Available from: http://www.fda.gov/ForConsumers/Consume rUpdates/ucm181577.htm 15. CFR- Code of Federal Regulations Title 21 [Internet]. 2012 [updated 2012 April 1; cited 2013 Jan 31]. Available from: http://www.accessdata.fda.gov/scripts/cdrh/c fdocs/cfcfr/cfrsearch.cfm?fr=101.9 16. NCSL: The Medical Home Model of Care [Internet]. 2013. [updated September 2012].

Available from: http://www.ncsl.org/issuesresearch/health/the-medical-home-model-ofcare.aspx

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Faktor Psikososial Penyebab Depresi pada Lansia Marviken Lunu Namseo, Gracesia Kwannandar, Douglas Tigor Hutahaean Universitas Kristen Indonesia Latar Belakang Proses menjadi lanjut usia merupakan proses alamiah sesuai peningkatan usia yang menyangkut penurunan kualitas hidup dalam aspek biologis, psikologis, dan sosial seseorang.

Sebagai contoh, saat seseorang menua, semua aspek biologis dalam tubuhnya mulai dari tingkat sel hingga sistem organ akan mengalami penurunan fungsi. Adanya perubahan biologis atau fisik pada lansia ini dapat berdampak pada kemampuan sensasi, persepsi, dan penampilan psikomotor yang sangat penting bagi fungsi setiap individu manusia.Penurunan fungsi inilah yang berefek pada kemampuan belajar, daya ingat, berpikir, intelegensi, menyelesaikan masalah, kreativitas, keahlian, dan kebijaksanaan.Perubahan – perubahan ini merupakan satu dari berbagai faktor yang dapat menyebabkan lansia mengalami depresi.

Depresi pada lansia memiliki prevalensi 15,9% di negara – negara berkembang dan pada 2020 diprediksi dapat menjadi penyakit teratas mengungguli penyakit – penyakit infeksi. Selain penurunan aspek biologis atau fisik, stressor psikososial juga menjadi penyumbang terbesar penyebab para lansia depresi dan ini kurang mendapat perhatian khusus.Faktor psikososial merupakan permasalahan yang sangat membebani hidup lansia yang dapat berpengaruh pada aspek fisik, sosial, dan mentalnya. Stressor yang dihadapi lansia antara lain modernisasi, kesepian, dan kehilangan pekerjaan akibat masa pensiun. Penelitian ini diajukan untuk meninjau seberapa banyak lansia yang depresi dan peyebab apa saja yang menyebabkan lansia depresi.

Metode Penelitian dilakukan secara cross sectional kepada masyarakat di kelurahan cawang dengan random sampling. Diambil responden dengan rentang usia 60 – 85 tahun sedikitnya 30 orang dengan kriteria tidak megalami gangguan jiwa berat, dapat berkomunikasi dengan baik dan bersedia menjadi responden. Data primer diambil dengan wawancara kepada subjek secara

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langsung dengan instrumen kuesioner yang berisi data pribadi, skala depresi pada geriatri untuk mengukur tingkat depresi pada lansia dan penyebab depresi.

Hasil Analisa dan Pengolahan Data Didapat 30 responden yang memenuhi kriteria pengambilan data dari RT 3, RT 4, RT 7 dan RT 9 yang bersedia diwawancara dan mengisi kuesioner. Hasil yang didapat adalah sebagai berikut: Berdasarkan jenis kelamin sebanyak 19 orang 63,3% lansia adalah wanita. Dari 19 orang wanita ini 1 menikah dan yang lainnya adalah seorang janda, dan dari janda – janda tersebut, 14 diantaranya menderita depresi.

Sedangkan untuk pria, dari 11 orang pria yang mengisi kuesioner, 7 diantaranya masih memiliki istri, sedangkan 4 diantaranya telah menduda. Dari para pria hanya 3 orang yang mengalami depresi. Sehingga total lansia yang depresi sebanyak 17 orang atau 56,7% bila dipersentasekan.

Untuk penyebab depresi, saat diwawancara, mereka mengaku bahwa kehilangan pasangan hidup merupakan hal terberat yang mereka lalui, disusul oleh kehilangan perhatian dari anak – anak. Mereka juga sering khawatir akan hal buruk yang akan menimpa dirinya dan keluarganya. Faktor ekonomi juga mungkin berpengaruh dalam penyebab depresi pada lansia.Namun, bagi yang tidak depresi, ditemukan bahwa pendekatan diri terhadap Tuhan melalui ibadah dapat menenangkan hati mereka.

Didapat juga bahwa, rata – rata yang tidak depresi akibat masih aktif dalam berbagai kegiatan sosial, seperti berkumpul bersama para lansia, aktif dalam perkumpulan PKK bagi yang wanita, dan aktif kerja bakti ataupun bergotong royong bagi yang pria.

Discussion Pada umumnya setelah orang memasuki lansia maka ia mengalami penurunan fungsi kognitif dan psikomotor. Fungsi kognitif

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meliputi proses belajar, persepsi, pemahaman, pengertian, perhatian dan lain-lain sehingga menyebabkan reaksi dan perilaku lansia menjadi makin lambat. Sementara fungsi psikomotorik (konatif) meliputi hal-hal yang berhubungan dengan dorongan kehendak seperti gerakan, tindakan, koordinasi, yang berakibat bahwa lansia menjadi kurang cekatan.

Dengan adanya penurunan kedua fungsi tersebut, lansia juga mengalami perubahan aspek psikososial yang berkaitan dengan keadaan kepribadian lansia. Beberapa perubahan tersebut dapat dibedakan berdasarkan 5 tipe kepribadian lansia sebagai berikut: - Tipe Kepribadian Konstruktif (Construction personalitiy), biasanya tipe ini tidak banyak mengalami gejolak, tenang dan mantap sampai sangat tua.

- Tipe Kepribadian Mandiri (Independent personality), pada tipe ini ada kecenderungan mengalami post power sindrome, apalagi jika pada masa lansia tidak diisi dengan kegiatan yang dapat memberikan otonomi pada dirinya - Tipe Kepribadian Tergantung (Dependent personalitiy), pada tipe ini biasanya sangat dipengaruhi kehidupan keluarga, apabila kehidupan keluarga selalu harmonis maka pada masa lansia tidak bergejolak, tetapi jika pasangan hidup meninggal maka pasangan yang ditinggalkan akan menjadi merana, apalagi jika tidak segera bangkit dari kedukaannya.

- Tipe Kepribadian Bermusuhan (Hostility personality), pada tipe ini setelah memasuki lansia tetap merasa tidak puas dengan kehidupannya, banyak keinginan yang kadangkadang tidak diperhitungkan secara seksama sehingga menyebabkan kondisi ekonominya menjadi morat-marit.

- Tipe Kepribadian Kritik Diri (Self Hate personalitiy), pada lansia tipe ini umumnya terlihat sengsara, karena perilakunya sendiri sulit dibantu orang lain atau cenderung membuat

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susah dirinya.

Konsep menua sehat pada hakikatnya sesuai dengan slogan Tahun Usia Lanjut WHO tahun 1982 adalah : â&#x20AC;&#x153;Do not put years into life,but life into yearsâ&#x20AC;?, yang berarti usia panjang tidaklah ada artinya bila tidak berguna dan bahagia serta mandiri sejauh mungkin, dengan mempunyai kualitas hidup yang baik. â&#x20AC;&#x153;Long life without continous usefulness, productivity and good quality of life is not a blessingâ&#x20AC;?. Tujuan hidup manusia adalah menjadi tua tetap sehat (healthy ageing).Healthy aging artinya menjadi tua dalam keadaan sehat.Healthy ageing akan dipengaruhi oleh beberapa faktor : i) endogenic ageing, yaitu yang dimulai dengan cellular aging, lewat tissue dan anatomical ageing ke arah proses menuanya organ tubuh, proses ini seperti jarum jam yang terus berputar ii) exogenic factor, yang dapat dibagi dalam sebab lingkungan (environment) di mana seseorang hidup dan faktor sosio budaya yang paling tepat disebut gaya hidup (life-style).

Faktor exogenic ageing ini, sekarang lebih dikenal dengan sebutan faktor risiko.Boedhi Darmojo menggambarkan dalam bentuk di bawah ini (Gambar 1).

Selanjutnya menua sehat (healthy ageing) harus diikuti dengan menua-aktif (active ageing). Menua-aktif adalah suatu proses yang mengoptimalkan kesempatan untuk sehat, partisipatif dan kesejahteraan dalam tujuan meningkatkan kualitas hidup saat seseorang menua. Menua aktif ini terjadi baik pada individu maupun sekelompok orang.Kata aktif menunjukkan peran serta berkelanjutan dalam bidang sosial, ekonomi, kultural, spiritual dan pemerintahan.Sedangkan kata sehat, merujuk ke masalah kesehatan fisik, mental dan sosial seperti tercantum di definisi WHO tentang arti sehat.

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Gambar 1. Faktor-faktor yang berpengaruh terhadap healthy aging (11)

Gambar 2.The determinants of active ageing (10)

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Gambar 3.Spider model: the relationship between risk factors and degenerative diseases kelompok â&#x20AC;&#x201C; kelompok sharing agar mendapat solusi dan saling menguatkan satu sama lain.

Conclusion Keluar rumah untuk berinteraksi dengan Telah diketahui bahwa proses menua adalah masyarakat sekitar pun juga dapat mengurangi suatu kepastian. Kita sebagai manusia tidak tingkat stress. Tetap beaktivitas sesuai energi dapat menolaknya namun kita dapat juga dapat membantu menurunkan tingkat stress mempersiapkan hari tua kita agar jangan sampai yang ada. mengalami depresi. Bagi yang depresi, disarankan untuk berbagi cerita melalui Refferences Nascher IL. What is geriatric? Cited by: Gray L.Addressing the need of geriatric education.Elderly1997; 7: 14.

Taliaferro PM, Price CA. Aging increases risk formedication problems. Senior Series 2001; 127: 1-3.

World Health Organization.Active ageing, a policyframework. Geneva: World Health Organization;2002.

Darmojo RB, Martono HH. Buku Ajar Geriatri.Jakarta: Balai Penerbit Fakultas KedokteranUniversitas Indonesia; 1999.

Kalache AA. Active ageing in the 21st century.Brazilia: World Health Organization; 2005.

Darmojo RB. Determinants of active vital ageingand prevention of disease in the elderly, KongresNasional Gerontologi, Jakarta, Oktober, 2003.

Ika SH, Pranarka K, Joni B, Andayani R, MartonoH. Deteksi dini gangguan fungsi

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kognitif denganMMSE. Temu Ilmiah Geriatri, Jakarta, 2005.

The Department of Health, USA: Guideline for thepromotion of active ageing in older adults.Formeset Cape Printers, June 2000.Departemen Kesehatan RI. PelayananGangguan Jiwa Usia Lanjut (Psikogeriatrik) diPuskesmas. Direktorat Jenderal PelayananMedik Depkes RI, 2000.

Sadock, BJ & Sadock, VA.Kaplan & Sadock's Synopsis of Psychiatry, 9th ed.

Lippincott Williams & Wilkins, Philadelphia, 2003.

Hawari, D. Al-Quran, Ilmu Kedokteran Jiwa dan Kesehatan Jiwa, edisi revisi. PT Dana Bhakti Prima Yasa, Yogyakarta, 1997.

Soewadi.Simptomatologi dalam Psikiatri.Medika, FK UGM Yogyakarta, 1999.Widiatmoko, D. Korelasi Dukungan SosialDengan Derajat Depresi pada Pasien UsiaLanjut di Poliklinik Geriatri RSUP Dr. Sardjito Yogyakarta, Tesis. Program

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Pendidikan Dokter Spesialis Universitas Gadjah Mada, Yogyakarta, 2001.

Arianti, M.R. Pengaruh Stresor Psikososialterhadap Depresi pada Lansia di PoliklinikGeriatri RS Dr. Sardjito, Tesis, FakultasKedokteran Universitas Gadjah Mada,Yogyakarta, Indonesia, 2004.

Lovestone, S., Howard, C. Depression in Elderly People, Martin Dunitz Ltd, London, 1998.

Lamsudin, R. Epidemiologi Klinik Demensia dalam Temu Ilmiah HUT ke-51 Fakultas Kedokteran UGM. Fakultas Kedokteran Universitas Gadjah Mada, Yogyakarta, 1997.

Suryo, S. Depresi Sebagai Faktor Risiko

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Insomnia pada Lansia di RS Dr. SardjitoYogyakarta, Tesis, Fakultas KedokteranUniversitas Gadjah Mada, Yogyakarta, 2003.

Hawari, D. Dimensi Religi dalam Praktek Psikiatri dan Psikologi. Balai Penerbit Fakultas Kedokteran Universitas Indonesia, Jakarta. 2003.

Marchira, CR, Arif, UF, Soewadi.

Hubungan antara Religiusitas dan Depresi pada Lanjut Usia di Kelurahan Wirosaban, Yogyakarta, dipresentasikan pada Konferensi Nasional I Kesehatan Jiwa Islami, 1-2 Juli 2006, Solo, Indonesia.2006.

Kaplan, H.I., & Sadock, B.J. Comprehensive Textbook of Psychiatry, 7th ed. Williams dan Wilkins, Baltimore, 2000

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Medical Service Quality Improvement in Geriatric Diabetes Mellitus Type II Patients

by Educational ApproachAs Multi-Disciplinary Healthcare Service Edwin Halim, Vinson Hartoyo, Rico Wicaksana Putra Universitas Pelita Harapan ABSTRACT Geriatri or commonly called as aging process is a natural process which will happen in all people.

Geriatric condition is characterized by aging which shows an increasing progress, senescence which shows a decline in the effort done by body in terms of secretion and many other functions which is related with homeostasis. This condition usually makes geriatric patient becomes more susceptible to many diseases. One of the main geriatric diseases is Diabetes Melitus which is defined as a hyperglycemic state in which many abnormalitites develop in blood including lipid and protein metabolism, especially Diabetes Melitus type2-adult onset diabetes which has risk factor of aging process.

We need to give our big attention to Diabetes Mellitus. We can see this problem from the dat which has been provided in the background. From the data, research has proven that in 2011 there are 366 million people who suffered from Diabetes Mellitus and half of them goes undiagnosed. A sad fact that from the total amount of Diabetic patient, 80% are in middle or lower economic level. This condition is believed to be also occuring in Indonesia, which based on WHO data is believed to have a great increase in diabetic patient from 8.4 million people in 2000 to 21.3 million people in 2030.

Diabetes Mellitus, beside becomes the 6th leading cause of death in uncomunicable diseases category, also becomes a major problem in Out Patient Department with Case Fatality Rate of 7.9%. Other than that, diabetic patient’s quality of life is slowly but sure facing a declinement. This shows that there are multiple factors which haven’t been solved in Diabetes Mellitus treatment, especially in education part.

Nowadays, education has become a very important aspect. As we all know, pharmecceutical treatment highly depends on patient adherence. Yet the Journal of Diabetics Nursing 2004 states that only a third of diabetic patients regularly take their medication. This journal also found that patient adherence is a major problem in the management of type 2 diabetes.

There are many factors that inhibit our progress, such as our government that remains inefficient and health programs that are ineffective shown by the increasing rate of diabetic prevalence each year.

Our doctors are too busy, owing to the doctor-patient ratio of 0,29 to 1000, thus there isn’t sufficient time for patient education during consultation. The patients themselves know very little of their disease and its complications, thus they make little or no lifestyle and dietary change, often resulting in dire complications such as gangrene and neuropathy. Datas by the Journal of Pharmacology shows only 5% of patients whose mean age is 64,6 years knows the toxic side effects of their medication.

We used a Meta-analytic method and review articles to know the multifactor that have relation with diabetes type 2, education – knowledge and quality of life. So after we get all datas, we analyze all the data and give the best solution to solve this problem. We faced several obstacles in terms of obtaining the data needed for this paper. Since there are only so few sources available in Indonesia, we use some foreign sources.

A practical and feasible solution to this problem is to have medical students deliver patient education. Thus not only does the patient and his/her family gains knowledge to prevent complications and improve quality of life, but us medical students will also gain a tremendous amount of exposure and experience that will be highly beneficial in our later career as a doctor who delivers a mutli-disciplinary approach. This solution tackles the government and doctors’ issue, whilst providing benefits not only to the patients, but to us as the future generation of doctors in improving geriatric treatment with a multidisciplinary approach.

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Background ‘Diabetes’ may not ring any new bells in our heads, and yet for a disease, which affects roughly 366 million people worldwide on 2011 and expected to nearly double into 556 million by 2030, diabetes surely is receiving far less attention than it deserves, as companies that produce consumable goods with a high calorie and sugar content are still thriving. A metabolic disorder, which could be autoimmune (type 1) or acquired through a lifestyle of sugar packed diet (type 2), this lifelong condition requires patients to live a significantly altered, albeit relatively normal, lifestyle.

Type 2 Diabetes Mellitus mostly occurs at an adult onset, and the risk tends to rise as a person ages, meaning that the elderly are most at risk.

There are 3 factors that occur in the aging process; aging, a process that occurs with the passing of time, senescence the reduction of function and structural integrity, and homeostenosis, a reduction in the body’s ability to maintain adequate homoeostasis. In fact, diabetes mellitus is a common disease in older people, with almost 50 % of Type 2 diabetic patients being over 60 years of age. Despite this fact, half of older people with diabetes go undiagnosed (WHO, 1998). An original article

by Diabetes Care on 2004 found that ‘the most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age’ (Diabetes Care 27:1047-1053, 2004). By 2011, people at the of >65 years have a 26,9% prevalence to contract type 2 diabetes, with a faster rate of increment than that of type 1.

Indonesia is the 4th-ranked country in the world with the most diabetics (Diabetes Care, 2004), and happens to have a case fatality rate of approximately 8%, with the addition of having diabetes as the no.1 cause of death in the Inpatient department of hospitals all around the country in 2005 (Universitas Sumatera Utara).

Contrary to popular beliefs, this phenomenon is not caused by the lack of technology or advancement in the field of pharmacy. A survey

by WHO and IFMS (International Federation of Medical Students) on 2002 show that only 22% of Indonesia’s medical faculties teach geriatric care, meaning our doctors are not well equipped

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in terms of geriatric healthcare. Another survey

by Pennsylvania State University at 2009 shows that the elderly in Indonesia spend the last 10-15 years of their lives dependent and incapable of taking care of themselves, meaning that they would surely have to rely on the care provided by their relatives, which will be unlikely, since care from relatives require good education and coordination with their corresponding doctors, whereas those doctors are lacking of education in the very field of geriatrics itself, as aforementioned. This is further aggravated by the fact that 80% of those who contract diabetes in Indonesia are those in the middle and lower strata of economy (WHO, 2011), thus certainly lacking education and knowledge, making them almost, if not altogether, fully reliant on their doctors’ advice. However, it is not of rare knowledge that most of our doctors tend to have the “drug dealer” habit; that is, they are more into prescribing drug combinations than into putting emphasis on patient education. This may seem trivial upon first glance, however in the case of lifelong ailments, as in hypertension, or, in this case, diabetes, such habit could lead to a bleak prognosis. Furthermore, this habit creates a “magic pill” social paradigm within Indonesia’s patients, not only those of diabetics.

That is, a view that the cure of an ailment is as simple as plunging a pill down one’s throat, without any alteration of lifestyle, habits, or mindset. When applied to an ailment such as diabetes, it is easy to see that most of our patients would feel disappointed, because certainly diabetes could not be ‘cured’, though it can be controlled, thus having minimal impact on one’s quality of life. Lifestyle changes are also necessary, which many of our patients are often repulsive to and are thus unwilling to do, partially owing to the ‘magic pill’ paradigm, as mentioned before, and a lack of self-discipline.

Thus far, it could clearly be seen that Indonesia’s geriatric healthcare issue, especially in the case of diabetics, is a multi-factorial, multi-faceted problem, which requires a multidisciplinary approach if a solution is ever to be found and effectively implemented. Due to the wide array and variations coupled with the consideration of time and cost’s efficacy, the writers of this paper decided that an approach in

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terms of patient education would be of the greatest relevance and impact, as well as the easiest to implement, as patient education, we believe, is a cost effective and highly practical yet effective method to improve Indonesia’s geriatric care.

Purpose As mentioned before, there are many factors that contribute to the quality of medical service in Indonesia. This paper is meant to determine the significance of patient education in establishing a multi-disciplinary approach for geriatric care. Type 2 diabetes was chosen over hypertension due to fact that the etiology of the disease itself was better known and there are fewer factors that contribute, thus reducing the chances of biases and assumptions.

We hope that by publishing the results of this paper, whatever the results may be, we will be able to bring as many as possible of Indonesia’s medical society to realize the importance of patient education and a multi-disciplinary approach, especially that in geriatric care.

Benefits Benefits that are of importance and significance include that of economical value, in that Indonesia is a developing country, whereas pharmacological and technological development in the field of medicine to improve patient welfare requires a hefty amount of monetary investment. On the other hand, proving that patient education has a significant impact on their prognosis and welfare means that we as a developing country need not invest an abundant amount of money to further the quality of our medical services, thus enabling us to utilize the aforementioned money for more urgent matters that we are facing as a developing country, such as infrastructure and housing for the poor. The setback, though, is that a considerable amount of effort on behalf of the corresponding doctor is needed if we were to improve the quality of the aforementioned patient education. Substituting medical personnel in training a.k.a. medical students to deliver the education service if the aforementioned doctor happens to be unavailable or busy, however, could ease the burden.

A focused approach to improve patient

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education as part of a multi-disciplinary medical service would benefit not only the patient, in that he/she will undoubtedly experience a better quality of life, but doctors will also benefit, such that they will no longer need to spend so much time tending a patient, for patients will be able to adequately take care of their basic needs with sufficient education, thus they have more time for new patients, not to mention positive referrals from their prior patients who receive positive service. From us medical students’ point of view, an approach from the patient education side is immediately practicable since their early years, thus enhancing their clinical exposure to a wider and deeper array at an earlier stage, while at the same time, preparing them to become physicians that deliver a multi-disciplinary and holistic care for their patients.

An important point to note is that Indonesia is a geographically disadvantaged country in terms of medical healthcare, because due to its multitude of islands, it is of great hurdle to transport medical goods and pharmaceuticals to the outskirts of the country. A multi-disciplinary and holistic approach means that the lack of pharmaceuticals and medical facilities can be counterbalanced, to a considerable extent, by extensive patient education and management.

Doctors practicing in the outskirts could be taught to teach their patients that, for example, malaria medication could be substituted with the bark of the quinine tree, and ORT (Oral Rehydration Therapy) could be home made with the correct ratio of salt and sugar, plus a banana if available. Thus this means that despite the lack of facility and medications, there will at least be a counterbalance measure to ensure the best possible service for patients at that time.

Theoritical Basis Type 2 Diabetes is, for the most part, an acquired ailment that causes body cells to grow resistant to insulin. Simply put, insulin is an endocrine hormone that acts pretty much like a key, which is required to transport glucose molecules into cells. Resistance to insulin is depicted as the “keyhole” where insulin is supposed to bind undergoes changes, thus making the process of glucose uptake into cells to require a bit of fumbling with the insulin “key”. This condition is known as Adult Onset

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promotes the release of insulin via exocystosis (Goodman Gilman). Metformin works by inhibiting gluconeogenesis in the liver, whilst increasing insulin functionality at muscle and fat tissues. Metformin lowers the availability of Vitamin B12 by 20-30% (DeFronzo et al, 1995) as a side effect, which could provoke megaloblastic anemia and thiamine deficiency (Goodman and Gilman). Glibenclamid, on the other hand, may cause hypoglycemia (Katzung).

On the long run, these side effects has great potential in reducing a patientâ&#x20AC;&#x2122;s quality of life, if they do not have sufficient knowledge regarding these side effects, thus affecting their adherence to the treatment regime.

Now, it is important to note that almost any drug has side effects, and yet survey results have shown that only 34,7% of diabetic patients, with a mean age of 64,6 years are given written information regarding their medications (Journal of Diabetes Nursing Vol 11 No 7 2007). These adverse reactions, if not clearly explained by the corresponding doctor, have a negative impact in the compliance and adherence to treatment regimes of diabetic patients, but less than 6% of these patients knew the toxic and side effects, or potential drug interaction (British Journal of Clinical Pharmacology June 2001).

Implementing patient education help make these patients more cooperative by means of granting understanding towards the side effects that they are experiencing, in that those side effects are expected, and they need not be alarmed. On the other hand, precautions need to be given as well, such that patients will know when to seek medical attention when the adverse reaction goes beyond the safety margin. The table below shows the significance of knowledge regarding medication in respect to adherence towards the intake of medicine;

Diabetes Mellitus that has a significant impact upon the elderly, due to the fact that glucose is our main source of energy, thus we heavily rely upon insulin sensitivity, which decreases as we age.

Consequently, this results in a glucose buildup within the bloodstream, which, one reaching a certain concentration, initiates pathological cascades such as tingling owing to neuropathy, a condition which is the main trigger for a patient to seek medical attention, due to their lack of knowledge regarding the classic symptoms of diabetes. An increased polyol pathway and the accumulation of Advanced Glycosylation End Product leads to endothelial dysfunction, a risk and comorbid factor of heart attack, as well as gangrene, which is more or less linked to the neuropathy mentioned above (IPD UI).

A majority of patients do not take into consideration these complications that may occur in later stages, thus they only seek alleviations for their current symptoms. Many are not willing to consider that diabetes currently has neither definitive treatment nor a complete cure. This causes patients to misinterpret their prognosis, leading to a false expectation that mere pharmacological treatment is sufficient for them to return to their daily routines. It is this very phenomenon that a good multi-disciplinary approach, which includes patient education, can give a holistic step up in the quality of life of Indonesiaâ&#x20AC;&#x2122;s diabetic elderlies.

Generic medications in Indonesia commonly used for treatment of type 2 diabetes are glibenclamide and metformin. Glibenclamide inhibits SUR-1 (Sulfonyl Urea Receptor), the regulator molecule of K-ATPase of pancreas Beta cells, causing the K-ATPase to open. This opening causes membrane depolarization, resulting in the opening of voltage-dependant Ca channels. An increased influx of calcium Knowledg e The purpose of Treatment Consequences of omission Risk of drug

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Yes No Yes No Yes

N

%

198 133 70 261 16

60 40 21 79 5

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Likelihood of adherence Drug Dose Regi OR OR men OR 9,5 1,8 3,7 12,3

2,3

1,8

108,0

0,6

0,5

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toxic effects No 315 95 N= Number of subjects, OR= Odds Ratio. OR is higher than 1 when adherence to medication is associated to knowledge regarding treatment. (Adapted from British Journal of Medical Pharmacology, 2001) acquires any knowledge concerning their sickness (as in this case, diabetes), the It is also important to recall that patients prognosis, impact on their life and those around come from various economical backgrounds, them, the significance of having that sickness and this may have an impact on the quality of under control instead of running rampant, and medication that they receive, in that those who precautions as well as preparations that are to be are financially impaired will be unable to gain made in order to ensure that those who are access to non-generic medications (e.g. diabetic have a life quality as close as possible to Dipeptidyl peptidase 4 inhibitor), which in turn that of a healthy person of their age. It is of may impact the outcome of their treatment. This significance to note that education enables disparity can be dampened (though not negated) effective widespread prevention of all types; be by sufficient patient knowledge acquired it primary, secondary, or tertiary. It also prevents through education. Even if the above the patient’s family from contracting diabetes in phenomenon does not occur, patient education the future, since there is a familial risk factor in can reduce the patient’s dependency towards type 2 diabetes (Type 2 diabetes, a cocktail of medication, resulting in less cost for their genetic discovery), Oxford Journal, 2006). treatment, and the deliverance of a more equal medical service for society from all strata of economy Method For this scientific paper, we chose to use a An interesting fact worth noting is that, meta-analysis approach and review article from although a certain medication’s route of many trusted sources such as articles, literatures administration, bioavailability, and half-life may and journals. We search for the data about the be perfectly tuned to extreme efficiency in correlation between patient’s knowledge and the dealing with its target, this is certain to be quality of health. We also observed changes that significantly hindered, if not altogether useless, resulted from the intervention done to the if the corresponding patient has a lack of patients. Other data, which have been collected compliance and adherence in taking his/her are some efforts done by the government in medication. In fact, only a third of patients purpose to improve diabetic patient’s quality of taking metformin or sulfonylurea had adequate life. After we analyze all the data, we seek for adherence (Journal of Diabetes Nursing 2004). the main problem in Indonesia then we devise a A study by Donnan et al. suggests the best solution, which offers a win-win solution that therapy available is unlikely to be effective if benefits not only for patients, doctors, and the strategy to improve adherence are not devised Indonesian government, but us as medical (Journal of Diabetes Nursing 2004). Low students as well. adherence to treatments has been associated with poor outcomes, even when the treatment was a placebo (Haynes and Dantes, 1987).

Result and Discussion Indonesia’s government has made efforts to Thus compliance and adherence of those stunt the growth of people suffering from undergoing treatment plays a huge role within diabetes through the realization of health the pharmacological aspect of diabetic promotions and collaborative training with ADA healthcare itself. These factors are the reason (American Diabetic Association) of Indonesian why communicative patient education plays a doctors on how to deal with diabetic patients. huge role, both as an independent element of The Indonesian Ministry of Health stated that treatment and as an adjunct for the conventional they have trained 200 medical personnel on last pharmacological side that has been the mainstay year’s 10th meeting.Yet there has no data which method of doctors in treating diabetes. relevently supports any positive outcomes; A good patient education is easily characterized by whether or not a patient

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1.

2.

3.

There has been no follow up on the outcomes of trained participants For a country the size of Indonesia, 200 medical personnel each year is barely enough to provide adequate medical service throughout the country. Even if the numbers do increase, it is far from possible to catch up with the rate of increase of diabetics in Indonesia.

Statistical data has shown that there is an increase in the rate of people contracting diabetes each year.

From another viewpoint, WHO has shown that the doctor patient ratio is 0,29 to 1000. This means a doctor will be very busy tending their patients, resulting in a decreased time available to educate every patient. Thus doctors will not focus on educating their patients reagarding lifestyle and habitual changes, expected side effects as well as treatment result, and contraindications in habit and lifestyle, instead they will merely give medication alone. Their patients thus hardly gains any knowledge regarding their ailment, medication, complication risks and self care techniques. In the end, this causes the patient to have to come back more often for consultation, since they know very little concerning their disease. In short, it could be said that our doctor’s ‘busyness’ are self-inflicted due to their unwillingness to spend more time educating their patients.

The Percentage Of The Diabetic Patient On Whether Or Not They Have Any Knowledge Regarding To Consequences Of…

21 79

Yes No

The Percentage Of The Diabetic Patient On Whether Or Not They Have Any Knowledge Regarding To The Purpose Of Treatment

40

60

Yes No

These graphs, taken from a research made in UK, shows that geriatric patients have insufficient knowledge regarding their treatment, despite the fact that sufficient knowledge actually has a positive effect towards a patient’s

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adherence to their treatment regime, which in turn, will assuredly provide a better outcome. If UK, a country whom education ranks 6th in the world (BBC News survey), has such a percentage as presented in the graphs, surely Indonesia would have a significantly worse result. Ironically, the Journal of Diabetes Care on May 2004 published by WHO states that there will be a 250% increase of diabetes incidence from 2000 to 2030. This means that we need to devise an effective strategy (practical, easy, and economical) to implement as soon as possible, in order to cope with the growing number of diabetics in this country.

The Percentage Of The Diabetic Patient On Whether Or Not They Any Knowledge On The Risk Of DrugToxic Effect 5

Yes No

95

From the governmental standpoint, it is important to evaluate to efficacy of the so-called diabetic education to medical personnels in terms of outcome and whether there were any significant positive effects. This program should be well published that only medical personnel are able to attend, but also medical students and most importantly, patients and their family. It is also important to note that the number of educators trained each year isn’t sufficient for Indonesia. Thus it might be better to have small and yet numerous as well as well spread training courses, rather than a single huge course situated only in the megapolitan area, where doctors from rural and isolated areas are most probably unable to attend. A more economical alternative would be to have the government authorize a Standard Operational Procedure for geriatric care, which then can be distributed and implemented in hospitals and health care centers all around Indonesia. With the implementation of these solutions, it is expected that the funds spent by the government to distribute medication

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throughout Indonesia could be allocated to more pressing matters such as infrastructure and education. Through educational therapy, it is expected that patients are more able of sustaining their quality of life through adequate self care, lessening their dependency on medications.

A change of mindset needs to be made in the minds of Indonesia’s young generation of medical personnel, in that we need to realize that education plays a vital role and is necessary in order for pharmacological treatment to have an effective impact. We too need to realize that patients are humans and not groups of ailment.

Despite having received this in our education, most of us graduate as doctors and lose our motivation, having focused on making money instead. A new curriculum that incorporates geriatric care as an independent branch of knowledge is necessary. Meanwhilst, patient education could be improved by the educator improving their methods of education by allowing two way communication and flexibility with their patient’s lifestyle and habit. It is important to include these knowledge into the education of a diabetic geriatric; • Outline of Diabetes Mellitus • Complications • Medications • Lifestyle changes • Side effects expected • Contributions their family could make Another important party is the patient’s family, since they are the ones closest to the patient, and often times an inseparable part of any geriatric patient’s life, owing to their dependency towards their family in caring for them. Thus an educated family can play a huge role in the treatment of geriatric patients through not only physical, but also motivational and psychological support as well. It is also important to remember that type 2 diabetes has a familial pattern, thus family education will reduce the risk of other members of the patient’s family from contracting diabetes later on in their life.

Perhaps one of the most important factors is the patient themselves. They need to know that diabetes is an incurable ailment, and yet if it is

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under control, then their quality of life can be restored to the point of hardly any reduction.

This mindset will erase the misleading thought that diabetes will be cured after the regiment of daily pills are finished, which usually causes patients to lose hope after undergoing a certain length of treatment, causing them to abandon their medication, coming back to seek medical attention after complications have developed, resulting in a severely reduced quality of life and often leads to death. Not to forget, motivational and psychological support is also vital, remembering that diabetes is incurable, thus those inflicted will surely have a heavy burden on their minds. They need to be reassured that despite having no definite cure at the moment, a diabetic who has his/her blood sugar under control will have no significant reduction in his/her quality of life.

Patients themselves need to be aware that it is important to listen to their doctors, instead of simply taking their prescription and doing nothing else, since education plays a major role not only in prevention, but also in treatment as well.

As mentioned before, most geriatric patients have lost their self care and independence, thus family has a significant impact on the outcome of diabetic treatment in geriatric patients.

The most vital essence of a solution is its practicality and feasibility, thus referring to our doctors being busy and the difficulty of changing their mindset, and not to forget the complexity of Indonesia’s bureaucracy, thus patient education for diabetic geriatrics will be more realistic to be performed by medical students ourselves.

Conclusion Clearly, there are many aspects at play, which affects the quality of delivery of service in geriatric healthcare in Indonesia, as clearly mentioned in data from the above section. We have analyzed data from various aspects and have given many solutions that is actually based upon one main point worth emphasizing; patient education delivered by medical students. We believe this solution offers many advantages in a win-win situation; the government, doctors, patients’ quality of life as well as their families,

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including ourselves as medical students and future doctors.

Our research are lacking in some fields, as in we use secondary data from third parties and literature, there are not many of our data which specifically targets Indonesia, since it is difficult to obtain credible data regarding Indonesia. We are open to critic and suggestions in improving future studies.

REFERENCE Barat I., Andreasen F., Damsgaard E. M. S. Drug therapy in the elderly: what doctors believe and patients actually do. British Journal of Clinical Pharmacology. 2001 Jun; 51(6):615622.

Davis E. D.A quality improvement project in diabetes patient education during hospitalization.Journal diabetes, American Diabetes Association. 2000; 13(4):234.

Depkes.go.id. Indonesia : Kementrian kesehatan republik Indonesia; 2012 [updated 21 April 2012; cited 6 February 2013] Available from : http://www.depkes.go.id/index.php/berita/pressrelease/1894-pelatihan-nasional-edukatordiabetes-indonesia.html Depkes.go.id. Indonesia : Kementrian kesehatan republik Indonesia; 2012 [updated 19 September 2012; cited 6 February 2013] Available from : http://www.depkes.go.id/index.php/berita/pressrelease/2053-kemitraan-pemerintah-dan-swastadalam-pengendalian-diabetes-melitus-diindonesia-.html

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Fan L., Sidani S. Effectiveness of diabetes self-management education intervention elements: a meta-analysis. Canadian Journal of Diabetes, 2009;33(1):18-26.

Freeman H., Cox R. D. Type-2 diabetes: a cocktail of genetic discovery. Human Molecular Genetics, 2006; 15(2):202-209.

Kumar V, Cotran R. S., Robbins S. L. Robbins Basic Pathology. 7th ed. Saunders: 2005.

Longo D. L., Fauci A. S., Kasper D. L., Hauser S. L., Jameson J. L., Loscalzo J. Harrisonâ&#x20AC;&#x2122;s Principles of Internal Medicine. 18th ed. McGraw-Hill: 2012.

Osterhoudt K. C., Penning T. M. Drug toxicity and poisoning. In : Goodman & Gillmanâ&#x20AC;&#x2122;s the pharmacological basis of therapeutics. 12th ed. McGraw Hill: 2010.

Spallarossa P., Schiavo M., Rossettin P., Cordone S., Olivotti L., Cordera R., et al.

Sulfonylurea treatment of type 2 diabetes patients does not reduce the vasodilator response to ischemia. Diabetes Care, 2001 Apr; 24(4):738-742.

Suyono S. Diabetes Melitus di Indonesia. In : Buku Ajar Ilmu Penyakit Dalam. 4th ed. Fakultas Kedokteran Universitas Indonesia: 2007.

Wild S., Roglic G., Green A., Sicree R., King H. Global Prevalence of Diabetes. Diabetes Care Journal, 2004 May; 24(5):1047-1053.

Kennedy M. S. N. Pancreatic hormones and antidiabetic drugs.In : Katzung B. G., Masters S. B., Trevor A. J. Basic and clinical pharmacology. 12th ed. McGraw Hill; 2011.

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Invention Of Alzheimer Vaccine (Alzheivacc) As A New Protection For Alzheimer's Disease In Elderly As Best Investment In Community By Using Herpes Simplex Virus Type-1 (Hsv1) Virus-Like Particles (Vlps) As Amyloid-Beta (Aβ)Antibody Inductor: Biomolecular Approach Deddy Dwi Septian, Khrisna Rangga Permana, Yosephine Adisti W

Universitas Brawijaya ABSTRACT Alzheimer's disease (AD) is a neurodegenerative disorder that occurs in the elderly and it is the most common cause of dementia. These diseases have neurological symptoms such as impaired memory, language, cognitive deficits, emotional and behavioral disorders, such as depression, agitation, and progressive psychosis. Alzheimer prevalence increased from year to year and it will be expected to reach 100 millions by 2050 in the world. So that, this disease is one of the major problems that occur at this time. Accumulation of amyloid-beta (Aβ) in the brain plays critical role as a risk factor in AD. But there is no potent protection for AD currently in community.

One prevention which currently developed is AD vaccine. Vaccine that works on Aβ peptide may be an alternative protection. The first developed vaccine shows decrease in Aβ plaques and reduction in neuronal pathology but unfortunately discontinued the study due to meningoencephalitis caused by the response of T-cells. Therefore it is necessary to develope vaccine which induces high antibody titer response mechanism to avoid self-tolerance and induction of T-cell responses that can cause inflammation. So one of the solutions is Virus-like Particles (VLPs) as the carrier to avoid those.

VLP is a structural proteins of the virus which is non-infectious and it can be used as vaccine against virus of the same derivatives. Recent research indicates that the VLPs can induce high titers of antibodies in humans. So, VLPs can be used as an effective vaccine to form strong antibody response.

Herpes Simplex Virus type-1 (HSV1) is an alpha herpes virus. HSV1 VLP can trigger the formation of antibodies against Aβ because it has the ability to directly bind to Aβ. So that, we induce HSV1 VLPs with Aβ peptides to make B-cells creating IgG against Aβ accumulation in human body and it can be used as a vaccine as a new protection for AD. Keywords: Invention, Alzheimer's Disease, Amyloid-beta Accumulation, Vaccine, Herpes Simplex Virus type-1, Virus-like Particles INTRODUCTION Dementia is a neurocognitive disease that many occurs in the elderly. Some risk factors for dementia that causes Alzheimer's disease (AD) are Parkinson's disease, Huntington's disease, etc.. Meanwhile, Alzheimer's disease is the most common cause of dementia. Alzheimer's disease alone is a neurodegenerative disorder that causes memory loss, language, behavioral and emotional changes such as depression, agitation, progessive psychosis. AD prevalence is progressively increased simultanously with its risk factors, age. Predicted demographic is increased in the elderly population and it is expected to reach 100 millions by 2050 in the

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world and it was already 616.100 in Indonesia in 2005. Therefore, this disease is one of major diseases at this time. 1 Besides age, there are several other risk factors such as the accumulation of amyloid (Aβ), tau protein hyperphosphorylation, cholinergic dysfunction, oxidative stress. Most cases occur due to accumulation of Aβ. Aβ itself has fibrilar form which is neurotoxic to be bonded with one of the neuronal protein Amyloid Precursor Protein (APP). This bond later that will contribute greatly to the degeneration of neurons in AD. 2 There are several treatments developed currently for AD. One of them is a vaccine that

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works on amyloid-β peptide and it can be an alternative immunotherapy in the treatment of AD. Originally found that first-generation vaccine, AN AD-1972, has been shown to reduce plaque and to reduce nerve pathology. 3 But the adjuvant in the vaccine induces T-cells resulting in inflammation that causes meningoencephalitis. Therefore, it now takes a new revolutionary alternative vaccines that do not induce T-cell responses but can induce high antibody titers.

VLP or Virus-like Particle is an arrangement of structural proteins of the virus-like viruses where they came from but because it has a bit of the viral genome, VLP is non-infectious.

Because it has similarities with the antigen and authentic virions, VLP can be used as a vaccine against the virus of the same derivatives. So that VLPs can be used as an effective vaccine because they have particular natural and multivalent structures that can provoke strong immune response. So it can form a strong antibody responses. Recent research carried out at the herpes simplex virus and it has been proven in human. The effect of virus vaccine is safe and it can induce high antibody titers in human. 2 HSV1 is the latent virus that has the ability to bind to Aβ directly. The interaction between APP and HSV1 is very significant because HSV1 directly binds to cellular APP and capable of responding B-cells to create IgG against Aβ accumulation. Therefore we have an idea of making a vaccine Alzheivacc as one alternative protection against Alzheimer's disease.

METHODS This scientific paper is based on literature review through biomolecular medicine that describes how the Alzheimer's vaccine that is represented by Herpes Simplex Virus type-1 (HSV1) Virus-like Particles (VLPs), which are supposed to act as the inductor-β antibody amyloid as a mean of protection by inhibiting βamyloid accumulation. Methods of Aβ antibody titers. Antibody titers were measured by conducting ELISA. The amount of Aβspecific antibody was ultimately detected with a horseradish peroxidase-linked second antibody against human IgG. Methods of neuropathology. All brains in this study were

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fixed in formalin and samples for histology were processed to paraffin wax by standard methods after macroscopic examination. Tissue from unimmunized AD cases satisfying CERAD criteria, 10 were drawn from the archives of the neuropathology laboratory.

Data collection methods in this study conducted by the method of literature (literature review) based on issues, both through digital and non-digital information from literature such as journals and medical books. The method of data analysis literature conducted through two approaches, namely: 1. Method of exposition, that the presented data and facts that may ultimately sought correlations between these data.

2. Analytic methods, namely through the analysis of data or information by giving the argument through logical thinking and were then taken to a conclusion.

RESULTS One potential vaccine which currently developed is AN-1792. One of the working mechanism of a vaccine that uses a combination of aggregation peptide antibody with potential adjuvant showed a reduction in cerebral amyloid plaques and improvement of behavioral deficits in experimental animals such as rats APP12. In a phase II clinical trial of human (AN-1792), AD patients immunized with full-length Ab (Ab 142) formulated with Th1 adjuvant QS-21. And of vaccination showed a decrease in Ab plaque pathology and reduction in nerve. 3 In addition, vaccination may slow down cognitive decline, but this effect is still lacking in success of clinical trial. 4 Unfortunately, research on AN 1972 was terminated due to meningoencephalitis in 6% of patients were vaccinated by the AN1792. 5 (Figure 1. Meningoencephalitis) Meningoencephalitis occurs because of the response of T-cells to the AN-1792 and other previous developed vaccines, while the benefits of the vaccine produced antibodies against the resistance caused by the antigen. The role of antibodies supported research on passive vaccinated APP mice using monoclonal antibodies against Aβ. From the study found a reduction in Aβ deposition in the brain. 6 In addition, patients who had been vaccinated AN-

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1792 showed high antibody titer to reduce plaque. 7 And it also can turn into profitable pathological process. (Table 1) Because Aβ is a self antigen in AD, induction of antibody response to Aβ only enables the avoidance response of B-cells to suppress the formation of auto-antibodies. Some groups were observed in vaccinated APP mice showed reduced Aβ antibody titer compared to mice nontransgenik.

From research AN-1792, self-tolerance occurs in Aβ vaccination of high-dose (225 microg) with QS-21 adjuvant is strong. However, only about 20% of the subjects in the AN-1792 is regarded as antibody responders. Thus, self-tolerance may be a risk factor in the AN-1792 vaccine.

In certain circumstances the B-cells to respond and proliferate through a mechanism that does not require T-cells (T-independent).

VLP antigen comprising an epitope on the surface again. Usually the antigen with a long and repetitive epitopes allow crosslinking with immunoglobulin receptors on the cell surface of B-cell.

Early cellular events induced crosslinking complex between antigen-B cell proliferation and differentiation initiated B-cells without activating the mechanism of T-cells (Tindependent). Previous research has shown the use of bacteriophage Qβ VLPs conjugated with Aβ 1-6 peptide representing a success rate of 50% in patients with AD. Things precedence in the selection of virus to be used as VLPs is due to the ability of Aβ association with VLPs alone carrier is unable to create a bond with Aβ. The interaction between APP and HSV-1 is very significant where HSV1 directly binds to the cellular AP where Aβ is a product of the metabolism of amyloid precursor protein, type-1 transmembrane protein. 8 So the making of HSV1 VLPs were conjugated with Aβ peptides capable of responding B cells to create IgG against Aβ accumulation. 9 DISCUSSION Alzheimer's Disease Alzheimer's disease (AD) is a neurodegenerative disorder that occurs in the elderly and is the most common cause of dementia. Most cases of AD occur after the age of 50 years with a progressive increase in incidence with age. Most cases are sporadic, but about 10% of patients, there is a history of

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dementia in family. 10 These diseases have neurological symptoms such as impaired memory, language, cognitive deficits, and behaviour such as emotional disturbances, depression, agitation, psychosis and these become increasingly severe. 11 The cause of AD is not fully known, but there are several risk factors for AD such as genetic factors, accumulation of amyloid, tau protein hyperphosphorylation, cholinergic dysfunction, oxidative stress, inflammation and dysfunction of synapses.

Increased oxidative stress seen in AD patients. Exposure to oxidative stress induced accumulation of reactive oxygen species (ROS) that cause damage to proteins, lipids and DNA oxidation in cells. Increased ROS also led to increased accumulation of β-amyloid and the formation of senile plaques in AD. ROS will also lead to oxidative stress and is responsible for neuronal cell death. 12 In AD autosomal mutation a protein known as the amyloid precursor protein (APP), presenilin 1 and presenilin 2, which causes the early onset of AD.Intracellular abnormalities and autonomic dominant mutation that causes the death of neurons in AD and the buildup of amyloid.13 In addition, one sign of lesions in AD is tau protein hyperphosphorylated. Tau protein has been largely studied as a barrier to forming a bonded structural and stabilizing microtubules and it is an important component of the neuronal cytoskeleton. In the neurons, microtubules form a structure that carries nutrients and other molecules from the cell body toward the end of the axon, forming bridges with other neurons. In AD neurons, there was an abnormal phosphorylation of tau protein, a chemical that causes a change in tau bound to microtubules can not be together. Spiral abnormal tau filaments into a double helix around each one was injured. With the collapse of the system of internal transport, intracellular relationship is the first time did not work, and finally followed by the death of cell. 10 Chemical changes in the central nervous system (cholinergic dysfunction) are also found in AD. The cortex of the human brain consists of a large number of cholinergic axons that release acetylcholine, a key neurotransmitter in

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cognitive function. Most cholinergic axons inhabit so much cortex and hippocampal cholinergic neurons which are damaged in degenerative changes that occur in AD. In neurochemistry, abnormalities in the brains of AD patients that occur earliest and most common is the depletion of cholinergic markers (eg, colinacetyltransferase). 10 Amyloid-beta (Aβ) Amyloid-beta buildup in the brain is a hallmark of AD. Notching fibrilar on Aβ is neurotoxic although the mechanism is not yet fully known. Conversion of fibrilar leads to increased bond formation with specific proteins on neuronal membranes, including the amyloid precursor protein (APP). Aβ-APP interactions contribute in the degeneration of neurons in AD. 8

Aβ is a product of the metabolism of amyloid precursor. Autosomal dominant AD caused by genetic mutations of APP or presenilin. Such mutations lead to changes in the process of making the production of Aβ APP or a 42-amino acid to form Aβ increases. While Aβ itself has properties require aggregation of Aβ neurotoxicity neurotoxic and peptide which is characterized by increased amyloid fibrils similar to mature amyloid plaques. 8 In vivo, it is also mediated by neurotoxic Aβ peptide formation fibrilar with some pathological characteristics of AD. Neurotoxic mechanisms of Aβ is not known, but some say the alleged influence of the increase of free radicals. As for other potential mechanisms of the interaction that Aβ activates receptors on the surface of the groove. This mechanism is also associated with the induction of phosphorylation of Aβ and tau protein phosphorylation of adhesion kinase. 8 The relationship between neurotoxic Aβ and normal biological function is not known.

However, the structure of APP (Amyloid precursor protein) may has function as receptors on the cell surface. APP can mediate cell adhesion and stimulates the development of neurit through interactions with extracellular proteins. Additionally secretions released by the APP itself can stimulate cell proliferation and function as neuroprotective against various toxic as oxidative stress, glucose deficiency and eksotositosis. But so far, it is not known for

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certain whether APP is involved in the mechanism of neuronal degeneration in ADterlepas from its role as a precursor of Aβ. 8 Formation of toxic Aβ fibrilar binding to membrane proteins including APP neurons with high affinity. Aβ interacts with holo-APP to a lesser extent with the secretions that are part of the soluble Aβ APP. Neurotoxicity significantly reduced in cortical culture in APP mice. In addition, the cortical culture was also found that the APP can modulate Aβ toxicity. Thus the interaction of Aβ with the normal cellular precursors that can lead to nerve degeneration through a mechanism of pathogenic prion.8 Virus Like Particle (VLP) Several protein structures have an intrinsic ability to become virus-like particles (VLPs).

The structure of the VLP resemble the virus from which they were derived but because it has a bit of the viral genome, VLP is non-infectious.

Because it has similarities with the antigen and authentic virions, VLPs can be used as a vaccine against the virus of the same derivatives. VLPbased vaccines are used to prevent infection. 11 Hepatitis B virus and human papilloma virus that has been proven in humans. The effect on both virus vaccine is safe and these can induce high antibody titers in human. 14 VLP-based vaccine developed clinical and preclinical as imunoprophylactic against the infectious virus to human. 15 VLPs can create an effective vaccine because they have particular natural and multivalent structures that can provoke an strong immune response. Particular structure is crucial to improve the interaction with B-cells that can form a strong antibody response.

Virus Like Particles (VLPs) Induce Antibody Formation Antibody production is initiated by the interaction between antigen and B-cell receptor (BCR) on the surface of a naive B-cells.

Response speed of B-cells to antigen stimulation is determined by the density of the antigen, thus also affecting the speed of antibody response.

Antigen having multivalent structures such as VLPs can activate B-cells and induce antibody responses at lower concentrations than the monomeric antigen and without the need for exogenous adjuvant. 7 Antigen consisting of repeated epitopes on the surface at a distance 5-10 nm in most viruses

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can induce B-cell responses optimally.

7 Multivalent antigen can provoke high BCR for the formation of stable lipid mikrodomain that can affect an increase in the signal to B-cell.

These signals stimulate the proliferation and differentiation of B-cells. This is because the antigens with repetitive epitopes allow crosslinking with immunoglobulin receptors on the cell surface induced premature B-cellular.

This complex crosslinks between antigen-B cell proliferation and differentiation of cells initiate B to further interact with Th cells. 7 Herpes Simplex Virus associated with APP Herpes Simplex Virus type-1 (HSV1) is an alpha herpes virus is endemic in a population.

The virus causes latent infection in neurons lifetime. As with other viruses that, through assembly of the HSV nucleocapsid core transported out through the cytoplasm to the surface of epithelial cells in both sexual and neuron. 17 Meanwhile, anterograde transport synthesis of the new virus on the cell surface of epithelial and neuronal cell bodies to the mucous membrane of the virus is essential for propagated virus to a new host in both the cellular and molecular mediators of virus.

Coordinating assembly in epithelial cells and neurons as well as various types of alpha herpes virus may be different and still be a controversy.

Recent evidence suggests that swine alpha herpes virus, pseudorabies virus (PRV) in the vesicle membrane transport on neuron. 18 It is a mechanism that will induce anterograde transport epithelial cells HSV1. 19 HSV1 capsid new synthesis walks alone out of the nucleus to be assembled with other components in the cell.

20 Electronmicroscopy from infected cells showed that the capsid-free in the cytoplasm as well as membrane systems that are at intracellular. 19 To coordinate wrapping mechanism (envelopment) with transport, the virus must take advantage of the cellular synthesis and transport machinery.

Backup transport machinery may underlie the pathology of HSV-1 provider, injure cells by interfering with normal cellular processes. Use of Green Fluorescent Protein (GFP) in HSV1 as a tool to reveal the cargo receptor motors are used to find the provider and the APP transmembrane glycoprotein that is a component of intracellular

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HSV1 virus particles. Changes in APP is a risk factor for the disease Alzheime. But APP interaction HSV1 has significant potential in the prevention of Alzheimer's disease. 20 The role of Aβ in the cell due to degenerative oxidative stress Aβ 1-40 is the major Aβ species and quite late, while Ab 1-42 (and 1-43 Ab) is a small species, less soluble and easily aggregate into fibrils, as exhibited in amyloid plaques. As it has been shown by several groups that the various regions of Aβ peptides have certain characteristics that may be important in explaining the mechanism of toxicity in vitro. In APP molecule, residues 1-28 of Aβ region is often referred to as the N-terminus and the 36-42 hydrophobic residues are often referred to as Aβ C-terminus. Residues 1-28 are in the extracellular domain, outside the cell membrane, whereas residues 29-43 are anchored in the lipid membrane. Hydrophobic region of Aβ peptide folding directs a beta-sheet forming lipids, thereby inducing fibrillation and aggregation of the peptide. Research shows that the more toxic Aβ fibriler of the monomer, and together with the fact that Ab longer before the onset of AD in patients carrying APP have been found to support the production of Aβ peptides again.

Hydrophobic regions of the peptide has also been shown to have properties that can do fusogenic destabilizing cellular membranes.

Various studies have provided strong evidence that Aβ plays an important role in the development and progression of AD. Study of embryonic neurons were incubated with primary Ab has shown that peptides can produce neurotoxic. Several studies have shown that Aβ causes neurotoxicity by inducing the production of free radicals. Further studies then showed that Aβ caused H2O2 accumulation in hippocampal neurons. It has also been shown that Aβ induces lipid peroxidation and that Aβ may lead to excess production of superoxide radicals by interaction with vascular endothelial cells. This process can lead to the production of harmful hydroxyl radicals through Fenton reaction.

Hydroxyl radicals are highly reactive molecules that can damage any nearby.

(Figure 2. The mechanism of free radical formation by Aβ) VLPs as antibody inductor

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Antibody production is initiated by the interaction between antigen and B-cell receptor (BCR) on the surface of a naive B-cells.

Response speed of B-cells to antigen stimulation is determined by the density of the antigen, thus also affecting the speed of antibody response.

Multivalent antigen that has a structure composed of repetitive epitopes such as VLPs can activate B cells and induce antibody responses at lower concentrations than the monomeric antigen and without the need for exogenous adjuvant. 16 Antigen consisting of repeated epitopes on the surface at a distance 5-10 nm in most viruses can induce B cell responses in optimal. 16 Multivalent antigen can provoke high BCR for the formation of stable lipid mikrodomain that can affect an increase in the signal to B-cell.

These signals stimulate the proliferation and differentiation of B-cells. This is because the antigen with a lengthy and repetitive epitopes allow crosslinking with immunoglobulin receptors on the cell surface induced premature B-cell. This complex crosslinks between antigen-initiated cell proliferation and differentiation of B cells without activating the mechanism of T-cell (T independent ). 16 The difference in antibody formation through the activation of T-cells (T-dependent) that can cause inflammation and mechanisms of VLP as an inductor antibody that is not through the mechanism of T-cell activation can be explained in figure 3 and figure 4 below.

(Figure 3. Formation of Antibody via Tdependent mechanism) B-cells can be activated in 2 ways namely the T-dependent and T-independent. On Tdependent antigen after bound with mIg, B-cells eat antigen, process and express MHC epitopes in the gap and presented to T-cells. T-cells modulate B-cell function through cytokines that will promote the proliferation of B-cells and differentiate into plasma cells, which then become antibody. But instead of stimulating the proliferation of B-cells, T-cells can also activate macrophages and inflammatory mediators.

Inflammation in the brain is very dangerous and lead to meningoencephalitis.

(Figure 4. Antibody Formation Through Tindependent mechanisms such as VLPs)

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In certain circumstances the B cells to respond and proliferate through a mechanism that does not require T-cells (Tindependent).VLP antigen comprising an epitope on the surface again. Usually the antigen with a long and repetitive epitopes allow crosslinking with immunoglobulin receptors on the cell surface of B. Early cellular events induced crosslinking complex between antigenB cell proliferation and differentiation initiated B-cells without activating the mechanism of Tcells (T-independent). It can prevents inflammation which lead to meningoencephalitis.

HSV1 VLPs triggers the formation of antibodies against amyloid-β Previous research has shown the use of bacteriophage Qβ VLPs conjugated with Aβ 1-6 peptide representing a success rate of 50% in patients with AD. Things precedence in the selection of virus to be used as VLPs is due to the ability of Aβ association with VLPs alone carrier is unable to create a bond with Aβ. The interaction between APP and HSV1 is very significant where HSV1 directly binds to the cellular AP where Aβ is a product of the metabolism of amyloid precursor protein, type-1 transmembrane protein. 8 So the making of HSV1 VLPs were conjugated with Aβ peptides capable of responding B cells to create IgG against Aβ accumulation. 5 CONCLUSION 1. Formation of amyloid-beta (Aβ) is the cause of most of the risk factors for AD. The mechanism of accumulation of Aβ due to the conversion of the establishment which is neurotoxic Aβ fibrilar causing neurotoxicity by inducing the production of free radicals in hippocampal neurons.Conversion bind to specific proteins on the neuronal membrane, the amyloid precursor protein (APP). AβAPP interactions contribute in neuronal cell degeneration in AD. 2. Several protein structures have an intrinsic ability to become Viral-like Particles (VLPs).

VLPs resemble the virus from which they originate but have little viral genome, so VLP is non-infectious. Because it has similarities with the antigen and authentic virions, VLPs can be used as a vaccine against the virus of

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the same derivatives. The working mechanism of the VLP is to activate B-cells and to induce antibody responses at lower concentrations than the monomeric antigen and without the need for exogenous adjuvant.

3. HSV1 VLPs can trigger the formation of antibodies against Aβ because it has the ability to bind to Aβ directly. The interaction between APP and HSV1 is very significant because HSV1 directly binds to cellular APP. HSV1 VLPs conjugated with Aβ peptides are capable of responding B-cells to create IgG against Aβ accumulation.

REFERENCES 1. Alzheimer Association. Prevalence of Alzheimer Diseases and other Dementias. In: Alzheimer Association (eds.) Alzheimer's Facts and Figures. 8th ed. United States of America: Alzheimer Association. 2012. p1416.

2. Poovorawan Y, Chongsrisawat V, Theamboonlers A, Bock H, Leyssen M, Jacquet JM.(et al.). Persistence of antibodies and immune memory to hepatitis B vaccine 20 years after infant vaccination in Thailand.

2010. p730-736.

3.

Satpute-Krishnan P, De Giorgis.

Fastanterograde transport tof herpes simplex virus: role for the amyloid precursor protein of alzheimer’s disease. 2003. V2 : p305–318.

4. Willard M. Rapid directional translocations in virus replication. 2002. p5220–5232.

5. Snyder A, Polcicova K. Herpes simplex virus IgE/IgI and US 9 proteins promote transport of both capsids and virionglyco proteins in neuronal axons. 2008. (l82):10613–10624.

6. Dodart J, Bales K, Gannon K, Greene S, DeMattos R, Mathis C. (et al.). Immunization reverses memory deficits without reducing brain Abeta burden in Alzheimer’s disease model. 2002. p452-427.

7. Geldmacher D. Differential diagnosis of Alzheimer’s disease. Neurology.

1997 (48):31-35.

8. Alfredo. Amyloid β interacts with the amyloidprecursor protein: a potential toxic mechanism in Alzheimer’s disease .2000 Vol 3 no V: 460.

9. Smith M, Casadesus,G, Joseph. Amyloid-beta and tau serve antioxidant functions in the

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aging and Alzheimer brain. 2002; (33):1194– 1199.

10. Karran E, Mercken M..The amyloid cascade hypothesis for Alzheimer’s disease: an appraisal for the development of therapeutics. 2011; (10):698–712.

11. Brookmeyer R, Johnson E, Zigler.

Forecasting the global burden of Alzheimer’s disease. 2007; (3):186-191.

12. Mettenleiter T .Herpes virus assembly an degress. 2007; (76): 1537–1547.

13. Jegerlehner A, Storni T, Lipowsky G, Schmid M, Pumpens P, Bachmann M (et al.). Regulation of IgG anti-body responses by epitope density and CD21-mediated costimulation. 2002; (32):3305-3314.

14. Nelson V, Dancik C. PAN-811 inhibits oxidativestress-induced cell death of human Alzheimer’sdisease-derived and age-matched olfactory neuroepithelial cells via suppression of intracellularreactive oxygen species. 2009; (17): 611-619.

15. Poovorawan Y, Chongsrisawat V, Theamboonlers A, Bock H, Leyssen M, Jacquet JM.(et al.). Persistence of antibodies and immune memory to hepatitis B vaccine 20 years after infant vaccination in Thailand.

2010; (28):730-736.

16. Janus C, Pearson J, McLaurin J, Mathews P, Jiang Y, Schmidt SD. (et al.). A beta peptide immunization reduces behavioural impairment and plaques in a model of Alzheimer’s disease. 2000; (408):1-6.

17. Von B. R. Glial cell dysregulation: a new perspective on Alzhemier disease. 2007; (12): 215-232.

18. Loret S, Guay G. Comprehensive characterization of extracellular herpes simplex virus type 1 virions. 2008; (82):8605–8618.

19. Masliah E, Hansen L, Adame A, Crews L, Bard F, Lee C.(et al.). Abeta vaccination effects on plaque pathology in the absence of encephalitis in Alzheimer disease. 2009; (64):129-131.

20. Kumar V. (et al). Buku Ajar Patologi. 7th ed, Vol. 1. Jakarta: Penerbit Buku Kedokteran EGC, 2007: 189-1.

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THE MOISTURIZER ROLE IN SKIN BARRIER FUNCTION OF ATOPIC DERMATITIS IN ELDERLY PATIENTS M. Evandiar Izwardy, Ivonne Sonia Phidrian Faculty of Medicine Tarumanagara University ABSTRACT Though atopic dermatitis (AD) is relatively uncommon in the elderly, elderly patients with AD are graduallyincreasing in industrialized countries associated with an aging society. Therefore, the clinical features of senile AD arebecoming more apparent in some aspects. Three patterns of onset—senile onset, recurrence of AD with a history ofclassic childhood AD, and recurrence or continuation of adult AD—are associated with AD in the elderly. A malepredominance in elderly AD may be a characteristic feature that differs from adult AD. Localized lichenifications in thefolds of elbows and knees that are typical of classic AD are uncommon. One might expect that a patients impaired skin barrier function should improve in association with a reduction in the clinical signs of dermatitis. despite visible relief of the dryness symptoms, however, the abnormal transepidermal water loss has been reported to remain high, or even to increase under certain regimens, wheares other moisturizer improve skin barrier function. Moisturizer with barrier-improving propertise may delay relapse of dermatitis patients with atopic dermatitis.

Keywords : senile AD, moisturizer, barrier function Introduction Elderly people in last two years have increased significantly in 2007, the number of elderly people at 18.96 million and increased to 20,547,541 in 2009 (U.S. Census Bureau, International Database, 2009)1. Indonesia as a developing country is expected to experience a boom of the number of elderly people in 20101.

Predicted results showed that the percentage of the elderly population will reach 9.77 percent of the total population in 2010 and to 11.34 percent in 20201. Several studies describe how almost one-half of persons over 65 years of age have at least one dermatologic disease requiring medical attention. About one-third of elderly people have more than one skin problem2.

Multiple skin conditions are characteristic of the very old, and the common ones are different from those affecting the young. Atopic dermatitis (AD) is an acute, sub-acute, or chronic relapsing skin disorder that usually begins in infancy and characterized principally by dry skin and pruritus consequent rubbing and scratching lead to lichenification and hence to be further itching and scratching (itch-scratch cycle)2,3. Increase in the incidence of childhood AD from the 1980s, cases

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in which clinical manifestations persisted or first appeared during adolescence, and adulthood had increased in industrialized countries, known as an adult AD2,3. It had a significant impact on the quality-of-life of patients and influenced public health policies worldwide. The prevalence of AD has increased two to be three-fold during past few decades in industrialized countries, including Indonesia2,3,4. The characteristic symptoms of AD are chronic course of the disorder, dry skin, itching and age-specific morphology and distribution of skin lesions. Elderly patients with AD are gradually increasing industrialized countries associated with an aging society, therefore clinical features of senile AD are becoming more apparent in some aspects4.

Many authors agree that the overall lipid and collagen content of human skin decreases with age5. The lipids contribute to the skin’s function as an effective water barrier are having alteration in older people. The changes in the stratum corneum have been linked to skin conditions, such as xerosis5. A defective skin barrier function drives disease activity in inflammatory dermatose , with possible negative consequences for senile dermatitis5. There are some clinical reviews that

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stated the epidermal abnormality is not merely a secondary phenomenon resulting from the infiltration of abnormal immune and inflammatory cells and their mediators, but rather a critical, if not the primary, exacerbate of this inflammatory skin disease5,6.

The aging process within a population gives effects on various aspects of life such as social, economic, and especially health. Older people, in addition to their health needs, should also be offered treatments for the aging skin to promote their self-confidence, offer greater acceptance by society, and reinforce their treatment expectations7. The composition of the moisturizer determines whether treatment strengthens or

deteriorates since the skin barrier function, which may have consequences for the outcome of the dermatitis8. Mild cases of atopic dermatitis are often controlled with a moisturizer alone, which prevents the potential side effect of topical medication. A daily moisturizing routine is a vital part of the management of patients with atopic dermatitis8. Little is known about Dermatitis Atopic in elderly people since it still rarely discussed in Indonesia. Therefore, author is quiet interested to discussed it in this paper. This review focuses upon the role of moisturizer in the skin barrier function of atopic dermatitis in the elderly8.

Epidemiology Because there is no precise clinical definition of AD, epidemiologic studies must be carefully interpreted as they can be plagued by problems of bias ascertainment2,3. Despite these limitations, several well-designed studies suggest that there has been at least a two- to threefold increase in the prevalence of AD during the past three decades2,3. Dermatitis is a common skin disorder among elderly people. It can be classified into several types according to the etiology, such as AD, contact dermatitis, seborrheic dermatitis and asteatotic dermatitis. However, the incidence of AD in elderly patients is markedly lower than other forms of dermatitis. The estimated incidence of dermatitis in the elderly (age 65 years and over) in our geriatric hospital in Tokyo, Japan, in the past 10 years was as follows: AD 0.39%, contact dermatitis (both allergic and irritant types) 20%, seborrheic dermatitis 20% and asteatotic dermatitis 33% 9,10. The prevalence of AD in the senile phase, which was reported as the point and/or 1-year prevalence, were 0.6% in Mexico (age 60 years and over) and 2.6% in Japan (age 60 years and over)11,12. The prevalence of AD in the elderly was lower than those in children and young adults: 10.1% in Mexico (age 6-10 years) and 11.2% and 9.8% in the age groups 6-12 years and the twentieth decade in Japan, respectively. A recent research

from Germany has reported a lifetime prevalence of AD of 4.3% in the elderly population (mean age 62 years, range 50-74 years)11,12,13 . A gender difference in the prevalence of senile AD is uncertain; however, a male predominance was found in studies from Japan and Australia11 . In our clinical study over a 9-year period, the male: female ratio of senile AD was 3:1. In contrast, several studies of adult AD have indicated that the prevalence in women is higher than that of men, especially in young adults. Thus, a male predominance in senile AD may be a characteristic that differs from adult AD. In a study from Turkey, it was reported that cases of AD with an onset after puberty (so-called adultonset AD) involved 73% of young adults (age 18-29 years) and 1.6% elderly patients (age in their 70s). In patients with a history of childhood AD, the recurrence rate of AD in the senile phase is still unknown11,12. In a study from Sweden, AD persisted in 59 to 68% of patients who had a history of AD as young adults; this was noted after 25 to 41 years of follow-up11,12.

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Table 1. Systemic Immune Abnormalities in Atopic Dermatitis

Etiology and Patofisiology Complex interactions among genetic, environmental, skin barrier, pharmacologic, and immunologic factors contribute to the pathogenesis of AD1,2. The development of new techniques in the study of naturally occurring and experimentally induced skin lesions has provided valuable new insights into the pathogenesis of AD13,14. The concept that AD has an immunological basis is supported by the observation that patients with primary T cell immunodeficiency disorders frequently have elevated serum IgE levels and eczematoid skin lesions indistinguishable from AD1,2. In patients with Wiskott-Aldrich syndrome, clearing of the skin rash occurs following correction of their immunological defect by successful bone marrow transplantation2,3. These data suggest that AD is not caused by a constitutive skin defect but is mediated by a bone marrow derived cell. Most patients with AD have peripheral blood eosinophilia and increased serum IgE level2,3.

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One of the most important clinical features of AD is coetaneous hyperactivity to environmental allergens and irritants that are innocuous to normal individuals2,3. Recently, two distinct subtypes of AD have been delineated based on this hyperactivity: an “extrinsic” form associated with IgE mediated sensitization to environmental allergens and an “intrinsic” form without detectable IgE-mediated sensitization2,3. This classification is also relevant in asthma and allergic rhinitis . Recent studies have indicated that the frequency of extrinsic and intrinsic AD is 70-80% and 20-30%, respectively, depending upon the country and defining criteria . A German study showed that the proportion of intrinsic AD in adult AD was 5.4% 11,12. Similar to other age groups, both extrinsic and intrinsic forms of AD exist in senile AD. In our study, the frequency of intrinsic AD in senile AD was 6.25 % (one out of 16 patients). If the “mixed” type of AD associated with intrinsic asthma (and/or rhinitis) is considered, contrary to the “pure” type of intrinsic AD without associated respiratory diseases, the frequency was 12.5% (two out of 16 patients)11,12.

Manifestations The characteristics of skin manifestations seen in senile AD are basically similar to those in adult AD, if the diagnosis of AD is based upon standardized diagnostic criteria11,12.Chronic eczematous dermatitis on the face and neck, lichenified/exudative lesions over the trunk and lichenification with or without pruriginous papules and nodules on the extremities are observed. Other stigmas of AD such as facial erythema and pallor, Hertoghe’s sign (loss of the

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lateral eyebrows), dirty neck and follicular lichenified papules may also be observed in senile AD11,12. Because of these variable features, skin manifestations tend to be diagnosed provisionally as unclassified eczematous dermatitis and/or erythrodermic eczematous rash11,12. Patients have a dry skin.(kaya kalimat belum selesai van, ga ngerti maksudnya apa hehe) Pruritus is the sine qua non of atopic dermatitis—"eczema is the itch that rashes." The constant scratching leads to a vicious cycle of itch- scratch –rash- itch2,3. A feature of senile AD that might distinguish it from adult AD is the involvement of the folds of elbows and knees.

Localized lichenification in the antecubital and popliteal fossae are typical signs of classic childhood AD and adolescent/young adult AD (Fig. 1a), but uncommon in senile AD. In our study of 16 patients with senile AD, this sign was observed only in one patient (6.25%)11,12. On the contrary, eczematous dermatitis surrounding the fossae was seen frequently in patients with senile AD (Fig. 1b)11,12. These findings in the antecubital and popliteal areas were observed in 12 patients (75%) and 10 patients (62.5%), respectively11,12. The reverse sign may be typical in senile AD, but are observed in classic childhood AD and adult AD as atypical features11,12 .

Fig (1b)The classic sign of localized lichenification in the elbowfold of a young adult with AD.

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Fig (2b) The reverse sign of lichenification around the elbow foldin a patient with senile AD

General Remarks inThe Pathogenesis of Atopic Dermatitis on Its Relation to Senile Atopic In general, AD is the result of a complex interaction of susceptibility genes, the host environment, epithelial barrier dysfunction and a deregulated immunologic response11,12 . This concept is applicable to senile AD but the authors just explain more about the epithelial barrier dysfunction11,12.

Susceptibility Genes Many different candidate genes have been identified, which are theoretically associated with the etiology of AD: a clustered family of T helper (Th) 2 cytokines including interleukin (IL)-4 and IL-13 genes on chromosome 5q31-33, serine protease inhibitor Kazal type 5 (SPINK5) gene on chromosome 5q31, IL-4 receptor gene on chromosome 16p12.1-11.2, mast cell chymase gene on chromosome 14q11.2, and filaggrin gene on chromosome 1q21 . Especially, the gene mutation of filaggrin—a protein with a key role in epidermal barrier functions by retaining water and increasing flexibility of the cornified layer— is now consider to be the most widely reproducible genetic risk for AD and other forms of dermatitis2,3,11,12. Decreased expression of filaggrin has been observed both in AD lesional skin and unaffected atopic dry skin. However, these geneticallyanalyses have not been performed in elderly patients with AD2,3,11,12.

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The Host Environment Environmental exposures to allergens (e.g. house dust mite, pollens, molds and foods), irritants (e.g. inappropriate clothing, sweat) and pathogens (e.g. Staphylococcus aureus) have been implicated in the pathogenesis of AD. For instance, Dermatophagoides species of house dust mites have been found at the tenfold concentration in the homes of atopic individuals when compared to those of controls. Avoidance and removal of mite allergens have been shown to improve AD symptoms11,12. In senile AD, a decrease in the activities of daily living (ADL) especially in those 75 years and over may develop a higher risk of environmental exposure to allergens, irritants and pathogens. Longevity might also increase the risk of sensitization to environmental allergens among older people11,12.

Epithelial Barrier Dysfunction Epithelial barrier defects, not only in the skin but also in the digestive canal, are involved in the pathogenesis of AD. The immature function of the digestive canal could predispose atopic infants to IgE reactivity directed against various foods, especially egg, milk, soy and wheat. Food allergens induce skin rashes in nearly 40% of children with moderate to severe AD. However, most patients outgrow a food allergies after the age of 3, as the result of immune tolerance caused by the maturation of the epithelial barrier function of the digestive canal15,16. Dry skin conditions are common in infants and children as a part of normal skin physiology before puberty, although a genetic predisposition (e.g. filaggrin) seems to influence severe disease15,16. Barrier impairment in dry skin conditions that allows the entry of allergens, irritants and pathogens, is thought to be a major contributor in the development of infantile and childhood AD. AD patients generally have relatively dry skin in both lesion and non-lesion area, with a complex mechanism and is closely related to damaging to the skin barrier15,16. Loss of ceramide in the skin, which serves as the main water-binding molecules in the extracellular space stratum corneum, is considered as a cause of skin barrier dysfunction15,16. Variations in pH of the skin can cause abnormal lipid metabolism in the skin.

Abnormalities of the skin barrier function has resulted the increased of transepidermal water loss (TEWL) 2-5 times normal, the skin will be

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drier and a port of entry for the penetration d'allergens, irritants, bacteria and viruses.

Bacteria in atopic dermatitis patients secrete ceramidase causes ceramide into sphingosine metabolism and fatty acids, in turn further reducing ceramide in the stratum corneum, thus causing more dry skin17. In addition, external factor (exogenous) that can aggravate dry skin is hot temperatures, high humidity, and excessive sweating. Impaired skin barrier increases the itching, scratching occurs repeatedly (cycle of itch-scratch-itch) that cause damage to the skin barrier. Thus, the penetration of allergens, irritants, and infection becomes easier17. In the elderly group, a decline in the epidermal layer of the skin physiologically predisposes additional atopic dermatitis17.

Aging-Related Changes in the Epidermis Dryness and roughness on the skin are two of the most readily appreciated changes that occur with aging. This could be due to either a decrease in the moisture content of the stratum corneum or a decrease in vertical height and increase in overall surface area of epidermal cells. The increased dryness results in a surface likened to â&#x20AC;&#x153;shingles on an old roof18.

One of the histological changes that occur most consistently in the elderly is the flattening of the dermoepidermal interface and effacement of the dermal papillae. This reduces the total area of dermoepidermal junction per area of external body surface area. This change predisposes older persons to blister formation and shear-type injuries and easy abrasions. Another observation is an aging-associated decrease of about 50% in the epidermal turnover rates between the third and seventh decades of life. This means fewer radical cells are replaced, and it takes longer for a basal cell to reach the stratum corneum and be exfoliated.18

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Barrier recovery to determine whether the measurements of TEWL under basal conditions masked an underlying abnormality in barrier function, we next compared the rate of barrier recovery in aged versus young humans and hairless mice18. After comparable insults (TEWL 20-30 g/m2 per h) the epidermis of aged and young each displays a barely detectable shiny appearance, with no obvious damage to the epidermis18.

This change is no longer visible in either young or old in subsequent time points. Despite subnormal TEWL rates under basal conditions, barrier recovery after comparable insults was much slower in aged than in young humans, regardless of the mode of barrier insult, i.e., acetone treatment or tape stripping. For example, whereas the aged human18.

Possible causes of a reduced TEWL could include decreased sweating, decreased microcirculation resulting in decreased integumental moisture content, decreased skin temperature, or increased corneocyte cell surface area18,19. Although neither decreased sweating , decreased microvasculature, nor decreased skin surface temperature can account for the decreased TEWL in aged epidermis. A combination of these factors could be operative.

In contrast, it has been long known that aged epidermis is abnormally permeable to a variety of drugs in vitro systems18,19. Thus, it seems likely to us that the seemingly normal and even

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subnormal levels of TEWL displayed by intrinsically aged epidermis might covers an underlying lack of functional reserve. The functional, structural, and lipid biochemical studies shed light on this apparent paradox. When the epidermal permeability barrier is subjected to stress, i.e., barrier abrogation, marked differences in the function of intrinsically aged versus young stratum corneum appear18,19.

Prevention of Dermatitis in Atopics and Hand Dermatitis In the treatment of atopic dermatitis, moisturizers are considered to offer a streroidsparing alternative to topical corticosteroids. In children with atopic dermatitis, the addition of a moisturizer reduced the need for corticosteroids to control disease severity. The addition of a moisturizer and mild cleanser to corticosteroid therapy also enhanced the degree of clearance of the dermatitis20,21.

Repairing the barrier or preventing the barrier dysfunction are important strategies for reducing the risks in dermatitis and prolonging the time to relapse of dermatitis. To my knowledge, however, only one published clinical study has investigated the delay in dermatitis relapse after treatment with moisturizer in patients with atopic dermatitis, furthermore, only one study appears to exist where the relapse of hand dermatitis has been monitored during treatment with and without moisturizers20,21.

In the atopic study, a strong corticosteroid cream was used to first cleared the dermatitis before patients were randomized to treatment with urea-containing cream, or no treatment for the maximum period of 26 weeks. The result showed the medium number of dermatitis-free days was than 26 weeks in the cream group and 4 weeks in a control group. The probability of not having a relapse during the 26-weeks period was 68% in the moisturizer group and 32% for those not using moisturizer, which resulted in a 53% relative risk reduction and 36% absolute risk reduction20,21.

In the hand dermatitis study, the time to dermatitis relapse was prolonged in the patients who used the urea-containing cream. The median time to relapse showed a 10-fold difference between the urea moisturizer (20 days) and no treatment (2 days). The shorter time to relapse in the hand dermatitis patients compared with the

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atopic patients was likely due to higher vulnerability of hands, which are frequently exposed to external stressors20,21.

The result from barrier-strengthening urea cream study could be compared with results from similar studies focusing on long-term disease control using anti-inflammatory agents20,21.

Although these studies have slightly different designs, the results suggest that a barrierstrengthening moisturizer may prevent relapse of dermatitis to a comparable extent as intermittent treatment with anti-inflammatory medicinals on controlled atopic dermatitis20,21. the close similarity in relapse rate between the barrierstrengthening cream with 5% urea and the reported anti-inflammatory treatments suggests that the use of barrier-improving treatments is effective in the prevention of dermatitis20,21.

Whether a similar delay in the flare-up of dermatitis would be seen with a moisturizer without barrier-improving properties has yet to be studied. Notably, the time to dermatitis relapse in the reported vehicle groups are compatible with the hypothesis that certain moisturizers actually promote the development of dermatitis20,21. in on eof the cited studies, the relapse of dermatitis was induced within 10 days in most of of the patients, despite the use of bland emollients to control the dermatitis. The author also noted that some patients appeared to have derived benefit from treatment with certain emollients because no relapse was noted20,21.

Conclusions As we know elder people in Indonesia will be booming because the developing program of economics and health is getting beter. it can be estimated that AD will increase in the elderly population. Therefore, AD should be divided into 4 phases: infantile, childhood, adolescent/adult, and senile phases, based on the period of life and the age-specific characteristics of this inflammatory and allergic skin disease. AD is very disturbing for elder people that creates uncomfortable condition. Moisturizer affect the SC architecture and barrier homeostasis, that is, topically applied ingredient are not as inert to the skin as one might expect. Whether moisturizers strengthen or weaken the skin barrier function is easily monitored. Measurement of TEWL may be a proper surrogate parameter for the prevention

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or promotion of the outbreak of flares by moisturizer treatment in dermatitis.

References 1. menegpp.go.id/V2/index.php/datadaninformas i/kependudukan?...

2. Leung Donald Y.M, Eichenfield L.F, Boguniewicz M. Atopic dermatitis(atopic eczema). In: Wolff K, Goldsmith L.A, Katz S.I, Gilchrest B.A, Paller A.S, Leffell D.J, editors. Fitzpatrickâ&#x20AC;&#x2122;s dermatology in general medicine 6th ed. New York: McGraw-Hill, 2003: 1180-93 3. Zulkarnain I, 2009. Manifestasi Klinis dan Diagnosis Dermatitis Atopik. dalam Boediarja S.A., Sugito T.L, Indriatmi W, Devita M, Prihanti S, (Ed). Dermatitis Atopik.

Balai Penerbit FK UI. Jakarta. Hal.21-38 4. Zutavern A, Hirsch T, Leupold W,Weiland S, Keil U, von Mutius E. Atopic dermatitis, extrinsic atopic dermatitis andthe hygiene hypothesis: results from a cross-sectional study. Clin Exp Allergy 2005;35:1301-8.

5. Rogers J, Harding C. Mayo S, Banks J, Rawlings A. Stratum Corneum lipids:the effects of ageing and the seasons. Arch Dermatol Res 1996;228;765-70 6. Saint Leger D, Francois AM, Leveque JL, de Rigal J, Mortimer PS. Age-associated changes in the stratum corneum lipids and their relation to dryness.Dermatologica 1988;177;159-64 7. Buraczewska L, Berne B, Lindberg M, Torma H, Loden M. Changes in skin barrier function following long-term treatment with moisturizers, a randomized controlled trial. Br J Dermatol 2007;156;492-8 8. Hoare C, Li Wan Po A, Williams H. Systemic review treatments for atopic eczema. Health Technol Assess 200;4;1-194 9. Tanei, R.; Katsuoka, K. Clinical analyses of atopic dermatitis in the aged. J. Dermatol., 2008, 35, 562-9 10. Becerril, A. M.; VĂĄzquez, M. CL.; Angeles, G.U.; Alvarado, M. LE. Vilchis, G. E. Prevalence of allergic diseases in the elderly.

Rev. Alerg. Mex., 2008, 55, 85-91 11. Muto, T.; Hsieh, S. D.; Sakurai, Y.; Yoshinaga, H.; Suto, H.; Okumura, K.; Ogawa, H. Epidemiology and health services research prevalence of atopic dermatitis in

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Japanese adults. Br. J.Dermatol., 2003, 148, 117-21 12. Wolkewitz, M.; Rothenbacher, D.; Löw, M.; Stegmaier, C.; Ziegler, H.; Radulescu, M.; Brenner, H.; Diepgen, T. L. Lifetime prevalence of self-reported atopic diseases in a population-based sample of elderly subjects: results of the ESTHER study. Br. J.Dermatol., 2007, 156, 693-7 13. Fölster-Holst, R.; Pape, M.; Buss, Y. L.; Christophers, E.; Weichenthal, M. Low prevalence of the intrinsic form of atopic dermatitis among adult patients.Allergy, 2006, 61, 629-32 14. Hatano Y, Man MQ, Uchida Y, et al.

Maintenance of an acidic stratum corneum prevents emergence of murine atopic dermatitis. J Invest Dermatol. 2009; 129:1824–35.

15. Elias PM. Stratum corneum defensive functions: an integrated view. J Invest Dermatol. 2005; 125:183–200 16. Elias PM. The skin barrier as an innate immune element. Semin Immunopathol.

2007; 29:3–14.

17. Gabard, B.; Chatelain, E. Concentration of urea in the stratum corneum and moisturizing effect. In: Wohlrab, J.; Neubert, RRH.; Wohlrab, W., editors. Trends in clinical and experimental dermatology vol 2 advances in experimental dermatology. Shaker; Aachen: 2003. p. 27-35 18. Shuster, S., and M. M. Black. 1975. The influence of age and sex on skin thickness. Br. J. Dermatol. 81:661-666 19. Elsner, P., D. Wilhelm, and H. I. Maibach.

1990. Frictional properties of human forearm and vulvar skin: influence of age and correlation with transepidermal water loss and capacitance. Dermatologica (Basel). 181:8891.

20. Ivens UI, Steinkjer B, Serup J. Ointment is evenly spread on the skin, in contrast to creams and solutions. Br J Dermatol 2001;145;264-7 21. Loden M, Pharm. Effect of moisturizer on epidermal barrier function, in Clinics in dermatology. J Dermatol 2012;30;286-96

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Scientific Poster

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Photo HERBAL FOR BETTER ELDER CARE

Abstract: The human conditionis becoming increasinglyolder, thelifestyle ofmodernpeopletakecustomaway from theurbantothenaturaldietfoodssuch asfresh fruits and vegetables. It takescreativemeasurestorealizethe importanceaway frommealshigh in fat, salt, andflavorings, and morenaturalfoods, full of fiber, andcontains many mineralsandvitaminslikevegetables and fruits arefresh. Inthis photoillustratesa vegetable sellerwhoeven thoughhe was alreadyahead of theold buthe isstillcampaigningontopof freshnatural foodsby sellingvegetablesto a mother whowas veryseriously lookingvegetableis good forfamilies. This photo wascalled on theobserverfortheolder peopleto get backinto the habit ofeating foodsthat are natural andnon-fat and flavoringsubstances. Inthis photothe photographerexpectsthe awareness ofolder peopleto be moreenvious of thegreengrocer's forhisabilityto consumeall-natural meals, as well asmore carefultochoose foods that aregoodas it lookson the expression ofa veryseriousbuyerlooking forthe bestvegetablesforhis family.

SoI created thisabstractpicture, withall due respectI say manythanksfor havingmerate images University Name of delegate

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Listen, Understand, and Care to Elderly Abstract: The number of elderly population is currently increasing. Many families are paying less attention to them, even abandoning them. Because of the decreasing physical abilities and their families can not afford to care for them, they were forced to put into a nursing home or old folks home. Sometimes their families listen less and less able to understand what is complained by the geriatric, even feel burdened because of their presence. They thought that is better to put them in to a nursing home because the nursing home was more proficient in handling elderly. Generally, the elderly are abandoned by their families to feel lonely and depressed because they feel left out.

As in this photo, an elderly woman who has droping physical condition necessary to get the attention of people around her, especially from her family. They want to be heard laments, understood their condition, and get attention. They often feel miss on their families, their children and their grandchildren at home. They longed to laugh togeher, sharing together, and gather in the home. Some of them is a longing to eat together, gather together in the living room, and see their grandchildren. So they feel stressed, sad, and lonely. This condition can actually make their condition dropped. Because they lost their social and emotional needs.

Therefore, whenever and wherever, if we could, give them attention and affection. Listen to their complaints, understand what they was feeling, and treat well and sincere, as sincere as they care for their children.

University : Brawijaya University Name of Delegate : 1. Muhammad Hafidl Hasbullah 2. Lailatul Purwasih Putri

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Elders Spirit Abstract: Be happy with healthy life style. It is not easy to dismiss the laziness in order to have exercise in the morning. However, the grandfather has shown to us that such activities are possible with determination and willingness. He is an old but still want to perform an exercise to achieve a healthy lifestyle. He walks to Malang Car Free Day (CFD) to join morning exercise (senam pagi). He always goes to CFD every Sunday and really enjoys the morning exercise (senam pagi). According Badriah (2009:32), there are 3 main indicators of physical fitness which are first, your body's ability to perform physical activity. Second, do not feel overload fatigue on physical tasks, and last is the ability to recover as soon as the physical task is completed.

Physical fitness is a state of physical ability to customize the function of body organs of the specific physical tasks and or the state of the environment that must be overcome in an efficient way, without excessive fatigue and has recovered completely before coming the same task on the next day (Giriwijoyo, 2007: 23). The components of physical fitness include various systems of the body, such as the musculoskeletal system, neurons, cardio-respire system, excretion, and cooperation between the various systems of the body.

Based on data from the Coordinating Ministry for People's Welfare (December 29, 2009) in Nugraha (2010:3): Indonesia is a country that entered the era of aging population structure with approximately 7.18% of the population aged over 60 years.Research shows that increasing the risk of hypertensionis related toage and lack of physical activity(Kaplan, 2002).

How great if all of the elderly people of Indonesia have a strong willingness to have physical activity. So the rate of NCD disease such as hypertension will decline and life expectancy will be rise.

Based on data from Menkokesra 2010 explain that the life expectancy of elderlyhas increased but not significantly.

If the elderly have a passion for healthy life, why do we, as the younger generation do not have such spirit? With healthy life and healthy spirit life expectancy in Indonesia will be rise.

University : Brawijaya University Name of Delegates : 1. Chrisandi Yusuf R. 2. PuspitaWidyasari

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To the world you may be one person, but to another person you are the world Abstract: According to the United Nation (UN), senior citizens are by definition people with age over 50.

While in other definitions, senior citizens are retirement-aged people (over 60 or 65 years old). Indonesia is one of the countries with the highest senior citizen growth rate. In 2007 alone, the estimated total of senior citizen has reached 18.96 million people (approximately 8.42% of the population). There are 11 provinces with the total of elderly people above 7%, which by the World Health Organization (WHO) grouped as the 'old structured area'. They are Daerah Istimewa Yogyakarta (14,04%), Jawa Tengah (11,16%), Jawa Timur (11,14%), Bali (11,02%), Sulawesi Selatan (9,05%), Sumatera Barat (8,74%), Sulawesi Utara (8,62%), Nusa Tenggara Barat (8,21%), Jawa Barat (8,08%), Lampung (7,78%), and Nusa Tenggara Timur (7,68%).

Over 50% of the senior citizens are the breadwinners in their family. This photo was taken at 6 AM at the Malioboro area, Yogyakarta.

As seen in the picture, there is an elderly man selling wayang or puppet dolls to provide his family. He has to walk from his house so early in the morning in order to earn more money than other merchants. He does not care about how carrying such weigh could fall him down or causing low back pain nor about the air pollution that got him cough all the time. All he cares is how to make all his wayang sold, so he can bring money for his family.

There are millions more families who financially depend on their elderly relative. With those numbers above, as futures doctors, we are obligated to concern about their welfare in creating a prosperous Indonesia. In geriatrics, we are not only concern about the patients' physical health, but also for their psychological welfare. It is important for us to care and know more about geriatric medicine in order to accomplished healthy and socially happy senior citizens especially those whose family depended on.

University : Universitas Indonesia Name of Delegates : 1. Arvianto R. N 2. Alvin Bramantyo 3. Abinisa Inaya Taim

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She Deserves Better

Abstract: In this picture, there is an old woman waiting in line for a free medical check up conducted by Universitas Indonesia’s medical students. She has been waiting for hours to learn about her symptom and its cure from the doctor. While waiting, she holds the rail in front her. The fence is like an anonym of the bureaucracy she has to go through in order to get a medical service. It lies between her and the doctors who are going to exam her. Same as the multiple steps elders should take to have a medical attention in Indonesia.

Senior citizens with age over 60 are susceptible to numerous acute and chronic diseases.

According to a survey conducted by Kesehatan Rumah Tangga Departemen Kesehatan Republik Indonesia in 2002, the most common disease among the elderly people is hypertension with percentage around 42.9%. That followed by arthritis (39,6%), anemia (46,3%), and cardiovascular disease (10,7%).

The survey shows that elderly has limited body function up to 88.9% of their functions. Moreover, limitation in social participation (43.4%) is shown. Other kind of disease such as degenerative and malignancy also found. Those numbers reflect the high risk factors owned by people above 60 years, thus routine examination is needed. In Indonesia, the awareness of elders’ medical condition is still very low.

More than half elderly people in Indonesia are not in good shape; either they have acute or chronic disease. In their age, any kind of disease could lead to a serious medical condition and worse, to death.

The Indonesian Health Ministry has a program in conducting free medical check up for geriatrics. It is a solution to raise the awareness of geriatric’s health in giving their opportunity to enjoy their life. As medical students, we have to help raise the awareness of geriatric health in community by giving education or conduct a medical check up on our own. All elderlies should know their medical condition without any obstacle in between. It is their rights to enjoy their old age and we have to give it to them because they deserve better.

University : Universitas Indonesia Name of Delegates : 1. Arvianto R. N 2. Alvin Bramantyo 3. Abinisa Inaya Taim

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Street Vendors: Should we be concerned about them?

Abstract: Everyone will experience an active aging process in their lives. Active aging process is a degenerative mechanism in which the cells experience a steady decrease in their functions. It is a physiologic process.

If the body is not in its proper condition, this active aging process can lead to degenerative disease like diabetes, osteoporosis, renal failure and many more. There are also a lot of factors that can increase the risk of degenerative disease, some of them are economic condition, psychological state and life-style.

In this photo, we can see an old woman sitting alone among her wares. In her old age, she still has to work hard for her life. Her poor economic condition leaves her with no choice but to do so. Every day she has to be exposed to air pollution; she has to sit uncomfortably in a dirty and messy place, there is even a big dustbin next to her.

As we see, she is living in a condition where her environment poses a great risk to cause many health problems for her. We are certain that there are still many elderly people in Indonesia who have to struggle for their lives and are not living properly in their old age. We, as medical students, should be concerned about them, especially about their health condition.

University: Universitas Indonesia Name of Delegates : 1. Fabianto Santoso 2. Della Puspita Sari

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Are you ready for getting old?

Abstract: Aging is one of the case that cannot be stopped. Many people fear to being old, especially womanhood.

The description about aging was difference one and another but in simply words it can describe as the combination of physiological change and the environmentally impact to our body.

This photographs was taken in Old folk’s Home Tresna Werdha Minaula at Kendari. It shows two different figures, an old and a young one.

Actually the young figure means the past time reflection of the old one, then the old figure means the future reflection of the young one.

Everyone will getting old. Are you ready for that? The answer must be ‘YES’. But there are still many people who didn’t prepare theyself especially theirs behavior and life style. Along with getting on in life, you would experience many change on your body and mind. Your body function was stop worked effectively like before. You would susceptible towards many disease and your brain started over to downturn function. Is it scared? Yes. Can you stop it? No. Once again, nobody can reject for being old. Prepare yourself now by applying healthy life, so you don’t need to make your second childhood as a scariest period.

University : Haluoleo University Name of Delegates : 1. Rahmawati Nur Ariyanti 2. Erlin Dwi Cahyani 3. Sitti Nursanti

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Geriatric Nutrition Abstract: This photograph shows some poor nutrient in geriatric. Each day they should have to eat complete foods including macro-nutrient (carbohydrate, protein and fat), micro-nutrient (vitamine and mineral), fiber and water proportionately. Moreover, the food they consume in this photograph is not enough to complete their daily requirement nutrition. Malnutrition is common in geriatric patients and associated with poor outcome. They have a high risk for that and it would make a problem health. If recognised, effective treatment is possible. But if not, their health is threatened.

University : Haluoleo University Name of Delegates : 1. Rahmawati Nur Ariyanti

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Rheumatic Diseases Abstract: Peole lackknowledge aboutrheumatic diseases, considered its common ,trivial. Rheumaticdiseases may disrupt activity because of the paineverydaynotable torecover quickly. In this modern age , people less in doing activity that included body move.

Rheumatic diseases (Rheumatoid Arthritis) is a chronic inflammation of the joints caused by an autoimmune disorder. Conditions of joint damage caused by the interrupted process improvement to continue to in the joint.Patients with Rheumatoid Arthritis is a very stout elderly.

The most common Arthritic symptoms are: - Stiffness in and around joints lasting about 30-60 minutes in the morning.

- Swelling in 3 or more joints at the same time.

- Swelling and pain generally occurs with a symmetrical pattern (pain in the same joints on both sides of the body) and primarily affects the wrist joints.

- Pain or inflammation and sometimes swollen wrist joints section fingers, hands, legs shoulders, knees (knee), waist, back and around the neck.

- Arthritic pain can move where and turns even simultaneously in various joints. usually recur foods containing purines so veins are foods that can trigger purine, such as organ meats, seafood or alcohol Treatment generally only reduces arthritic symptoms and do not cure or eradicate the disease actually Treatment for patients with rheumatoid arthritis: - Exercise regularly and get up early - Apply cooking oil on body - Eat regularly and drink water - Treatment of leg (knee to the sole of the foot), approximately 10 minutes on the left and right legs, especially in the gap fibula and tibia - Keep up with your knees folded them so that no combustion and evaporation of the body.

Some myths: -Frequent showers and cold nights caused arthritic In pathological, there is no connection between this myth and rheumatic diseases. However, water or cold air will cause the joint capsule shrinks -Antibiotics are needed to cope with swollen joints Antibiotics are only used on a type of arthritis caused by infection. Although the joint looks swollen and red, are not routinely given antibiotics.

- symptom of arthritis symptoms commonly occur in patients with rheumatoid arthritis are stiffness and inflammation in the joints (redness, swelling, hot, and difficult to move). This phenomenon is not limited at night and can strike at any time.

University : Christian University Of Indonesia Name of Delegates : 1. Melianti Togatorop

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Healthy in Old Age Abstract: In the modern world, humanâ&#x20AC;&#x2122;s life expectancy was increased. The development of science and technology in many sectors able to prolong human life. In medicine, many doctors began to enter geriatric. In the old age, human is easy to get many kinds of disease and complication. Doctor has a role to cure and treat the elderly. It would be nice if the elderly can enjoy and relaxed in the rest of their rest.

In this photo, as we can see, a doctor was examining the elder patient. The doctor treated the patient early to prevent a lot of disease that can harm them. They can stay healthy and if they get a disease, it can be cured as soon as possible. Prevent is better than cure, right? Also, if you see the picture, the doctor treated the patient with smile and full of love. As we know, elderly is very vulnerable, in physically and mentally. It would be nice if we are not only curing the disease, but also make a calm, comfortable feeling to patient.

University : Unika Atmajaya Name of Delegates : 1. Swastiko Wiweka Adi

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Vol. IDecember 2013

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WHY MY SON LEAVE ME???

Abstract: This image describes how lonely a grandfather who left his family in a nursing home. Should now the grandfather be able to play with his grandson, cleaning the park in front of the house or just talk with his neighbors. But unlike the situation now, he's just waiting in front of the window with a blank stare ahead.

A Moment the grandfather could only smile at our cameras. So touched when we saw a man should receive more affection from their children but now just end up in a nursing home. It appropriate grandfather left the family? Very Reasonable when we get depressed parents in a place like this. Not only depressed but sometimes experiencing hallucinations about his son. Implementation of the family should not be like this, the family is a barrier and protection of one's person, but why in old age barrier and protection are gone??? The old man can only wait and continue to wait for the awareness of all those who left him.

University : Universitas Haluoleo Name of Delegates : 1. Nurul Alif Exanisah 2. Novita Sachniar

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Disabled and Ignored Abstract: According to World Health Organization, Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations.

Elder people has higher risk for disability. Disability for elders is commonly causes by Osteoarthritis, Osteoporosis, Stroke, damaged nerve system, Diabetes, and many others. Due to ageing, the number of disabled elders is also increasing massively. According to WHO, around 785 million persons (15.6% of world population) is currently living in disability. With disability, these elders can not enjoy their old days at its fullest. They can only enjoy their old days in suffer and burdened by their physical condition.

The respond of the society is not even making the situation better and giving psychological burden for the elders. The society doesn’t seem care and aware about disabled people, especially elders. For example, we oftenly see that some normal people use facility that is intented for the use of disabled people, such as toilet and parking lot. The society also seems to ignore that there are disabled elders living among them. The society may not realize that one day in the future, they may become disabled as well.

The disability of elders and the respond of the society are the main topics of this photograph that I have captured. We’re trying raise awareness and concern of the society about the issue of disability in elderly. We’re trying to show the society that these elders who are living among us have been ignored.

We’re trying to show to the society that these disabled elders need caring and compassion and they should not be ignored. We’re also trying to raise awareness and concern that we are ageing as well and one day, we may also be disabled as well. That is why the society and we as young generation must treat these disabled elders with caring and compassion in order to ease their burden.

University : Universitas Hasanuddin Name of Delegates : 1. Ahmad Aulia Rizaly

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Vol. IDecember 2013

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False Pleasure Abstract: Onecharge,twocharges..

This routineismy duty fora bite of rice..

One drop, two drops..

These sweatis the spirit ofmy lifeandmy family..

Oneday, twodays..

Tired is my secret.Who knows? My face shows braveness but mybodysays another. Now theyouthis replacedbyold age.Oneor two suctionsof cigaretteshave mushroomed inmy daily. Iknow theriskofthis smoke, but only smoking can wipe out my fatigue, bothtired of mind and body.Justsmoking , itcould understandme. "I am the construction workercoveredby pleasure of smokeâ&#x20AC;?

This photo wastaken onFebruary 3rd 2010in thearea ofresidentialconstructioninTembalang, Semarang.

Sadly ,thefact thatsmokersare dominatedbymaleworkers whoactually is thebreadwinner and the backbone of the family. As the man in this photo, which hispoverty made himto takethis risky job as construction worker in his old age. But itâ&#x20AC;&#x2122;s so pitty, he spend some of his salary to buy cigarattes .To buy cigarettesfirst, then to buyrice.This conditionrepresentswhat happenedin Indonesia , and more surprisingly, SUSENAS(National Socioeconomic Survey) in 2010 said that household needs budget on cigarettesis 12% in poor family , this is so large compared torich familythatonly about7% spendto buy cigarettes. Plus, spending money on cigarettes at poor family is greater thanthe other essential needssuch aseducation, clothes, and especially health. They are alreadypoor, buycigarettesand will get sick, then they will fall into deeper poverty because of it.

University : Universitas Diponegoro Name of Delegates : 1. Dwi Widyani Rosnia Savitrie 2. Yurisal Akhmad D

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Support Your Beloved Persons Abstract: Alzheimer is become the main problem in Indonesia , as it’s equivalent with increasing national development of Indonesia system health, improve the age-lifetime expectancy . It’s affected to higher number of total elderly people population in Indonesia . As it’s physiologycally that our body system will having a reduce function as increasing age . It can conclude that elderly people has higher risk to get neurodegenerative or neurophysiathric disease such as Alzheimer.

Alzheimer’s disease (AD) is an agerelated progressive neurodegenerative disease commonly found among elderly. It will make deficits on behavioural and also cognitive .

People with Alzheimer have a difficult try to memorize , having a very shortterm memories, difficult to knowing people even their families , deficits on vision and also verbal capability.

Elderly people with Alzheimer wil lhave promblems to face their social world and do that social action to the community. It will make them feel unsocial, feel lonely, and feel likes they already knock out from the community . The message within this poster, we want to show the clinical signs of Alzheimer itself ( represent by the words of alzheimer’s definition that become blurr or not clearly) and it’s contradictive with the picture of a pair old man and old woman that cheating happily . This contradictive draws the condition of normal elderly without Alzheimer and elderly with Alzheimer. And in the end, we put the message “ doing social and logical activities to prevent them from late onset alzheimer” , in addition give a message about how to prevent the Alzheimer especially in older people. We, as society, can help them to maintain their social activities by simple way like family gathering and also the researchs showed that logical activities that use brain will help elderly to prevent alzheimer happen to them .

Last , the word “ suppot your beloved persons” is the climax and main goal of this poster. We want to make all of social component to has sense of belonging about prevention of alzheimer. And the key is : Support the one that near with you, that has a blood-relations with you, and it is your family . Please care of them, thats the simple way to prevent Alzheimer and any other disease.

University : Universitas Diponegoro Name of Delegates : 1. Dwi Widyani Rosnia Savitrie 2. Jacob Bunyamin

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Vol. IDecember 2013

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Don’t Let Your Elders Alone Abstract: This photos take a old man called Daeng Naba as a model. He’s a newspaper courier at Makassar and He is 82 years old now. The background of this photo tells Dg. Naba’s life as an elder who didn’t enjoy he’s old age, he is alone and looks unhealthy, he is work over hard than the others elder should have, it gives any risk to him, especially for him health. He stands at the center of the road and hawking the newspaper into everyone landed to traffic light.

As the world’s population ages, the interdisciplinary site of geriatric medicine has begun to expand. That recognition that aging brings with it changes in neurobiologic, psychosocial, and physical functioning. According to that, successful aging was needed. It doesn’t just absence the disease. It is : Physical Health, Financial Security, Productivity and Employment, Independence, Coping Well and An Optimistic Outlook, Staying Involved in Activities and with People who Bring Meaning and Support.

The concept of “wellness” has been associated with successful aging, wellness represent balance among the environment, emotional, spiritual, social, physical, and cultural aspect of the individual’s life.

Health is a part of wellness. New definition of successful aging continue to be develop as research and practice with the older adult population progresses. There was too much research at the previous talking about successful aging, but the fact didn’t show. There was approximately 2,7 millions elder has been displaced. Especially at psychosocial and economic side. Most of them still have to earn a living for survival in life, being a newspaper courier, to sufficienting their life. We know that the men no longer young again, 82 years old is too old for being a courier man, but there’s not other choice, Dg. Naba has to do In other side, psychological situation of the elders need more care from their family as a closest person at their life. So why we should be care? Because the elders have too complicated medical and pshychoscial problems, they have decreased the physical function, increased sensitivity of the central nervous system, non-verbal communication, auditory and visual difficult to obtain, seizure and dysphagia common problems, sensitivity to meds, cognitive difficulties, communication difficulties, abnormal behavior, impaired cognitive, easy to get mad, and many more. They have so much limitation at their life, so they need our caring, the need our love, didn’t just by drugs we bring but with some love we spread so the successful aging concept would raise wider.

University : Hasanuddin University Name of Delegates : 1. Januar Richard 2. Jeanne Vibertyn

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Vol. IDecember 2013

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My health is my happiness

Abstract: Diabetes mellitus is a chronic disease which cannot be cured except in very specific situations.

Management concentrates on keeping blood sugar levels as close to normal as possible, without causing hypoglycemia. This can usually be accomplished with diet, exercise, and use of appropriate medications.

The prevalence of diabetes in the elderly is likely to increase, mainly due to diabetes in the elderly are affected by the intrinsic muktifactorial and ekstrinsik. Age proved to be one of the factors that are independent in their effects on changes in the body's tolerance to glucose. Generally, 90% of adult patients with diabetes, including type 2 diabetes. Of this amount is said to be 50% of patients aged> 60 years.

This photo was taken at â&#x20AC;&#x153;Terataiâ&#x20AC;? nursing home in Jln.Sukabangun, KM 5, Palembang, South Sumatera. The photoshowsa medical studentwas checking blood sugar levels of an elderly woman (74th years old). Related to thelack ofhealthcare in nursing homes, checking blood sugar levels can be the firts step to diagnose diabetes. And, we can give some suggestions for the elderly related to the blood sugar levels that her has.

Hopefully, we are as a medical student should have a big attention for elderly health especially their who lived in a nursing home.

University : Muhammadiyah Palembang University Name of Delegates : 1. Ramona Fitri 2. Winda Rolita Firda 3. Maya Dwinta Sentani

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How About My Blood Pressure (?)

Abstract: Hypertensionis acommonhealth problem in the worldwide. The incidenceof hypertension usually increased inold age becauseof the degenerativefactors, that might be caused by functional decline, such as liverand kidneyfunction.

Hypertensiondoes notalwaysprovidethe signsand symptoms, it can be a "silent killer". The problem is, hypertensioncan overloadthe heart andblood vesselsin excess,andcan lead tostroke, heart failure, and kidney failure. This complicationsof hypertension can be very dangerous and, especiallyby the elderly people.

One of the effortsto preventthe occurrence ofhypertension for the elderlyis by checking their blood pressureregularly.But most of elderly people rarelycheckstheirbloodpressure. This situation canincrease the risk ofhypertensive complicationsthat will impactworse forpeople with hypertension.

This photo showsan elderly woman was watching the manometer during the examiner checking her blood pressure. Although an elderly womandidn'tknow how toread the manometer, but she surely hopesthe results which will be presentedby the examinerabouther bloodpressureisstable.

This photo was takenat one of thenursing homein theregion of Palembang. This picturetells abouta medical studentwas checking an elderly woman blood pressure, she israrelycheck herhealth, especially check her blood pressure.

We should care about medical for geriatric. Support them to check their blood pressureregularly.

Method for checkingblood pressureis so simple but it is useful. The stable blood pressure will makethe elderly life can be better in her old days.

University : Muhammadiyah Palembang University Name of Delegates : 1. Ramona Fitri 2. Winda Rolita Firda 3. Maya Dwinta Sentani

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Small Actions for A Better Life Abstract: Acute Respiratory Tract Infection (ARTI) is a major cause of morbidity and mortality of infectious diseases in the world.

Almost 4 millions people are dying because of ispa each year, 98% are caused by lower respiratory infections. The mortality number is very high among the children and elderly, especially in countries with low per capita income.

The most often pathogens that can cause ispa is a virus or combined virus-bacteri infection.

Meanwhile, the new organism that can inflict epidemic or pandemic ispa needs special precautions and readiness. There are many factors that can caused ispa, such as air pollutan, environmental conditions, predisposition factor (age, nutrition status, Immunites conditions and public health conditions), the characteristic of pathogen and the role of health services in prevention against infections.

There are appear to be a direct relationship between increasing age and suceptibility to infection factors that may contribute to the predisposition of the elderly to infections include impaired immune function, anatomic and fungtionil changes, and degree of exposure to infections. The environtment of an elderly individual can also influence his or her exposure to infection.

In this photo showing about a toy seller was walking around in Benteng Kuto Besak. That elderly who work in the open environment like that can be easily infected by pathogenic microorganisms that can cause lower or upper respiratory tract infections, due to that conditions, one of preventive action to reduce risk of spreading infectious agents from the outside is by using a mask.

The prevention action against ARTI is not only concerned by health services, but also awareness of public participation, especially elderly to alter behavior in improving their health with pay attention of their food nutrition, avoid exposed to irritans, clean the environmental, take a good care of individuals cleanliness, so the elderly can always stay health in their old age.

University : Muhammadiyah Palembang University Name of Delegates : 1. Ramona Fitri 2. Winda Rolita Firda 3. Maya Dwinta Sentani

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With Love for Elderly Spirit Abstract: This photo was taken at “Teratai” nursing home on Sukabangun street, KM 5, Palembang, South Sumatera. This photo describes a little story about “Teratai” nursing home that two elderly women are being cared by a visitors. These two elderly in this photo told the visitors about their sadness, they recounted thechronologywhytheycouldbe inthis nursing home.

In this era, we could see the phenomena which a child board out his/her parents in a nursing home that is such a sad thing we ever see whereas the family is an important thing for orderly’s spirit. In this photo we can also see the visitors tried to share her cheerfulness to these two elderly women, so that it can restore their spirit of life. Share our cheerfulness to the elderly woman is one of the geriatric medicine activities. Geriatric medicine is a branch of general internal medicine, concerned with the clinical, preventive, remedial and psycho-social aspects of disease and health in the elderly. The aims of geriatric medicine are to maintenance the health in old age, by avoid the disease and continue social engagement, to maintenance of maximum independence, to do early detection and appropriate treatment of disease, and to do sympathetic care and support during terminal illness.

Geriatric medicines for elderly not only give drugs but also give our love, spirit, show our empathy, build a good relationship and communication, and give our concern to them. Those actions which we given for, can call as psychotherapy. The aims of This psychotherapy action is to increase the individual's sense of his/her own well- being. Psychotherapists employ a range of techniques based on experiential relationship building, dialogue, communication and behavior change that are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family).Our concern to them could be given by listening to their laments, preparing food and drugs, and someotherforms of little things which could make them smile. So, our cheerfulness is one of important aspect for their mental health which can affect to their physical fitness and to improve their quality of life.

University : Muhammadiyah Palembang University Name of Delegates : 1. Rani 2. Almira Dina Mariski 3. Muhammad Ragil Pamungka

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Caring to Others Abstract: Incidence of hypertension increased with increasing age. This is often caused by natural changes in the body that affect the heart, blood vessels and hormones. Hypertension in aged less than 35 years will increase the incidence of coronary artery disease and premature death.

This photo was taken at “Teratai” nursing home in Jln. Sukabangun, KM 5, Palembang, South Sumatera and tells us how important controlled the blood pressure, especially in the elderly. Besides that, in this photo shows us about sense of caring from a medical student to elderly woman that life in nursing home. Ways toshowher concern for elderly women’s health are bycheckingtheirbloodpressure and give some suggestions for them in order to maintain their health.

In the other word, checking blood pressure regularly, eating a healthy diet and exercise routine can be a variety of efforts to prevent the occurrence of hypertension. Hopefully, withthisphotocan enhanceoursense ofconcern forthe health ofthe elderlywho livein nursing homes.

University : Muhammadiyah Palembang University Name of Delegates : 1. Rani 2. Almira Dina Mariski 3. Muhammad Ragil Pamungkas

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Drink Enough for Better Life

Abstract: Body water balance is controlled by setting the input and fluid excretion. Normally, water intake is affected by the thirst, which is the primary defense against dehydration. Thirst is a conscious desire to drink water that is governed by a center in midhipotalamus.

Dehydration is a condition of too many body fluids are lost and can not be replaced properly.

Dehydration due to increased loss of body fluids, lack of water intake, or by both. Dehydration is characterized by the emergence of thirst. If it does not respond thirst by drinking water in sufficient quantities then the situation would worsen. The thirst will be more difficult to accept and respond with age. As a result, the thirst is likely to evolve into a sense of weakness and weakness, fatigue, loss of consciousness, and even death.

Fulfillment of the water is important to maintain the body's fluid balance. The body maintain fluid balance by replacing fluids lost through urine, feces, skin and lungs.

This photo was taken at â&#x20AC;&#x153;Pasar 26â&#x20AC;?, Palembang, South Sumatera. It describes, the awarness of an elderly woman about the importance of maintaining her body's fluid balance in extreme weather.

Therefore we should keep the balance of body fluids by drinking water regular and sustained, especially in old age. Hopefully, thisphotocan enhanceour awarenessabout the importance ofwater for our bodies.

University : Muhammadiyah Palembang University Name of Delegates : 1. Rani 2. Almira Dina Mariski 3. Muhammad Ragil Pamungkas

Public Poster BRAINs|

Vol. IDecember 2013

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5 Steps to Respect Older People

Elderly people are now who you will one day become. Respecting their wisdom, knowledge, grace and fortitude should be second nature to younger generations but it isn't always the case. Sometimes we need reminding of why it is so important to respect our elders for what they have to impart to us that will help ease our journey through life.

They should always be respected like you want them to respect you.

Start today by throwing aside assumptions about people going by their age. No matter our age, we are still unique individuals, with the same range of values, gifts and flaws as any other person.

Show respect through manners that acknowledge the greater breadth of wisdom and life experience of each older person.

Consider nurturing cross-generational activities in your local community to help every generation learn the benefits of stepping outside of its own generational mindset. In particular, find ways to help older people to stay connected with younger generations too, by giving them opportunities to participate in community, school and other events that they can use their skills in. By doing this, you increase wider community respect for elderly people in a way that is active, positive and sharing.

Share memories. Take time to talk to people older than yourself, and the older, the better.

Remember, one day youâ&#x20AC;&#x2122;re going to grow old too.

Name of University Name of Delegates

: Maranatha Christian University : - Lidya Fransiska Suherman - Mai Norryslla - Maysella Suhartono Tjeng

Stop Elder Abuse BRAINs|

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Name of University Name of Delegates

: Maranatha Christian University : - Lidya Fransiska Suherman - Mai Norryslla - Maysella Suhartono Tjeng The entire life span of a human being have been broadly divided into 5 stages- infancy, childhood, adolescence, adulthood, and old age. Our culture was automatically respectful towards elderly but today, this phenomenon is gradually declining by the forces of urbanization and modernization. Today elderly are not only, given less respect but also, they are unintentionally abused by the society and family members. Eventually, the problem of elder abuse (which was initially called â&#x20AC;&#x153;granny batteringâ&#x20AC;?) emerged.

According to California Welfare and Institutions Code, elder abuse can be of various forms such as physical, psychological/emotional, sexual, and financial abuse. It can also simply reflect intentional or unintentional neglect, which can be in the form of refusal or failure to fulfill a care-taking obligation.

They should always be respected like you want them to respect you.

DEMENTIA BRAINs|

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Name of University Name of Delegates

: Brawijaya University : Sofi Nur Fitria Dyah Kusuma Purwitasari Nisrina Nur Afina

Dementia is a major health problem facing developed countries, and has also become an emerging health problem in developing countries, such as Indonesia. This is due to the increasing of degenerative diseases in Indonesia (some of which are risk factors for the onset of dementia) as well as the increasing life expectancy in almost all parts of the world. The total number of people with dementia worldwide in 2010 is estimated at 35.6 million. There are 7.7 million new cases of dementia, implying one new case every four seconds (WHO-ADI, 2012).

Dementia defined as a syndrome, usually of a chronic or progressive nature, caused by a variety brain illnesses that affects memory, thinking, behaviour and ability to perform everyday activities. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there.

Clinically, the emergence of dementia intheelderlyis oftennot realizedbecause ofunclearonsetandprogressivecourse of their illnessbut slowly. In addition, patientsand familiesoftenassumethat the decline incognitive function indementia, mostly characterized bymemory loss, is a natural thingto someone whoisolder.As a result, cognitive declinewill continue untilthe endaffectthe functionalstatusof patientsand causethe patientto lose.

By thisposter, we wanttoincreaseourawarenessaboutdementia, so we can do an early detection to know the early sign of dementia. Early detectionisvery importantindementia. When the symptoms ofcognitive impairmentrecognized since thebeginning, we can do someefforts toimproveor at least maintaincognitive functionin order not tofallina stateof dementia.

Dementiais notjust aboutlosingmemories. It can affect other cognitive functions severe enough to reduce a person's ability to perform everyday activities. Aswe mentionedat theposter, they could feel losinginterest, often misplacing things, confused in everyday places, etc. Itis not anaturalpartofgrowingold.

If youareworriedsomeoneclosetoyou hasdementia, no need towaitinglongertoconsulthemto thedoctortogetthe bestmedication.

People oftomorrow, let'stogetherweleadthefightagainstdementia!

Donâ&#x20AC;&#x2122;t Let your Elders Alone BRAINs|

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Name of University : Hassanudin University Name of Delegates : Januar Richard Jeanne Vibertyn As the world’s population ages, the interdisciplinary site of geriatric medicine has begun to expand. That recognition that aging brings with it changes in neurobiologic, psychosocial, and physical functioning. According to that, successful aging was needed. It doesn’t just absence the disease. It is : Physical Health, Financial Security, Productivity and Employment, Independence, Coping Well and An Optimistic Outlook, Staying Involved in Activities and with People who Bring Meaning and Support.

The concept of “wellness” has been associated with successful aging, wellness represent balance among the environment, emotional, spiritual, social, physical, and cultural aspect of the individual’s life. Health is a part of wellness. New definition of successful aging continue to be develop as research and practice with the older adult population progresses. There was too much research at the previous talking about successful aging, but the fact didn’t show. There was approximately 2,7 millions elder has been displaced. Especially at psychosocial and economic side. Most of them still have to earn a living for survival in life, to be a vendors, newspaper courier, a beggar, etc to sufficienting their life. In other side, psychological situation of the elders need more caring from their family as a closest person at their life. So why we should be care? Because the elders have too complicated medical and pshychoscial problems, they have decreased the physical function, increased sensitivity of the central nervous system, non-verbal communication, auditory and visual difficult to obtain, seizure and dysphagia common problems, sensitivity to meds, cognitive difficulties, communication difficulties, abnormal behavior, impaired cognitive, easy to get mad, and many more. They have so much limitation at their life, so they need our caring, the need our love, didn’t just by drugs we bring but with some love we spread so the successful aging concept would raise wider.

ROAD TO BE HEALTHY ELDER BRAINs|

Vol. IDecember 2013

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Name of University : Hassanudin University Name of Delegates : Fidesha Nurganiah S Andi Muh. Fadlillah Life expectancy in Indonesia is getting better, so the numbers of elders in Indonesia are rising. But, unfortunately, we are less aware of diseases that we will acquire when we are old. Aging process is the physiologic phenomenon, but when we are not aware of our health, it will not be physiologic. There are many stigmas that elder people cannot do anything, not productive, etc, but it all depends on lifestyle when we are young. The key of healthy life when we are old is to start living on healthy lifestyle, such as eating balanced diet, not smoking, active body and mind, do regular checkups ,etc. This poster is made on purpose to invite people to start living on healthy lifestyle for their elderly life.

We have to start giving our concern to this issue because the numbers of elders in Indonesia are keep rising every year. In fact, in 2010 the number of elder reach 18,57 million people and rising about 7,93% from 14.44 million in 2000. It's forecasted that in 2025 it will reach about 34,22 million people (Badan Pusat Statistik, 2010).

Not all the elders are in good condition, some of them are being strayed or even live with their family but in sick condition. For example, the survey of Elder Care House, Binjai, in January 2012, there are 47 of 70 people that have Body Mass Index lower than 17. In other words, there are a lot of elder that are not in healthy condition and of course this will make a new problem toward health issue (BKKBN 2012).

There are many diseases that often happen to elder, such as Coronary Heart Disease, Diabetes Mellitus, Stroke, etc. Letâ&#x20AC;&#x2122;s take stroke as the example. Stroke often manifest in disability. Disability makes us unable to move, walk, touch, and feel freely, it limits us to do anything we want, even with help of other people or tools. Imagine, if we become older, disability will disturb us to do our activities. So, to avoid the disability to occur, we must pay attention and start living in healthy lifestyle, and we, as the next generation in humanity, have to build healthy future for ourselves, the world, and the following generation. So, we should start living healthly to reach the goal of being a healthy elder and reduce the problems in health, especially in elder care.

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FALL CASES IN GERIATRIC Name of University : Hassanudin University Name of Delegates : Achmad Randi Uswah Hasanuddin Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable. Among older adults (those 65 or older), falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma. The opportunity to help reduce falls among older adults has never been better.

Today, there are effective fall prevention interventions that can be used in community settings. By offering effective fall prevention programs in our communities, we can reduce falls and help older adults live better, longer lives. The decision to acquire and use a walking stick should be based on facts that it is a practical solution to an existing problem. Avoiding the use of a walking stick may :minimize a personâ&#x20AC;&#x2122;s degree of mobility thereby restricting daily activities, reduce a personâ&#x20AC;&#x2122;s confidence in moving around unassisted thereby contributing to depression, lead to repeated falls, which in the elderly may have dire consequences due to weakening bones and poor healing time, limit self-care and increase the need or dependence on caregivers.

Demands of older care systems BRAINs|

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Name of University: Tarumanagara University Name of Delegate: - Febie Putra Suwana -Schoolaus Daleru -Rio Alexsandro Based on WHO data, The world population over the last few decades has been increase, especially older people in both developing and developed countries. This trend will accelerate over the next two or three decades. The total number of older people (defined as 60 years of age and over) worldwide is expected to increase from 605 million in 2000 to 1.2 billion by the year 2025 Population ageing changes the nature of demands on health care systems, which will have to accommodate the needs of the older population as well the care-needs of other population age groups From the data obtained from 36 countries, the conclusion was that the majority of the health care systems were not prepared to provide adequate care to a growing older population even though a steep increase in the older.

Throughout the 21st century health professionals will increasingly be required to be familiar with old age care whatever the specialty they choose, because routine practice will increasingly include older patients.

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Title of Poster : Support Your Beloved Persons

Name of University

: Diponegoro University

Name of Delegate

:Dwi Widyani Rosnia Savitrie Jacob Bunyamin

Alzheimer is become the main problem in Indonesia , as it’s equivalent with increasing national development of Indonesia system health, improve the age-lifetime expectancy . It’s affected to higher number of total elderly people population in Indonesia . As it’s physiologycally that our body system will having a reduce function as increasing age . It can conclude that elderly people has higher risk to get neurodegenerative or neurophysiathric disease such as Alzheimer. Alzheimer’s disease (AD) is an agerelated progressive neurodegenerative disease commonly found among elderly. It will make deficits on behavioural and also cognitive . People with Alzheimer have a difficult try to memorize , having a very short-term memories, difficult to knowing people even their families , deficits on vision and also verbal capability. Elderly people with Alzheimer wil lhave promblems to face their social world and do that social action to the community. It will make them feel unsocial, feel lonely, and feel likes they already knock out from the community . The message within this poster, we want to show the clinical signs of Alzheimer itself ( represent by the words of alzheimer’s definition that become blurr or not clearly) and it’s contradictive with the picture of a pair old man and old woman that cheating happily . This contradictive draws the condition of normal elderly without Alzheimer and elderly with Alzheimer. And in the end, we put the message “ doing social and logical activities to prevent them from late onset alzheimer” , in addition give a message about how to prevent the Alzheimer especially in older people. We, as society, can help them to maintain their social activities by simple way like family gathering and also the researchs showed that logical activities that use brain will help elderly to prevent alzheimer happen to them .

Last , the word “ suppot your beloved persons” is the climax and main goal of this poster. We want to make all of social component to has sense of belonging about prevention of alzheimer. And the key is : Support the one that near with you, that has a blood-relations with you, and it is your family . Please care of them, thats the simple way to prevent Alzheimer and any other disease.

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An Easy Early Screening Test for Alzheimer’s Disease: The Mini-CogTM Name of University Name of Delegate

: Universitas Indonesia : Vito Filbert Jayalie Arvin Pramudita

Dementia is a syndrome which affect memory, thinking, behaviour and the ability to perform daily activities and can be caused by a number of progressive illnesses. In 2010, there are around 35.6 million people in the world suffered from dementia and it is projected that in 2050 there will be around 115.4 million people. In Indonesia, 606,100 people were diagnosed as dementia in 2005 and around 65% of the elderly had dementia in 2008. Alzheimer’s disease (AD), the most common dementia (account for 6070% cases of dementia), is a neurodegenerative disease which need for care within several years after diagnosed due to cognitive declining. People with AD will have a lower quality of life and they may experience symptoms such as memory loss, difficulty in recognizing relatives, unable to think logically, and even groaning, moaning or grunting which result in discrimination, isolation and different treatment from surroundings. High cost also become a problem for the caregivers beside stresses as dementia cost up to €20,000 per person annually.

Early diagnosis and intervention of AD benefits much to the patients since it may improve patients’ cognitive function, independency, quality of life and lower cost (saved more than US$ 10,000 per patient).

On the other hand, there are still many people in the world, especially in Indonesia, who have not been diagnosed and treated (only 10% were documented in low- and middle-income countries). Country like Indonesia also has a problem for AD early diagnosis since it has a huge population. To cope with those problem, health provider especially doctors and public especially families should be taught about early screening of AD. One type of early screening is by using TheMini-CogTM. The Mini-CogTM is a well accepted screening tool to detect cognitive impairment instantly (takes only 3 minutes) in any situation for instances routine visits. There are two components tested to the patient, those are patients’ remembrance of 3 unrelated words (0-3 points) and drawing a clock (0-2 points). If the patients score 3-5, they do not have dementia. This testing method has a great sensitivity and specificity ranging from 76-99% and 89-93% respectively. This test, which do not test patients’ education, culture, or language, is also less stressful to the patient since it require only 3 minutes to administer. By using this type of test, we believe that AD will be diagnosed earlier and patients’ quality of life will be improved.

Non-pharmacological Therapy for Patient of Dementia BRAINs|

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Name of University: Tarumanagara University Name of Delegate: Monica Djaja Saputera Based on data from the WHO (World Health Organization) in 2010, it is mentioned that the prevalence of dementia incidence figures in the world reached 35.5 million people. While in Indonesia, in 2010 it was reported that nearly 1 million people suffer from dementia.

The purpose of this poster is to raise awareness of the medical team that in coping with dementia not only drugs that can be used, but we can also provide alternative therapies such as music therapy that can be performed by therapists, doctors, or family. Where music has the effect of audioanalgesic which is capable of giving effect to relax, reduce negative behaviours, and enhanced positive social interactions as well as improving the quality of life of sufferers.

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Keep Healthy Life with Diabetes for Elder

Name of university Name of delegate

: Christian University of Indonesia (UKI). : 1. Firman wirasto saptadi siregar.

2. Diah ayu adiati.

3. Noviana indah sulistyowati.

Diabetes melitus is a deadly disorder throughout Indonesia and most of the subjects are elder. This is an anuall disorder which cannotbe cured butcan be controlled with vary way. By havingself conciousness and increasing the level of awareness to such disorder, changing life style, consuming necessary precribtions, routine blood test, and public education of diabetes. But changes may not be applied without the inclination of the subjects themselves. Then spirit and motivation to keep on healthy living are needed from the subjects thus all the changes are going to be meaningfull.

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Dementia, Know It, Solve It Name of university Name of delegate

: Gadjah Mada University : Abdi Marang Gusti Alhaq Gita Trisna Putu Trahinari Satvika Rumthi

In 2012, WHO reported that there were 35,6 million people suffered from dementia. It was predicted to increase twofold by 2030. More surprisingly, this already huge number was predicted to increase threefold by 2050. Based on these facts, WHO included dementia as one of major priority for public health.

Dementia cases in our regionâ&#x20AC;&#x201D;Asia-Pacificâ&#x20AC;&#x201D;reached 4,3 million per year (in 2005), which was predicted to reach 19,7 million cases per year in 2050. This means, there is one new discoverable case for each 7 seconds. In Indonesia itself, there are 1 million people suffered from this illness.

Dementia means a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities. Dementia is identical with forgetfulness, losing track of time and becoming lost in familiar places. When Dementia has reached an alarming stage, patients will be unaware of time and place, have difficulty to recognize relatives and friends, also have an increasing need for assisted self-care.

Dementia symptoms are often mistaken as a mystic phenomenon or an abnormal occurrence.

Because of that stigma, patients are being sent to a nursing home, as people perceived them burdening. Lack of knowledge on Dementia creates a more miserable life for the patients.

In Indonesia, the symptoms are shamefully forgotten and ignored. It needs a complication like stroke or diabetes to send a dementia patient to the hospital. This creates a late treatment for the patient. The patients have already got severe complications, hard to be cured.

Knowledge on how to treat Dementia is also critically low. In addition to medication by doctors, patients also need non-drug rehabilitation. The true essence of the treatment is to provide a more comfortable, safe and uncomplicated life for the patients. These things require family and doctors to collaborate, not leaving the patients to struggle by themselves.

They need support from their loved ones, not a nursing home or worst, isolation.

We hope people will be eager to learn more about dementia after seeing this poster.

Dementia need to be known, early recogniziton can avoid severe complications and the treatment will be much easier. Family will know what to do, patients will have a more meaningful life.

Dementia, know it, solve it.

Act now before thereâ&#x20AC;&#x2122;s no time for us to act BRAINs|

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Name of University Name of Delegates

:Unika Atma Jaya, Jakarta :Florencia Putri Marcia Kumala Sardono Widinugroho

We know about the cycle of life. Children will grow up, be teenagers, adults, and then grow older and older. At that time, their bodies will degenerate and can’t be function as it used to be. That’s why there’s geriatric medicine that provides facilities for their treatment.

In Indonesia, geriatric medicine is not so popular. That condition is so unfortunate because of the fact that there’s a lot of elder people population. We also know that there are still lots of elder people that don’t have a good quality of life and a proper treatment. As medical students, this kind of condition should have touched our hearts. If we don’t do something, it will happen again in the future. From that point, we choose the title “Act now before there’s no time for us to act”. We have to act now, by doing something even if it’s just in simple ways. Otherwise, maybe at that time, we can’t do anything to our parents, who will grow old someday, simply because geriatric medicine will not be popular again.

We have to do something now, maybe just in simple ways, such as care about them, visit our grandparents, take them to a geriatric doctor if they feel pain, and help them more often. As we do it everyday, we will get used to it and eager to help elder people now and in the future as a doctor. By that, we believe that someday our actions will improve public health in Indonesia especially for the elder people and by that we also support the development of geriatric medicine in our community. Second, we will never know how long they will live in this world, so if not now, why do we have to wait for their living? Care about them as long as they live and be there for us, because we don’t want to regret anything in the future of course.

It is clear for us to have to do something from now because we will never know when the time will tell us to start or to stop. As long as the elder people live (especially they who have a close relationship with us) we should care and help them.

Indirectly, we also support the geriatric medicine in Indonesia in the future.

Healthy Life Style is The Way To Prevent The Hypertension

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Name of University Name of Delegates

:Universitas Jenderal Achmad Yani :Niza Zitka Samkova Anis Nurfatimah

The poster public with title “Healthy Life Style is The Way to Prevent Hypertension” talks about the hypertension because there is a lot of elder in Indonesia have hypertension and this disease is very dangerous. Hypertension is the third morbidity’s causes in Indonesia. The purpose from this poster is to tell everyone about what hypertension is, the factors that make the blood pressure (Hypertension) goes up, and also this poster tells how to prevent the hypertension.

Hypertension has the same meaning with the high blood pressure, which is the condition when the blood pressure is too high. Elder people have two type conditions of hypertension, there are systolic and diastolic. For systolic pressure is about≥140 mmHg and for diastolic pressure is about ≥90 mmHg. There are a lot of elder have systolic type and different with diastolic who have by the younger.

According to Rikerdas Balitbangkes 2007 the prevalence of hypertension in Indonesia is about 31.7, and the majority of this case in public is not yet known or undiagnosed.

A lot of factors who can make the blood pressure go up, there is 1. Age, older have the incidence or the risk of hypertension is bigger, age is the risk factor that cannot be modified. Usually hypertension attack people who have age around 50 and 60 years old. 2. Genetic or familial is one of hypertension’s risk factor.

Person who has parents with hypertension have bigger risk than the person who does not have parents with hypertension, 4.87 times than the person who does not have parents with hypertension. 3. Less activity or never do sport, person who has less activity or never do sport have the risk 4.73 times bigger than person who always does sport. 4. Obesity, the opinion of the some experts stated that obesity can make hypertension 2-6 times bigger than person who does not have obesity. 5. Smoking, usually hypertension happened in smoker’s body, because smoking will make the blood pressure goes up. 6. Alcohol can be harm for organ’s system. Alcohol damage several organs in the body including the heart. If the heart damaged automatically the blood pressure also go up. So, the habit to drink alcohol is the one of hypertension risk factor. 7. Stress, stress who happened continuously will make the high blood pressure stay on the body. Although there are no studies who talk about stress is the one of hypertension risk factor, but if we see from the incidence of hypertension is bigger in urban areas that the rural areas, than fact can be related with the stress make hypertension. So, from those risk factors life style is the main of those risk factors for hypertension.

Start Caring and Make A Change

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Name of University Name of Delegates

:Unika Atma Jaya, Jakarta :FidelisJacklyn Adella Laura Agnestasia Djunaedi

Geriatry is a growing sub-specialty in medicine that focuses on health care of elderly people. The health care of older people becomes a focus because as we enter old age we experience changes in our body that distinct us from younger people. Our bodies start to deteriorate. We become less immune to infections and more prone to chronic diseases. The main problem for older adults is chronic diseases. The prevalence of chronic diseases increases throughout the years.It has been found that the conditions that are most common in older age groups require more care, are more disabling and are more difficult and costly to treat than conditions most common in younger age groups. All of these conditions lower the life quality of the elderly.

Maintaining (or possibly improving) older people’s life quality is not always about treating an occurring disease. Geriatry is a multidisciplinary approach that covers treatment, prevention, education and all other aspects that may affect the health of older people. Prevention of diseases is always better as it usually costs less and inflicts a lot less suffering to the patient. The changes from chronic disease to impairment can be reduced if we are able to minimize the risk factor, detect the disease early and treat it adequately.

The easiest way is reminding or taking them to do general check-up and to do preventive actions, such as dietary control, and giving additional healthsupporting supplement. Some of these actions are very easy to do and can be done by anyone.

Geriatric medicine’s popularity is not yet comparable to other specialties of medicine such as pediatrics or gynecology, especially in Indonesia. However, as medical students we have to remember that as the prevalence of older people’s diseases, impairments and disabilities increase throughout the years, it is most likely that geriatry is going to be a bigger issue and continue to grow when we start to enroll in our profession. It’s time to familiarize ourselves to the issue. Look around and begin with those closest to you. Start caring now.

PAY ATTENTION FOR THEM BRAINs|

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LESS LONELINESS MORE HAPPYNESS University Name : Brawijaya University Name of Delegate : 1. Muhammad HafidlHasbullah 2. Ludya Wahyu Pratiwi 3. Lailatul Purwasih Putri Indonesia is currently the top five countries with the old people population in the world. This population is about 18.04 million in 2010 or 9.6 percent of the population. The number of old people population has increased four times compared to 1970 which recorded about 5.3 million or 4.48 percent.

The increasing number of elderly and the rate of bustle which high of the population in this globalization era has implications for the pattern of community life such as change the value system of society, especially for caring to the erlerlies. The busy people will put their oldy parents to old folks home.

In some cases elderlies often seen as a burden in their family, so they will put them into old folks home. Because of this situation, they will receive less attention even abandoned. These problems will make the elderlies feel lonely even feel wasted. According to experts, loneliness old people will impact on the complex physical health problems. The old peoples suffering from loneliness more often come to the emergency services 60% more when compared with another one who did not get the oneliness, twice as much in need of nursing home care, the risk of influenza twice, four times the risk of heart attack and death from heart attack, also increase the risk of mortality and incidence of stroke compared with elderlies who are not lonely.

Loneliness is a complex problem, because it will make them depressed and resulting in a decrease in their physical condition. The elderly who life alone will feel stress and bear, either without the love from their family. This is a classic problem for the elderly. Stress will affect their healh, affection will make them happy.

Always listen, pay attention, and caring will minimize their problem.

Therefore, care, attention, affection, care, respection and trust should be given to the eldrly. The happy life will make our life longer and full of quality.

Because they have been love us sincerely, so we should love them sincerely too.

Caregiver support For Increase Quality Of Life Of Elderly and Public Awareness

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University Name Name of Delegate

: Tadulako University : Mitras Labiro

I Gede Aditya W.A Caregiver support is a program that provides an opportunity for elderly to get a healthcare based home care,soelderly in old age will get a run in the prevention of transmission of infection diseases as well as some degenerative diseases, in this case the service by a family member of the elderly so that the service given from his own family would be more ideal and feels close perceived by the elderly. as a medical students will be doing some form of control over some of the families who are willing to run this program, but before doing so, we first conduct a survey to all homes in the area to do the checking as well as the request for approval by the members of the family concerned.

There was problems that we often found in a family that has older, sometimes exhausted caring for the elderly often lead to stress which can lead to violence on elderly nursed, so occasional caregiver is given an opportunity to break eldery care within a certain timeframe for the next take Again, the solution can be either elderly put for a while in panti wherda. If the program held, it means we contribute to incresing violence also mistreatment due to eldery.

This lack of understanding, knowledge and skills often affects the elderly mistreatment.

So the program is perceived to be quite interesting for further examination to be held in Indonesia. This activity has previously been carried out by the U.S. government, but it will be interesting if this activity is carried out by the student as a driving force to the families who have elderly at home. The criteria elderly who receive services through this program which is based on life expectancy in Indonesia namely; Elderly weak, elderly living alone, elderly who experience mobility problems and health, elderly, lonely and abandoned.

The type of services to be performed, among others; 1. Individual counseling 2. First medicine (health care) 3. Caregiver education (informative)

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The development program is carried out by forming groups based on interests that began with a meeting together to identify ways and tools needed to carry out those activities. A student as a representative establish and coordinate this program as implementation of these activities. For the development of citizen participation, then conducted monthly meetings. The program will also be carried out under the supervision of the university concerned and also one of the health care center and hospital in order to be more concrete implementation. This is because if the implementation of this program that are not yet able to handle multiple health problems as well as promotive for the elderly then further action left to piece clinic or hospital for further treatment.

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