Utilization of Comprehensive Geriatric Assessment (P3G) in Primary Health Center at Medan City and Deli Serdang District of North Sumatera Province Indonesia

Abstract

The Ministry of Health of the Republic of Indonesia has issued Comprehensive Geriatric Assessment (P3G) guidelines in 2017, but data regarding its use in health care institutions are still limited. Community health centers as the spearhead of primary care always accept geriatric patients and should utilize CGA. The objective is to find out the results of using a comprehensive assessment guide for geriatric patients at the Medan City Health Center and Deli Serdang Regency Health Center in 2018. This research was conducted using a descriptive method with a cross-sectional design, the respondents taken were elderly people seeking treatment at three health centers, namely Sukaramai Health Center, Medan City, Bandar Khalipah Health Center and Tanjung Rejo Health Center, Deli Serdang Regency in the period August and September 2018. The number of respondents was taken using the Slovin method, data collection was carried out through questionnaire interviews and data analysis using SPSS. There were 120 respondents, 60.8% of respondents experienced mild- moderate dependence. In the IADL examination, 89.2% were still able to carry out activities independently. The results of checking the risk of falling showed that 57.5% of respondents experienced a low risk. On the GDS examination, 67.5% of respondents did not experience depression. In the Mini-Cog examination, 78% of respondents had normal cognitive function. On the MMSE examination, 80.8% of respondents’ cognitive function was still normal. On the AMT examination, 73.3% of respondents did not experience memory problems. In the MNA screening examination, 66.7% of respondents did not have nutritional problems. Conclusion: Most of the elderly who come to the health center are in the age range 60–74 and still have good functional abilities.

1. Introduction

Elderly health maintenance aimed to keep the elderly healthy and productive socially and economically. For this reason, it is necessary to have health service facilities to facilitate the elderly so that they can live independently and productively socially and economically. Apart from the right to health, seniors also have the same rights in social, national and state life. Efforts to improve the welfare of the elderly are directed so that the elderly are still empowered so that they can play a role in development activities by taking into account the functions, skills, age and physical condition of the elderly [1].

One of the successful impacts of health development is the reduction in birth rates, morbidity and mortality rates as well as an increase in the life expectancy of the population. Based on data, Life Expectancy (UHH) in Indonesia has increased from time to time. From 68.6 years in 2004 to 70.6 years in 2010. In 2022 it will increase to 72 years. This condition resulted in an increase in the number of elderly people. According to the results of the 2010 Population Census, the elderly population in Indonesia is 18.04 million people or 7.6% of the total population. In 2025 it is estimated that the number of elderly people will increase to 36 million people [2].

The increasing number of elderly people will also affect the number of dependency burdens. The old dependency ratio is a number that indicates the degree of dependence of the elderly on the productive age population. This figure is a comparison between the number of elderly people (60 years and over) and the number of productive people (15–59 years). To reduce the burden of dependency, the efforts made so that the elderly can live independently and remain productive must be increased. Naturally the process of getting old causes a person to experience physical and mental, spiritual, economic and social changes. One of the very basic problems in the elderly is health problems so that health coaching is needed in the pre-elderly and elderly groups, even from an early age (Figure 1) [3].

Figure 1.

Flow of services for elderly patients in primary care health facilities.

Primary health care facilities as the leading unit in public and individual health services are available in all districts and even every village in Indonesia. In this regard, Primary Health Service Facilities are expected to be able to carry out promotive, preventive, curative and rehabilitative efforts and hospital transition care for the elderly [4]. Elderly health services in Primary Health Care Facilities must be carried out in a professional and quality manner, complete, integrated and integrated with due regard to the elderly aspects of the elderly [5].

The Ministry of Health of the Republic of Indonesia has published the 2017 Comprehensive Elderly Assessment (P3G) guidelines for use in comprehensive elderly health checks at first-level health care facilities. P3G is part of the Comprehensive Elderly Management (CGM) with a multidimensional assessment approach, in the form of medical, psychosocial, functional abilities and limitations of elderly patients. In general, Indonesian sociodemographics, the ratio of the percentage of elderly women is higher than that of men (53.3, 46.7). In order to improve the quality of elderly health services in primary health care facilities, a handbook for elderly health services is needed [6].

2. Elderly health services at primary health service facilities

Primary health service facilities are health service facilities that carry out community health efforts and individual health efforts at the first level, by prioritizing promotive and preventive efforts, to achieve the highest degree of public health in their working area [7]. The implementation of elderly health services in Primary Health Service Facilities is carried out in a comprehensive manner with the following principles [8]:

1. Providing good and quality service

2. Prioritize services for the elderly and provide safe and easily accessible facilities

3. Provide support/guidance to the elderly and their families on an ongoing basis in maintaining and improving their health, so that they remain healthy, independent and active

4. Carry out services proactively to be able to reach as many elderly targets as possible in the working area of the Primary Health Service Facilities through service activities outside the building;

5. Coordinating with cross-programs using a life cycle approach as one of the approaches to realizing healthy, independent and active elderly; And

6. Collaborating with cross-sectors, including social organizations and the business world on a partnership basis, to provide services and coaching in order to improve the quality of life for seniors.

7. Elderly services at Primary Health Care Facilities are provided to elderly patients in accordance with the competence of general practitioners at Primary Health Care Facilities

2.1 Definition of elderly

Elderly or geriatrics comes from the words geros (old) and iatrea (maintenance); so it is clear that the science of old age is part of medicine and gerontology which specifically studies health and diseases in the elderly. Elderly patient also refers to the condition that he is 60 years and over. Elderly patients have a number of characteristics that differentiate them from adults in general [9].

2.2 Elderly characteristics

Elderly patients have several characteristics, namely multipathology, atypical appearance of symptoms and signs, decreased physiological reserve, usually accompanied by impaired functional status and in Indonesia generally with nutritional disorders. Multipathology refers to the notion that an elderly patient has more than one disease at the same time. The diseases he suffers are usually accumulations of degenerative diseases that have been attached to him for years and due to certain acute conditions result in the patient having to be hospitalized or being forced to lie at home (bedridden). This multipathological condition causes the symptoms and signs that appear in a patient to be unclear [10].

2.3 Symptoms and signs

signs and symptoms of elderly patients are usually not typical. For example, an elderly patient with pneumonia rarely shows the full range of symptoms, such as fever, cough, shortness of breath and leukocytosis. Symptoms that often appear are loss of appetite, general weakness and on physical examination, disturbances of consciousness such as apathy or delirium can be seen. Likewise, elderly patients with a premorbid history of osteoarthritis in several large joints who have congestive heart failure, often come to the emergency department with complaints of ‘falling’. On further anamnesis, there were no complaints of shortness of breath, dyspnoea d’effort or paroxysmal nocturnal dyspnea. In addition to changes in consciousness and ‘falls’, the presenting symptoms of elderly patients are often milder than the actual severe condition.

Due to the course of age, the function of the elderly organs will decrease. This decrease in physiology will have the consequence of decreasing the reserve power of the physiology. For example, an elderly patient suffering from pneumonia is usually accompanied by decreased non-specific immune systems such as decreased respiratory ciliary activity and cough reflex. Both of these make it impossible for elderly patients to be treated only with antibiotics and mucolytics; several efforts are needed to increase the non-specific resistance of the body such as tapping, breathing exercises and postural drainage. Another example, for example, is a decrease in the number of kidney glomeruli that causes drug administration in elderly patients to require consideration of dose adjustments (because drug excretion is mostly through the kidneys) [11].

Elderly patients also often come for treatment with impaired nutritional status. Malnutrition is often not noticed by patients and their families until the patient actually falls into a state of poor nutrition. Body mass index describes nutritional status more accurately. Deficiency of vitamins and minerals often accompanies undernutrition and malnutrition [12].

These various characteristics cause a doctor or nurse to have high sensitivity in compiling a list of diagnoses or a list of patient health problems in order of priority. A medical diagnosis alone will not adequately describe the patient’s health problems. Conditions of immobilization, inability to transfer the body independently, difficulty eating, communication disorders are some examples of health problems that often escape medical diagnosis, even though they greatly affect the overall success of treatment [13].

2.4 Principles of management of elderly patients

In the management of health problems in the elderly, it is necessary to pay attention to the characteristics of elderly patients that can affect clinical appearance, the management program provided, including drug administration, as well as the risks of potential complications. Functional status is a very useful monitoring tool in assessing the severity of the disease and the success of treatment [14].

2.5 Principles of drug administration

Starting from a low dose and increasing gradually until you get the desired effect (Start Low and Go Slow), except for giving antibiotics. As far as possible the patient should not take too much medicine; even though there is no agreement on the term polypharmacy itself, at least if there is one type of drug that is not properly indicated then monitoring of adverse effects should be carried out. The more drugs consumed, the higher the iatrogenic risk that may occur. It often happens that patients submit subjective complaints which turn out to be side effects of the drugs given, so doctors must carry out periodic reviews of the drugs the patient is taking [14].

2.6 Pharmacokinetics

Drug pharmacokinetics greatly influence the effect of treatment in elderly patients. A decrease in the composition of body fluids and an increase in the central fat component will affect the concentration of the drug in the target organs. For drugs that are fat soluble (lipophilic), they will be dissolved and bound longer in tissues (especially the central nervous system) thereby extending the half-life; the clinical implication is that the dose of lipophilic drugs should be sparing. For water-soluble (hydrophilic) drugs, the concentration in plasma will increase so that the dose needs to be lowered [15].

Drug metabolism occurs in the liver via conjugation or oxidation pathways [16]. Oxidation pathways that use cytochrome P-450 enzymes will experience a decrease in activity with increasing age. So that drugs that will be metabolized through this pathway need to pay attention to the amount of dose. The conjugation pathway usually does not decrease in activity as a person ages. Once metabolized, the drug will be excreted through the kidneys. The number of glomeruli and kidney function will gradually decrease according to a person’s age so that drugs that are excreted only through the kidneys have a risk of accumulation. Drugs that besides having renal and liver (bile) excretion pathways will have a lower risk [14].

2.7 Pharmacodynamics

After the drug enters the blood circulation it will be bound to albumin. Each drug has a different affinity for albumin. The higher the affinity, the lower the concentration in plasma and the lower the binding to albumin, the higher the free level in plasma. This will affect the distribution and pharmacodynamics or drug effects in body tissues [14].

3. Health services for the elderly

Health services for the elderly who come to the Primary Health Care Facilities should be provided in a special room so that the elderly do not have to queue together with other public patients. However, if the condition of the Primary Health Service Facility is not possible, it can be carried out in the general examination room with the condition that elderly patients must be prioritized [5].

4. Comprehensive geriatric assessment

Every elderly who visits a primary health care facility on their first visit or contact with a health worker will carry out a plenary assessment program using the Comprehensive Geriatric Assessment or Pengkajian Paripurna Pasien Geritri (P3G), which is an interdisciplinary diagnostic process, to determine medical problems and capabilities, functional abilities, psychosocial and environment for elderly patients. Because the characteristics and syndromes in elderly patients are different, a special bio-psycho-social oriented approach is needed for each elderly patient which is absolutely necessary for complete management [6].

This plenary assessment itself is a basic instrument that must be owned by every doctor, nurse, nutritionist, physical therapist and others who manage elderly patients according to their respective competencies. With P3G health workers carry out a thorough assessment of the elderly from biological, cognitive, psychological and social aspects to determine management problems for the elderly and plan according to the needs and available manpower can be added. P3G is carried out by a team led by a doctor with other members namely nurses, nutrition workers, and trained community health workers [17].

Completeness in question is actually not only limited to what must be studied but also concerns other aspects. These aspects are: doctors do not only carry out treatment (curative aspect) but also need to carry out various disease prevention, as well as prevention of complications (preventing decubitus, preventing deep vein thrombosis in immobilization cases). The next aspect is taking a rehabilitative approach for cases with disabilities, for example coughing disorders, expectoration disorders of sputum, swallowing disorders and position change disorders. In the end, doctors must also make promotive efforts such as maintaining range of motion in immobilization, stimulating physical and mental activity, increasing family knowledge about caring for elderly patients at home and so on [18].

4.1 Elements of elderly plenary assessment in primary health care facilities

Elderly patients must be managed according to lege artis rules. In the identity component, in addition to personal identity, economic, social, environmental issues must also be asked, with whom the patient lives or who is the closest person to contact if something happens, etc. In the anamnesis component, in addition to the main complaints and medical history, a history of surgery, medical history (both from doctors and over-the-counter drugs), family history of illness, simple nutritional history and system history should be asked. System anamnesis is very important because often the main complaint is not in accordance with the main problem which is the priority of management (which is life threatening). In addition, it is very likely that the elderly and elderly patients will not express their complaints unless asked [19].

4.2 Vital signs examination

Examination of vital signs is highly recommended to really pay attention to the degree of decrease or change in consciousness (if any). Examination of blood pressure and heart rate should be done in a lying position and sitting and standing (if possible); Orthostatic hypotension is more common in elderly patients [20].

4.3 Physical examination

The physical examination is carried out according to the systematics of the organ systems starting from the cardiovascular system, respiratory system, gastrointestinal system, genitourinary system, musculoskeletal system, hematological system, endocrinology metabolic system and neurologic examination [21].

4.4 Nutritional status assessment

Assessment of nutritional status begins with early detection using MNA, followed by recording nutritional intake, measuring BMI (if the patient can still stand upright), or measuring fathom length, knee height, or sitting height (if the patient cannot stand straight). Mini Nutritional Assessment (MNA) is one of the instruments to detect the risk of malnutrition or the presence of malnutrition in the elderly group. Examination with the MNA Instrument consists of two stages, namely the first stage (screening), and the second stage (assessment). If the score in the first stage <11, will proceed to the second stage. Furthermore, a person is classified as: malnourished if the total score is <17, and at risk of malnutrition if the total score is between 17–23.5 [22].

Body mass index (BMI) or Quetelet index is a method used to determine a person’s nutritional status. BMI is a prediction bodyhuman based on a person’s weight and height. The ideal normal standard used for people mature aged over 20 years is BMI between 18.5 to 24.9. A person is said to be overweight if the BMI is between 25.0 and 29.9. If BMI < 18.5 means underweight and BMI ≥30 means obesity [23].

In some cases, BMI can help doctors determine a person’s overall health status and risk of developing chronic disease. But, still doctorit is not only possible to rely on BMI as a consideration factor because BMI is not completely a reliable assessment for every different body type. BMI figures need to be known because they can be a signal about a person’s health condition. A low BMI can indicate that someone has it malnutrition. It is possible that his body is not capable of absorption nutrition well or the person is not getting intake calories sufficient to support its activities. Conversely, if the BMI number is higher, it indicates that a person is at risk heart disease, diabetes and cancer higher than someone with a normal BMI. Knowing this, doctors can refer patient on dietitian registered to help patients achieve their ideal body weight and reduce the risk of developing various health problems [24].

4.5 Functional status check

Examination of functional status is intended to determine a person’s ability to carry out activities of daily living independently. For example, getting up from a lying position, sitting, walking, bathing, urinating, dressing, preening, eating, going up and down stairs and defecating. Due to the acute illness that attacks, usually elderly patients will experience a decrease in functional status, for example from independent to mild or moderate dependence, from mild dependence to moderate to severe dependence, even total dependence. In determining the degree of dependence of a person, it should be noted that the data obtained from direct information must be adjusted to data from the family living with the patient as well as from direct observation by health workers. Determination of this functional status must be done carefully, preferably by involving the family and being observed alone. The determination needs to be made several times to evaluate the progress or setbacks that may occur [25].

Functional status was examined using Barthel’s ADL index and Lawton’s Instrumental Activities of Daily Living (IADL). The Barthel scale is ordinal scale used to measure ability to perform daily life activities or activities of daily living (ADL). Each activity item is scored on this scale with a number of points assigned to each level or rating. ADL uses ten variables that describe a person’s mobility. A higher number is associated with a greater likelihood of being able to live at home more independently. Instrumental Activities of Daily Living (IADL) Lawton useful for assessing a person’s ability to perform daily tasks such as using the telephone, washing clothes, and handling finances. The IADL measures eight domains, can be assigned within 10–15 min [26].

4.6 Fall risk assessment in elderly patients

Fall is defined as a sudden, uncontrolled, unintentional displacement of the body onto the ground or other object. A near fall is a sudden loss of balance that does not result in a fall or other injury. This can include a person who slips or trips but is able to regain control before the fall. Based on existing data, the incidence of falls in the elderly is increasing from year to year, which is caused by environmental factors and illnesses. Therefore, it is necessary to carry out prevention efforts by assessing the risk of falling in elderly patients using the above instruments. To carry out a fall risk assessment, it can be done by using the Fall Risk Assessment questionnaire for Elderly Patients. Medical personnel need to identify the symptoms/criteria as stated in the questionnaire. If the patient has these symptoms/criteria, then the patient gets a score according to the scale listed.

If not, then the patient gets a value of 0.

Furthermore, all scores are summed up and classified according to the level of risk, namely:

• Low risk if score 1–3 Perform low risk interventions

• High risk if score ≥ 4 Perform high risk interventions

Patients with a high risk of falling should be given a fall prevention program in the form of:

1. Give the patient a bracelet indicating the risk of falling that is worn when the patient is in a public facility

2. Egrief prevents falls in patients and families.

3. Patients at high risk of falling should be referred to a physician trained in geriatrics for further management.

4. Treatments that can be given are: addressing the risk factors found include:

   1. Using overcome: where this is caused by hypertension so hypertension needs to be controlled more regularly

   2. Visual disturbances (cataracts) are treated by being referred to an ophthalmologist for cataract surgery

   3. Strengthen muscle strength with training

4.7 Supporting examinations, carried out as needed

From the results of the plenary assessment, the elderly will then be divided into several groups:

1. Seniors are healthy and independent;

2. Healthy seniors with mild dependence;

3. Healthy elderly with moderate dependency;

4. Elderly with heavy/total dependency;

5. Post-hospital elderly (first two weeks);

6. Seniors who need nutritional care; or

7. Seniors in need accompaniment (having psycho-cognitive problems).

Based on these groups, appropriate programs for the elderly will be carried out, including:

Group a (healthy and independent elderly) and group b (healthy elderly with mild dependence) can directly participate in the Elderly program in a certain room.

Elderly belonging to group c (healthy elderly with moderate dependence) and group d (elderly with severe/total dependence) must take part in a home care service program if necessary involving caregivers or possibly need to be referred to hospital.

For group e (elderly after first two weeks of treatment), group f (elderly who need nutritional care), and group g (elderly who need assistance, have psycho-cognitive problems) with independent functional status can be served in the activity room, while the elderly with a mild to moderate degree of dependence must be monitored by a doctor while participating in the program in the activity room [27].

4.8 Assessment of psychosocial status

Assessment of the psychosocial status of the elderly experiencing various psychological problems that need to be considered by doctors, nurses, families and health workers. Handling problems early will help the elderly in implementing problem-solving strategies. Changes in psychosocial status that often occur in the elderly are mature, dependent, self hater, angry, arrogant, and others [28].

4.9 Social status assessment

Assessment of social status is to assess the treatment of people around the elderly who are very influential on the physical and mental health conditions of the elderly such as mistreatment/abuse, and neglect of the elderly (neglected). In addition, an assessment of social status can find family potential that can be utilized to help the patient’s recovery [29].

4.10 Services for healthy seniors

Cognitive status examination is a screening for dementia (senility); the simplest modality is Abbreviated Mental Test (AMT), categorizing it into mild, moderate and severe cognitive impairment. To check cognitive status can also be assessed by Mini Cog and clock drawing test. Dementia is a condition of continuous progressive mental function decline, getting worse over time, including decreased memory of things that have just happened, decline in language proficiency, intellectual decline (thinking power), which interferes with daily activities and is generally accompanied by changes in behavior and personality. The two most common types of dementia are dementia of the Alzheimer’s type and vascular (post-stroke) dementia.

decreased short-term memory (recent memory), thinking power, value power, orientation abilities, language skills and other cognitive functions. the patient often appears apathetic or indifferent, but may appear alert and reasonable, despite poor memory. Decreased function of basic daily activities (dressing, bathing, cooking, etc.) Loss of emotional control: easily confused, prone to crying or easily offended (angry). Examination of memory and thinking power, can be done in several ways, including:

Mini Cog: the ability to recall the names of three objects immediately after saying them and after a while (approx. 3 min). examination of the clock drawing test or clock drawing test (CDT). AMT test examination. MMSE examination. Note: If the situation is not possible then one of the instruments above can be selected [30].

5. Research finding

5.1 Research on the description of a complete study of geriatric patients at the Medan City Health Center and Deli Serdang Regency in 2018

A descriptive study with a cross-sectional design, determining the number of respondents using the Slovin formula and using the Comprehensive Geriatric Assessment questionnaire instrument. The authors conducted this by involving several primary health care facilities in two districts and cities, namely Medan City and Deli Serdang District, North Sumatra Province. The research population is the elderly aged ≥ 60 years. who went to Primary Health Facilities in 2018 involving 120 elderly respondents. the study was carried out for six months. The study population was elderly aged ≥ 60 years. who went to the Sukaramai District Health Office in Medan City, Bandar Khalipah Primary health center Deli Serdang district and Tanjung Rejo Primary health center Deli Serdang district on 27 August 2018–20 September 2018.

Sociodemographics, it was found that the ratio of elderly women was higher than that of men (53.3% :46.7%). Statistics in Indonesia state that the elderly population over 60 years is dominated by women compared to men. The sociodemographics of the respondents were 60–74 years (90%), 75–90 years (8.3%) and >90 years old (0.9%) (Table 1).

Category	Subcategory	Count	Percentage
Sample size		120	100
Sex	Male	56	46.7
	Female	64	53.3
Age	Elderly (60–74 years old)	109	90.8
	Old (75–90 years old)	10	8.3
	Very old (>90 years old)	1	0.9

Table 1.

Characteristics of respondents.

ADL examination showed the results of respondents with a mild-moderate dependence level of 61%, 37% were independent and 2% were totally dependent. Based on the IADL examination, it was found that the independent level was 89.2%. Based on the examination of the risk of falling in this study, it was found that 54.2% had a low risk of falling. Research confirms that in patients who come for treatment at Primary Health Care Facilities are still able to walk on their own. However, this study did not confirm whether the respondent came alone or was accompanied by his family for treatment at a primary health facility.

Based on the GDS examination, in this study 62.5% did not experience depressive disorders. One of the factors that supports the high number of elderly people without depression in this study can be caused by high social activity and interpersonal relationships among fellow residents. Where residents work together and interact in everyday life. Getting high social and environmental support will make the elderly feel more comfortable and happier, so that they can keep them from the risk of depression.

Based on the Mini-Cog examination in this study, 73.3% did not experience a decrease in cognitive impairment. Based on the MMSE examination, in this study it was found that 83.5% of respondents did not experience cognitive impairment. Based on the AMT examination in this study, it was found that 77.1% did not experience memory impairment/normal. Based on the MNA examination, in this study it was found that 66.7% were in the category of good nutrition and the risk category of undernutrition was 33.3% [6] (Table 2).

Category	Age
	60–74 (%)	75–90 (%)	>90 (%)	Total (%)
ADL
Independent	38.5	30	0	37.5
Mild Moderate Dependence	61.5	60	0	60.8
Total Care	0	10	100	1.7
IADL
Unable to do at all	0	0	0.8	0.8
Need help all the time	0	0.8	0	0.8
Need some help	7.5	1.7	0	9.2
Independent	83	5.8	0	89
Total care
Risk of falling
No risk	9	0	0	9
Low risk	65	4	0	69
High risk	35	6	1	42
GDS
Normal	75	6	0	81
Probable depression	34	4	1	39
Indicative of depression	0	0	0	0
Mini Cog
Normal	88	6	0	94
Probable cognitive impairment	21	4	1	26
MMSE
Normal	91	6	0	97
Mild cognitive impairment	17	3	0	20
Severe cognitive impairment	1	1	1	3
AMT
Normal	84	4	0	88
Moderate impairment	25	6	1	32
MNA
Normal	76	4	0	80
At risk	33	6	1	40

Table 2.

Frequency distribution of comprehensive geriatric assessment.