Morning report Geriatri RSHS 07092023.pptx

morning report in geriatric division

1. Morning Report Geriatric Division Supervised by: Dr. Med. Sc. dr. Irma Ruslina Defi Sp.KFR-Ger ((K) dr. Istingadah Desiana. Sp.KFR-Ger (K) Maximizing mobility and bilateral hand use in geriatrics with unrehabilitated chronic stroke and co-existing anxiety and insomnia

2. IDENTITY Date Of Examination : 06/09/2023 Mr. HS Name 000 0426549 Medical Record December 19 th, 19 52 ( 70 years old) Born date Bandung Address Married Marital Status Sundanese Tribes Moslem Religion Retired star territorial soldier (lapsus) Occupation High school graduated Education Neurologist Referred by Referral diagnosis August 25 th 2023 Date of Referral Sequelae stroke

3. Chief complaint : Unstable and slow walking March 2021 Salamun Hospital June 2021 Salamun Hospital Neurologist August 2021 Salamun Hospital Neurologist September-December 2021 Salamun Hospital Neurologist Weakness of left extremities without loss of consciousness No dysarthria After onset brought to Salamun hospital (7 days hospitalization) → given medication without operative measure Patient does not know CT-scan result Known hypertension (200/120) ADL all dependent Weakness does not improve, still flaccid Consult to neurologist → suggestion to do injection for thrombolysis Injection was done, strength of upper extremity improve rapidly Difficulty in sleeping (+): entering and maintaining sleep ADL partial dependent (eating, grooming independent) Can move lower extremities, but not against gravity Suggestion to do 1 more injection Injection for thrombolysis was done, strength of lower extremity improve ADL partial dependent (eating, grooming, upper dressing independent) Able to walk with slow pace, with walker Patient asked to be moved to Melinda Hospital for closer access CPG 1x75 Bisoprolol 1x5 mg Amlodipine 1x10 mg Routine control to neurologist and internist

4. 2022-2023 Melinda Hospital May-August 2023 RSHS September 6th 2023 IKFR Able to walk with walker, progressively change to cane Difficulty in initiating sleeping (+) Complaint of palpitation and sweating on uncertain times, sometimes triggered by thinking about life problems. No complaint of easily tired, chest pain, swollen ankle, or awakening during night due to shortness of breath Because of possible long-standing hypertension complication, patient is referred to Hasan Sadikin hospital for echocardiography Patient routinely controlled in RSHS for hypertension, undergo additional examination: Doppler (May 2023) Myocardial Perfusion Study (August 2023) Consulted to Neurologist department for evaluation of sequelae stroke Unstable walking, felt weakness of left limb Slow speed during walking, climbing up and down stair Left arm still unable to carry >500 grams, unable to lift and carry with both arms Able to walk for 1 km, but stops every 500 meters because he feels tired Difficulty in memorizing recent events, forgets where he puts things, but still remembers daily routines Difficulty in initiating and maintaining sleep still present, able to sleep only 2.5 hours at night, felt tired in the morning. Only use alprazolam as sleep medication 1x/week. Easily feeling full after meal ADL partial dependent (expect eating with pacing) Alprazolam for sleeping medication Referred to RSHS Suggestion for carotid doppler study Consulted to rehabilitation department Rehabilitation program

5. Past Medical Condition No medical history condition Comorbidity Hypertension ( + ) , known 2021, controlled with antihypertensive DM (-) Coronary artery disease

6. History of Habit Smoking (+) since 40 years ago, occasional smoker 1-2 sticks/week Alcohol (-) Drug abuse (-)

7. Recent Medication Candesartan 1x16 mg Amlodipine 1x10 mg Bisoprolol 1x2.5 mg Clopidogrel 1x75 mg Uresix 1x20 mg Mecobalamin 2x500 mcg Simvastatin 1x40 mg Adalat oros (Nifedipine) 1x30 mg

8. Nutrition History of nutrition Before illness, patient still able to eat 3 times/day, with ric e, egg, meat or vegetable, finish all his food. Currently patient feel decrease of appetite since he was ill. He eats 2 times/day, only likes to eat rice and vegetable, occasionally eats egg or meat (around 1x/week). There was loss of body weight from 80 kg (2021) to 47 (2022), then he starts to gain more weight until now.

9. Physical Activity Before I llness Time Activity before illness METs 4 . 3 0 – 05. 3 Waking up and shalat 1.3 05.30 – 06.00 Take a bath 2.0 06.00 – 06.30 Breakfast 1.5 06.30 – 12.00 Sitting (watch TV) and help with h ouse chores 4.0-5.0 12.00 - 12.30 Lunch 1.5 12.30 – 1 7 .00 Gather with friends/meeting 1.5 17.00 – 19.00 Sitting 1.3 19.00 - 19.30 Dinner 1.5 19.30 - 20.30 Sitting , watching, chatting with family 1. 5 20.30 – 05.00 Sleep 1.0

10. Physical Activity After I llness Time Activity before illness METs 4 . 3 0 – 05. 3 Waking up and shalat 1.3 05.30 – 06.00 Take a bath 2.0 06.00 – 06.30 Breakfast 1.5 06.30 – 12.00 Sitting (watch TV) , chatting with family 1.5 12.00 - 12.30 Lunch 1.5 12.30 – 1 7 .00 Gather with friends 1.3 17.00 – 19.00 Sitting 1.3 19.00 - 19.30 Dinner 1.5 19.30 - 20.30 Sitting , watching, chatting with family 1. 5 20.30 – 05.00 Sleep 1.0 Average 1.6

11. History of Psycho and Socioeconomic Status PSYCHOLOGICAL CONDITION Patient often feels suddenly palpitated, anxious, and sweating without certain reasons. This feeling is sometimes triggered by thinking of his life and problems. He usually had bad dreams during sleep (always about the death of his twin). He has good relationship with his children, wife and grandchildren. Patient was and is still an active and extroverted person. He loves to go to veteran gatherings and association. Family hopes that patient can recover and do his daily activities as before he was hospitalized.

12. History of Psycho and Socioeconomic Status SOCIAL CONDITION He lives with his wife ( 68 years old), h is daughter ( 42 years old) and family; his son (44 years old) and family. His children move back to his house after he was sick. Family is very supportive of treatment. He had three children (one daughter and two sons) . Her first son had pass away (2012). His veteran association is very supportive of his recovery. He has good friend there. His main caregiver is his wife.

13. History of Psycho and Socioeconomic Status ECONOMIC CONDITION Daily expens e from pension fund , approximately 3 million per month The patient uses BPJS as health insurance.

14. History of Psycho and Socioeconomic Status HOUSE CONDITION He lived in a two-leveled house with 3 bedrooms, his activity is on the first floor. There is a sitting toilet on all bathrooms. Good ventilation and lighting. There is no obstacle upon entering the house. House is located near the main road.

15. Genogram

16. Physical Examination (11/8/2023) Consciousness : Compos mentis Blood Pressure : 1 73 / 106 mmHg Heart Rate : 88 x/minutes, reguler Respiratory rate : 2 x/minutes Temperature : 36. 7 C SpO2 : 9 7 % (room air) Nutritional status Body weight : 5 2 kg Height : 16 5 cm BMI : 19.10 ( normoweight )

17. a.r Head and Neck : Deformity (-) Conjunctiva anemic -/- , Scleral icterus -/- a.r Thorax : Shape and movement symmetric, retraction (-), abdominothoracic pattern Lung : VBS dextra = sinistra, ronchi -/-, wheezing -/-, secrete -/- Cor : BJ SI-II regular, Murmur (-), Gallop (-) Chest expansion : 3.5/3/3 cm a.r Abdomen : Soepel, ascites (-), bowel sound (+) normal Liver and lien not palpable a.r Upper Extremities: Look : Deformity (-), edema - / - Feel : warmth (-), CRT <2” Move : ROM : full/full, except : shoulder flexion: full/0-140 (empty end feel) Shoulder abduction full/0-140 (empty end feel) shoulder external rotation full/0-50 (empty end feel) MMT : 5/4 Spastisity: Shoulder internal rotator MAS 0/1 Brunnstorm stage 6 Physiological reflex : BTR ++/++ Pathological reflex : Hoffman tromner -/- Mid arm circumference 32/32 cm

18. a.r Lower Extremities: Look : Deformity (-), edema -/- Feel : tenderness (-), adhesion (-), edema -/-warmth (-), CRT <2” Move : ROM full/full MMT : 5/4, except: Hip extensor 5/3 Ankle dorsiflexor 5/2 Ankle plantarflexor 5/2 Spastisity: Brunnstorm stage 4 (dominant extensor synnergic pattern) Physiological reflex : APR (++/+++), KPR (++/+++) Pathological reflex : Babinsky -/- Calf circumference: 33/33 cm

19. BODY FUNCTION Cranial Nerve Interpretation I-VI, VIII-XI Normal/normal VII Motoric: Facial symmetrical Facial muscle strength Eyebrows raising: symmetrical Eyes closing: symmetrical Nasolabial fold: symmetrical Smiling: symmetrical Buccal tone: function/function Sensory: normal XII Tongue fasciculation (-), tremor (-), atrophy (-) Tongue movement functional to all direction Tongue deviation (-) CRANIAL NERVE FUNCTION

20. BODY FUNCTION MENTAL FUNCTION Emotional Function DASS Depression (8: N), Anxiety (14:moderate), stress (18: mild) Sleep Function Insomnia severity index 20 (Clinical moderate severity insomnia) Cognitive Function MOCA Ina 1 9 (m ild cognitive impairment)

21. 20

22. SENSORY FUNCTIONS AND PAIN Function Items Result Description Seeing function Visual acuity Not tested, normal by impression Hearing function Whispering test Not tested, normal by impression Proprioceptive function Joint position sense normal Light touch function Dermatomal normal Pain in body part No pain BODY FUNCTION

23. FUNCTION OF THE CARDIOVASCULAR SYSTEMS Function Items Result Description Heart functions Heart rate 88 x/minute   Heart rhythm Regular   Contraction force of ventricular muscles Adequate pulse Blood vessel functions Function of arteries Carotid doppler: thickening carotis bilateral   Function of capillaries CRT<2 sec   Function of veins JVP 5+2 cm H2O Blood pressure functions   1 73 / 106 mmHg BODY FUNCTION

24. FUNCTION OF THE RESPIRATORY SYSTEM Function Items Result Description Respiratory function Respiratory rate 2 x/minute Respiratory rhythm Abdominothoracic Depth of respiration normal Respiratory Muscle function   Respiratory muscle function Chest Expansion, adequate 3.5 / 3 / 3 cm Additional respiratory function Single breath count test : 25 Cough ability : adequate BODY FUNCTION

25. SENSATION AND THE CARDIORESPIRATORY FUNCTION Function Items Result Description Cardiorespiratory function   Oxygen saturation 9 7 % room air Exercise tolerance function   General physical endurance Can walk 500 m until fatigue Aerobic capacity 6MWT: METs 2.1 Fatigability Fatigue Severity Scale : 21 /63 (no fatigue) BODY FUNCTION

26. Fatigue severity scale Score total: 21 (No Fatigue)

27. FUNCTION OF THE HEMATOLOGICAL AND IMMUNOLOGICAL SYSTEMS Function Items Result Description Hematological system functions Production of blood No data Oxygen-carrying functions of the blood No data Immunological system functions Immune response No data BODY FUNCTION

28. FUNCTION RELATED TO THE DIGESTIVE SYSTEMS Function Items Result Description Swallowing function Oral Swallowing Pharyngeal swallowing GUSS 20/2 Defecation Function Elimination of feces Spontaneous Fecal consistency Bristool type 3-4 Frequency of defecation Once a day No incontinence Fecal continence Weight maintenance functions MNA : 18 ( at risk of malnutrition ) Sensation associated with the digestive system Sensation of nausea No nausea Loss of appetite Present since 2 years ago BODY FUNCTION

29. GUSS 5 5 5 5 20

30. 1 1 1 1 2 2 1 1 1 1 0.5 1 1 0.5 18 ✓ 3

31. GENITOURINARY FUNCTION Function Items Result Description URINARY FUNCTION Urinary filtration function Filtration of urine Ureum : 15.6 Creatinine: 0.8 4 Urinary function Urination Spontaneous Frequency of urination 5-6 x/day Urinary continence Continence Sensation associated with urinary function   present BODY FUNCTION

32. NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTION Functions of the Joints and Bones Function Items Result Description Mobility of joint functions Mobility of joint functions ROM full/full, except shoulder external rotation full/0-50 (empty end feel), shoulder flex ion full/0-140, shoulder abduction full/0-140 (empty end feel) Stability of joint functions Stability of joint functions   Normal MUSCLE FUNCTIONS Muscle power functions MMT Brunnstorm stage Upper extremity: 5/4 Lower extremity: 5/4, except: hip extensor 5/3, ankle dorsiflexor 5/2, ankle plantarflexor 5/2 UE 6 LE 4 Muscle tone functions normal tone Muscle endurance functions Handgrip Strength 25/10 kg MOVEMENT FUNCTIONS Motor reflex functions Physiological reflex BTR +2/+2+, KPR +2/+ 3 , APR +2/+ 3 Pathological reflex Hoffman tromner -/-, Babinsk y -/- Morse Fall Scale Risk of Fall 40 ( Low risk of fal l ) BODY FUNCTION

33. 15 15 10 40

34. BODY FUNCTION NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTION Involuntary movement reaction   Balance / postural control Sitting supported Sitting unsupported Good Good     Standing unsupported static dynamic Good Fair   Clonus   -/-   Coordination finger to nose heel to shin Good/good Good/good  

35. BODY FUNCTION NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTION Assessment Tool Result Interpretation Berg Balance Scale (BBS) 4 4 Needs cane indoor and outdoor Fear efficacy scale 24 Moderate concern

36. Sitting unsupported 4 Standing unsupported 4 Standing with eyes closed 4 Standing with feet together 3 Standing on one foot 1 Turning to look behind 3 Retrieving object from floor 3 Tandem standing 2 Reaching forward with outstretched arm 3 Sitting to standing 4 Standing to sitting 4 Transfer 4 Turning 360 3 Stool stepping 2 Total 44/56

37. Functions of the Skin Function Items Result Description Protective functions of the skin Protective function of the skin Ulcer (-) Dry skin at extremities ( - ) BODY FUNCTION FUNCTIONS OF THE SKIN AND RELATED STRUCTURES

38. SCREENING SARCOPENIA BODY FUNCTION TOOLS Result Interpretation SARC-F SARC-Calf AWGSOP 5 1 5 S arcopenia Suggestive of sarcopenia S arcopenia

39. SCORE : 5 (Sarcopenia)

40. 1 5

41. AWGSOP: Sarcopenia Calf Circumference 3 3 cm/3 2 cm

42. SCREENING FRAILTY TOOLS Result Interpretation Fried Frailty Phenotype 4 Frailty Clinical Frailty Scale Frailty index 40 4 0. 2875 Vulnerable Frail BODY FUNCTION

43. Fried Frailty Fenotip (4 = Frailty)

44. Total : 1 1.5 /40 = 0, 2875 (frail)

45. GERIATRIC GIANTS ADA TIDAK ADA Isolation √ Instability √ BBS 44 Impecunity √ Intellectual impairment √ MOCA Ina 1 9 /30 Impairment of vision √ Impairment of hearing √ Immobility √ Demmi score 74/100 Infection √ Immune deficiency √ Inanition √ MNA 1 8 Insomnia √ Insomnia severity index 20 Impaction √ Incontinency √ Iatrogenic √ BODY FUNCTION

46. Doppler Echocardiography (22/05/2023) Conclusion : Normal all chambers dimension, concentric LVH Normal LV systolic function with global normokinetic at rest LV Diastolic dysfunction grade I Normal anatomy and function of all valves, low probability of PH Normal RV systolic function BODY STRUCTURE

47. Carotid Doppler (21/08/2023) Tidak tampak plak pada arteri karotis komunis dan arteri karotis interna Normal flow pada arteri karotis komunis, karotis interna kanan dan kiri, karotis eksterna kanan dan kiri Tampak penebalan arteri karotis komunis bilateral

48. Sidik Perfusi Miokard (28/08/2023) Defek perfusi demikian menunjukkan adanya iskemia miokard reversibel parsial luas terutama pada area pembuluh darah RCA, LAD, dan sebagian kecil LCx (3VD) Seluruh segmen ventrikel kiri masih viabel Tidak tampak dilatasi ventrikel kiri dengan fungsi global ventrikel kiri masih baik, nilai fraksi ejeksi saat istirahat 65% Ischemic burden : 8.8% Stratifikasi resiko : High risk

49. Test Normal Value 10 / 4 Kolesterol Total < 200 164 Kolesterol HDL >= 60 40 Kolesterol LDL < 100 127 Trigliserida < 150 103 HbA1c 4.5-6.2 5.1 Glukosa Puasa 70-100 92 Glukosa 2 Jam PP < 140 122 SGOT 15-37 18 SGPT 0-55 18 Ureum 18-55 15.6 Creatinine 0.72-1.25 0.84 Asam Urat 3.5-7.2 7.6

50. AREA ACTIVITY ITEMS RESULT Receiving Messages Spoken messages Able Nonverbal messages Able Written messages Able Producing Messages Speaking speech Able Nonverbal messages Able Writing messages Able

51. ACTIVITY AREA ITEM RESULT Changing basic body position Lying down able Sitting without support Able Maintaining a body position Maintaining a lying position able Maintaining a sitting position Able

52. ACTIVITY AREA ITEM RESULT Walking Short distances Able Long distances Able On different surfaces Not tested Around obstacles Not tested Moving around Crawling Not tested Climbing Not tested Running Not tested Jumping Not tested Swimming Not tested Moving around in different locations Within the home Not tested Within building outside the home Not tested Outside the home and other buildings Not tested Moving around using equipment Walking aids Able, handcrafted single cane Wheelchair Not tested ACTIVITY AREA ITEM RESULT Transferring oneself While lying A ble Able While sitting

53. ACTIVITY AREA ITEM RESULT Using transportation Using private motorized transportation Not tested Using public motorized transportation Not tested Driving Driving human-powered transportation Not tested Driving motorized vehicles Not tested

54. ACTIVITY AREA ITEM   RESULT Fine hand use Picking up A bl e, up until 500 gr Grasping able Manipulating Unable Releasing able Carrying, Handling, and Moving Object

55. No. Activities Score 1 Bowel control 10 2 Bladder control 10 3 Grooming 5 4 Toileting 1 5 Eating 10 6 Transfer 15 7 Mobilization 15 8 Dressing 10 9 Stairs 1 10 Bathing 5   Total 10 0/100

56. ACTIVITY AREA ITEM   RESULT Washing oneself Washing body parts Able Washing whole body Able Drying oneself Able Caring for body parts Caring for skin A ble Caring for teeth Able Caring for hair Able Caring for fingernails Able Caring for toenails Able Toilet use Able Bladder Regulating urination A ble Bowel Regulating defecation Able Dressing Putting on clothes Able Taking off clothes Able Putting on footwear Able Taking off footwear Able Choosing appropriate clothing Not tested

57. ACTIVITY AREA ITEM   RESULT Eating Bringing it to the mouth and consuming it in acceptable ways Able Cutting food into pieces Able Using eating implements able Drinking Taking hold of a drink and bringing it to the mouth able Opening bottles and cans Not tested Pouring liquids for drinking Not tested Looking after one’s health Ensuring one’s physical comfort Able Managing diet and fitness Able Maintaining one's health Able

58. ACTIVITY AREA ITEMS RESULTS Acquisition of goods and services Shopping Able Gathering daily necessities Able Preparing meals Preparing simple meals Able Preparing complex meals Able Doing housework Washing and drying clothes and garments Not usually do Cleaning cooking area and utensils Able Cleaning living area Able Using household appliances Able Storing daily necessities Able Disposing of garbage Able

59. Participation Item Results General interpersonal interactions he is an friendly and extrovert person Particular interpersonal relationships Formal relationships he did not have formal relation. Informal social relationships he has good informal relationship with neighbour Family relationships Close to his family.

60. PARTICIPATION ITEM RESULT Community life Informal Association Routinely recital Formal Association Veteran’s club and community gathering Ceremonies None Recreation and leisure Sport None Hobbies None Socializing Patient socialized with her neighbors and peers Religion and spirituality Pray at home and mosque Self-satisfaction EQ 5D : 21112 EQ VAS : 60 %

61. Products and technology Result For personal use in daily living A ble For personal indoor and outdoor mobility and transportation A ble For communication Able For culture, recreation and sport A ble For the practice of religion and spirituality A ble Design, construction and building products and technology of building for public use A ble

62. RELATIONSHIP RESULT Immediate family Live with his son, daughter, son in law, dau ghter in law, 6 grandchildrens and his wife Friends Has good relationship with friends Personal care providers and personal assistants wife, at home and hospital Caregiver Burden No burden (Zarit Burden Scale : 8 ) AREA ITEMS RESULTS Health Health services Near health service Health systems Use BPJS Health policies No obstacle to use BPJS

63. NO Pertanyaan Nilai 1 Apakah anda merasa bahwa saudara anda tersebut meminta pertolongan lebih banyak dari yang dibutuhkan? 1 2 3 4 2 Apakah anda merasa kehabisan waktu untuk diri anda sendiri karena harus merawat saudara anda tersebut? X   3 Apakah anda merasa tertekan antara merawat saudara anda dan kewajiban lain di dalam keluarga dan pekerjaan? x   4 Apakah anda merasa malu dengan kelakuan saudara anda tersebut? x   5 Apakah anda merasa marah jika anda berada di dekat saudara anda tersebut? x   6 Apakah anda merasa saudara anda tersebut pada masa ini berpengaruh negatif terhadap hubungan anda dengan anggota keluarga yang lain atau teman-teman? x   7 Apakah anda khawatir tentang masa depan saudara anda tersebut? x   8 Apakah anda merasa saudara anda tersebut tergantung pada anda? x 9 Apakah anda merasa tegang bila anda berada di dekat saudara anda? x 10 Apakah anda merasa kesehatan anda terganggu karena mengurus saudara anda tersebut? x   11 Apakah merasa tidak punya cukup kebebasan/keleluasaan pribadi bagi anda sendiri karena mengurus saudara anda tersebut?  x   12 Apakah anda merasa bahwa kehidupan sosial and terganggu karena anda merawat/mengurus saudara anda tersebut? x   13 Apakah anda merasa tidak nyaman bila teman-teman berkunjung karena anda mengurus saudara anda tersebut? x   14 Apakah anda merasa bahwa saudara anda tersebut kelihatannya mengharapkan perhatian anda seolah-olah anda adalah satu-satunya orang yang dapat diharapkan? x   15 Apakah anda merasa tidak punya cukup uang untuk merawat saudara anda dengan kondisi keuangan anda?   x 16 Apakah anda merasa tidak mampu merawat saudara anda tersebut lebih lama lagi? x   17 Apakah anda merasa kehilangan kendali terhadap kehidupan anda sejak saudara anda sakit? x   18 Apakah anda mengharapkan dapat mengalihkan perawatan saudara anda tersebut kepada orang lain saja? x   19 Apakah anda merasa tidak tahu harus berbuat apalagi terhadap saudara anda? X   20 Apakah anda merasa harus berbuat lebih banyak lagi untuk saudara anda? X   21 Apakah anda merasa dapat melakukan tugas merawat saudara anda dengan lebih baik? x   22 Secara keseluruhan, seberapa berat beban yang anda rasakan dalam merawat saudara anda?  x   Zarit Burden Mrs. S (Patient’s wife ) Total Score = 8 ( No burden)

64. Comprehensive Geriatric Assessment Total Score Detail Impression 1 ADL Barthel 10 /100 Independent in all aspect Full independent ADL 2 I-ADL 7/8 High Function, Independent 3 MOCA INA 1 9 /30 Impaired executive, abstr action , delayed recall Moderate cognitive impairment 4 Mini Nutritional Assessment 18 At risk of malnutrition 5 Insomnia severity index 20 Clinically insomnia (moderate insomnia) 6 DASS 26 Depression: 9; Anxiety: 9; Stress: 8 Mild Anxiety 7 SARC-F 5 > 4 = sarcopenia Sarcopenia

65. 69 Total : 7 /8 High Functioning

66. Comprehensive Geriatric Assessment Total Score Detail Impression 8 Sarc-Calf 1 5 calf circumferential < 34 Suggestive of s arcopenia 9 AWGSOP Calf circumferences 3 3 /3 3 Sarc-F 5 Sar c Calf 1 5 S arcopenia 10 Clinical Frailty Scale 4 Not dependent to others for help, slowed up and/or easily tired during the day Frail 11 Fried Frailty Phenotype 4/5 4 out of 5 phenotypic criteria (reduce grip strength, low physical activity, fatigue) Frailty 12 Frailty index- 40 0. 2875 pre-frail apabila skor FI 0,08-0,25 frail apabila skor FI>=0,25 Frail 1 3 GUSS 20/20 Indirect 5/5 direct 15/15 safe oral intake (solid) 1 4 Demmi score 74 Can walk with assistive device

67. 17 74 11 6

68. Comprehensive Geriatric Assessment Total Score Detail Impression 1 5 Fatigue severity scale 21 /63 No Fatigue 1 6 Morse fall scale 40 Low Risk 17 EQ5D 21112 mobilization, anxiety/depression 18 EQ5D VAS 6 0% 19 Zarit burden scale 8 No burden

69. Case Resume A 70 years old man was diagnosed with chronic stroke, hypertensive heart disease, and coronary artery disease. Chief complaint was unstable and slow walking. Stroke occurred 2 years ago, coronary artery disease was diagnosed in 2022 . He had history of hypertension. From anamnesis and physical examination, it was found: He had unstable and slow walking. Berg balance scale was 44, needs to use cane to walk. There is weakness on his left extremities of MMT 4, except for MMT 2 in ankle dorsiflexion. Spasticity is MAS 1, Brunnstorm stage 4. No deficit in sensibility, propioception, and coordination. He cannot manipulate and lifting weight with his left hand and arm, although MMT is 4 and Brunnstrom stage 6. No deficit in sensibility, propioception, and coordination. Stiffness in his left shoulder, limited but functional ROM of shoulder flexion, abduction, and external rotation. Frequent palpitation, sweating with unclear cause, sometimes when thinking about his life problems. Examination of myocardial perfusion shows defect of perfusion reversible partial, especially in RCA, LAD, and LCx (3VD). Moderate anxiety with DASS score anxiety 14 (moderate) and stress 18 (mild) He had mild cognitive impairment with MoCA-INA 19 and deficit in executive function, memory, and abstraction. Laboratorium shows low HDL, high LDL, and high uric acid. He lost appetite since 2 years ago with risk of malnutrition with MNA score of 18. ADL all independent. Moderate to severe burden for primary caregiver. Good family support and caregiver He has frailty and sarcopenia. He is still socially active and involved in community

70. Problem List Medical Problem -Stroke Chronic Phase -Hypertensive Heart Disease -Coronary Artery Disease -Geriatric syndrome (instability, intellectual impairment, immobility, inanition, insomnia, frailty, sarcopenia) Rehabilitation Problem -Mobilization disturbance -Balance disturbance -Hand function disturbance -Suspected cardiopulmonary endurance disturbance -Psychosocial disturbance (anxiety) -Geriatric syndrome (instability, intellectual impairment, immobility, inanition, insomnia, frailty, sarcopenia)

71. Prognosis Ad vitam : Dubia ad malam Among adults with stroke, those with poor sleep have a 76% greater risk of early death than those with normal sleep. Unrecognized and untreated sleep disorders may influence rehabilitation efforts, lead to poor functional outcomes following stroke, and increase the risk of stroke recurrence. Data from several studies suggest that sleep and sleep loss bidirectionally alter structural plasticity, which can affect the functional output of the brain in terms of alertness and mood. Niu, S.; Liu, X.;Wu, Q.; Ma, J.;Wu, S.; Zeng, L.; Shi, Y. Sleep Quality and Cognitive Function after Stroke: The Mediating Roles of Depression and Anxiety Symptoms. Int. J. Environ. Res. Public Health 2023, 20, 2410. https://doi.org/10.3390/ ijerph20032410 In summary, insomnia, old age, stroke recurrence in the first-year follow-up and hypertension were high-risk factors for mortality over 6 years of follow-up in the large sample of patients with first-ever stroke. Participants with insomnia suffered a higher recurrence of stroke during the first year of follow-up. Whether prompt and efficient interventions for insomnia can decrease mortality in patients with first-ever stroke is still ambiguous Li L, Yang Y, Guan B, et alInsomnia is associated with increased mortality in patients with first-ever stroke: a 6-year follow-up in a Chinese cohort studyStroke and Vascular Neurology 2018; 3: doi: 10.1136/svn-2017-000136

72. Ad sanationam : dubia ad malam The principal findings of this study are that (1) the cumulative 10-year risk of a first recurrent stroke was ≈40%; (2) after the first year after first-ever stroke, the average annual risk of recurrent stroke was ≈4%; (3) ≈40% of recurrent stroke events were fatal within 30 days, which is nearly twice the 30-day case fatality of a first-ever stroke; (4) about one seventh of 10-year survivors of first-ever stroke require institutional care; and (5) almost one half of 10-year survivors of stroke are disabled. we indicated that the most important predictors of poor outcome (death, institutionalization, or disability) at 5 years after stroke were increasing age, prestroke disability, severe stroke-related deficits at onset (severe hemiparesis, urinary incontinence), presence of risk factors for recurrent stroke (current smoking and intermittent claudication), and occurrence of recurrent stroke. Thus, once a stroke has occurred, the only modifiable factors for functional outcome are continued smoking and recurrent stroke. Hardie K, Hankey GJ, Jamrozik K, Broadhurst RJ, Anderson C. Ten-year risk of first recurrent stroke and disability after first-ever stroke in the Perth Community Stroke Study. Stroke. 2004 Mar 1;35(3):731-5.

73. Prognosis Ad functionam : ad bonam Mobilization : community ambulator with cane Able to do bimanual lifting to help household chores Able to do manipulation with left hand

74. Target Oriented Rehabilitation Goal Rehabilitation Problems Short Terms (<1 months) Mid Terms (1-3 months) Long Terms (>3 months) Instability (balance disturban ce) BBS 4 5 (standing with feet together) Fear of fall 22 (walking up and down slope, cleaning the house) BBS 4 6 ( tandem standing) Fear of Fall 21 (walking on uneven surface, walking around in neighborhood ) BBS 47 (standing with one leg) Fear of fall 19 (walking on uneven surface) Immobility Walking speed 0.41 m/s Walking speed 0.6 m/s Walking speed 0.8 m/s Psychological Disturbance DASS: A: 12 S: 16 DASS: A: 9 S: 14 DASS: A: 7 S: 12 Cardiopulmonary endurance Functional capacity improved METs 2.5 Functional capacity improved METs 3.0 Functional capacity improved METs 3.5 Sarcopenia Decrease sarcopenia (SARC-F < 4) Decrease sarcopenia (SARC-F: 2-3) Decrease sarcopenia (SARC-F: 2-3)   Frailty Decrease frailty (CFS 5) Decrease frailty (CFS 4) Decrease frailty (CFS 3) Risk of Malnutrition MNA 19 MNA 20.5 MNA 22 Hand function disturbance Improvement in hand power Able to lift with both hand Able to manipulate Intellectual impairment Maintain cognitive function (MOCA-Ina 19)

75. Target Oriented Rehabilitation Program Rehabilitation Problems Short Terms (<1 months) Mid Terms (1-3 months) Long Terms (>3 months) Instability (balance disturban ce) Strengthening exercise Balance exercise Strengthening exercise of left lower extremity Immobility Same as instability program Stretching and flexibility exercise of left lower extremity Same as instability program Stretching and flexibility exercise of left lower extremity Walking exercise on treadmill Psychological Disturbance Consult to psychologist for possible anxiety Consult to psychiatry if anxiety problem is not solved Cardiopulmonary endurance Cardiopulmonary endurance exercise by ground walking exercise Cardiopulmonary exercise by treadmill and ground walking exercise Risk of Malnutrition Education about nutritional intake (water and protein) Education about nutritional intake and same as psychological disturbance program Sarcopenia Same as immobility, cardiopulmonary endurance, and malnutrition program Frailty Same as immobility and cardiopulmonary endurance program Hand function disturbance Strengthening exercise Bimanual activity training Hand manipulation training Intellectual impairment Cognitive stimulation and training

76. Rehabilitation program Mobilization disturbance Clinical Target Obstacle Potency Program • Balance problem • Weak lower left extremity • Spasticity • Suspected low cardiopulmonary endurance (METs 2.1) Increased flexibility Improved balance Decreased spasticity Increased cardiopulmonary endurance • Hypertension • At risk of malnutrition (MNA 1 8 ) • Low physical activity • No fatigue • Demmi score 74 • High motivation to exercise • Good family support and financial source ● Flexibility training of lower left extremity ● Stretching and inhibition of spasticity on knee extensor, hip adductor, hip extensor, ankle plantarflexor Aerobic exercise with supervision F : 5-6x/ wk I : Light intensity by talk test T : 30 minutes T : treadmill and/or ground walking exercise

77. Rehabilitation program 2. Hand and arm function disturbance Clinical Target Obstacle Potency Program • Stiffness of shoulder • Unable to lift >500 gr on left hand • Unable to manipulate on left hand • Fair power and prehension of left hand Able to use left hand as supporting for bimanual lifting Able to manipulate with left hand Mild cognitive impairment Shoulder adductor spasticity MAS 1 Good muscle power Preserved sensibility and propioception Brunnstrorm stage 6 Good support from family and financial source ● Hand and arm function training ● Flexibility training of left upper extremity

78. Rehabilitation program 3. Moderate Anxiety Clinical Target Obstacle Potency Program • DASS score anxiety 14 (moderate), stress 18 (mild) DASS score anxiety 9 (mild), stress 14 (mild) • Mild cognitive impairment • Possible concurrence of cardiac problem Good family relationship Good social suppport and no isolation ●Consult to psychologist and con tinue to psychiatry if anxiety not solved Routine control to cardiologist for CAD medication

79. Rehabilitation program 4. M alnutrition Clinical Target Obstacle Potency Program • MNA 18 MNA 24 Easily feeling full Preference (do not like meat) GUSS 20/20 No financial issue Education of balanced nutritional intake (increase in protein and water intake), increase in frequency of intake Same as psychosocial program

80. Rehabilitation program 5 . Intellectual impairment Clinical Target Obstacle Potency Program • Moca Ina score 1 9 /30 •Maintain moca ina Chronic stroke Anxiety and stress • not demented Cognitive stimulation and training Preventing social isolation by actively participating in community activity

81. Rehabilitation program 6 . Sarcopenia & Frailty Clinical Target Obstacle Potency Program Sarc F: 5 AWGSOP: sarcopenia CFS : 4 Improvement of SARC-F to 2-3 Decrease CFS to 3 Poor nutritional intake Low physical activity Preserved strength of upper and lower extremity No financial burden Same as immobility, cardiopulmonary endurance, and malnutrition program

82. THANK YOU

83. PENGKAJIAN KUALITAS HIDUP (EQ 5D) Bagian kedua EQ-5D (VAS) Pasien diminta untuk menggambarkan kondisi kesehatannya pada skala 0 -100 (0 jika sangat buruk dan 100 jika sangat baik) Misal : pasien menunjuk angka 35, maka tingkat kesehatan yang dirasakan 60% (VAS 60%) Hasil 20%