5th CASE PRESENTATION

REHABILITATION APPROACH FOR PATIENT WITH

CHRONIC OBSTRUCTIVE PULMONARY DISEASE GOLD 3 +
CORONARY ARTERY DISEASE FUNTIONAL CLASS 2 +
HYPERTENSION + GERIATRIC SYNDROMES (IMOBILITY,
ISOLATION, IATROGENIC, IMPAIRMENT OF
VISION AND HEARING)

Presented by:
M. Luthfi Dharmawan, dr.

Supervisor:
H. Sunaryo B. S., dr., SpKFR
Marietta Shanti P., dr., SpKFR

Physical Medicine and Rehabilitation Department

Faculty of Medicine Padjadjaran University
Dr. Hasan Sadikin Public Hospital
Bandung
2016
 Table of Contents

Chapter 1. Introduction……………………………………………………………...... 1
1. Chronic Obstructive Pulmonary Disease (COPD)………………………………….. 1
1.1 Definition……………………………………………………………………....... 1
1.2 Risk Factors……………………………………………………………………… 1
1.3 Pathology, Pathogenesis, and Pathophysiology…………………………………. 1
1.4 Systemic Features in COPD…………………………………………………....... 3
1.5 Diagnosis……………………………………………………………………….... 4
1.5.1 Spirometry Classification………………………………………………….. 4
1.6 COPD Management……………………………………………………………… 7
1.7 Pulmonary Rehabilitation………………………………………………………… 8
1.7.1 Component of Pulmonary Rehabilitation………………………………….. 8
2. Coronary Artery Disease (CAD) in COPD Cases…………………………………… 11
2.1 Pathogenesis……………………………………………………………………… 11
2.2 Management……………………………………………………………………… 12
3. Geriatric Syndromes………………………………………………………………… 15
3.1 Giants of Geriatrics………………………………………………………………. 15

Chapter 2. Case Report………………………………………………………………… 21

Follow Up………………………………………………………………………………… 35

Discussion………………………………………………………………………………… 37

Case Analysis……………………………………………………………………………. 41

Attachment……………………………………………………………………………… 42

References……………………………………………………………………………….. 55
 CHAPTER 1
INTRODUCTION

1. Chronic Obstructive Pulmonary Disease (COPD)

COPD remains a major public health problem. Its incidence is increasing
rapidly with the aging of the general population. Many people suffer from this
disease for years and die prematurely of it or its complications. It is the fourth leading
cause of chronic morbidity, disability and mortality in the United States, and is
projected to rank fifth in 2020 in burden of disease worldwide, according to a study
published by the World Bank/World Health Organization. Yet, COPD remains
relatively unknown or ignored by the public as well as public health and government
officials.1,2,3

1.1 Definition
COPD is a preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the severity in individual patients. The
pulmonary component is characterized by airflow limitation that is not fully
reversible. The airflow limitation is usually progressive and associated with an
abnormal inflammatory response of the lung to noxious particles or gases.3,4

1.2 Risk Factors

Identification of cigarette smoking as the most commonly encountered risk
factor for COPD has led to the incorporation of smoking cessation programs as a
key element of COPD prevention, as well as an important intervention for patients
who already have the disease. However, although smoking is the best-studied COPD
risk factor, it is not the only one and there is consistent evidence from epidemiologic
studies that nonsmokers may develop chronic airflow obstruction.3,5

1.3 Pathology, Pathogenesis and Pathophysiology

Pathologic changes characteristic of COPD are found in the proximal
airways, peripheral airways, lung parenchyma, and pulmonary vasculature. The
pathologic changes include chronic inflammation, with increased numbers of
specific inflammatory cell types in different parts of the lung, and structural changes
resulting from repeated injury and repair. In general, the inflammatory and structural
changes in the airways increase with disease severity and persist on smoking
cessation.1,3,6

Nutrition

Infection

Socio-economic status

Lung growth & development

Oxidative stress

Gender

Gene

Comorbiditieses

Aging Populations

Figure 1. Chronic obstructive pulmonary disease risk factors.3

The inflammation in the respiratory tract of patients with COPD appears to

be an amplification of the normal inflammatory response of the respiratory tract to
chronic irritants such as cigarette smoke. The mechanisms for this amplification are
not yet understood but may be genetically determined. Some patients develop COPD
without smoking, but the nature of the inflammatory response in these patients is
unknown. Lung inflammation is further amplified by oxidative stress and an excess
of proteinases in the lung. Together, these mechanisms lead to the characteristic
physiologic abnormalities and symptoms in COPD, such as mucous hyper secretion
and ciliary dysfunction, airflow limitation and air trapping, gas exchange
abnormalities, pulmonary hypertension and systemic effect.

2
 Inflamation in COPD

Small airway disease Parenchymal destruction

Airway inflamation Loss of alveolar attachments
Airway remodelling Decrease of elastic recoil

Airflow limitation

Figure 2. Mechanisms underlying airflow limitation in COPD3

There is a decreased FEV1 primarily results from inflammation and

narrowing of peripheral airways and a dynamic airway collapse in more severe
emphysema, whereas decreased gas transfer arises from the parenchymal destruction
of emphysema. The extent of inflammation, fibrosis, and luminal exudates in small
airways is correlated with the reduction in FEV1 and FEV1/FVC ratio, and probably
with the accelerated decline in FEV1 characteristic of COPD. Gas exchange
abnormalities result in hypoxemia and hypercapnia, and have several mechanisms
in COPD. In general, gas transfer worsens as the disease progresses. Mild to
moderate pulmonary hypertension may develop late in the course of COPD and is
due to hypoxic vasoconstriction of small pulmonary arteries. It is increasingly
recognized that COPD involves several systemic features, particularly in patients
with severe disease, and that these have a major impact on survival and comorbid
diseases.1,3,6

1.4 Systemic features of COPD

Cachexia is commonly seen in patients with severe COPD. There may be a
loss of skeletal muscle mass and weakness as a result of increased apoptosis and/or
muscle disuse. Patients with COPD also have increase likeliness of having
osteoporosis, depression and chronic anemia. Increased concentrations of
inflammatory mediators may mediate some of these systemic effects. There is an
increase in the risk of cardiovascular diseases, which is correlated with an increase
in C-reactive protein (CRP).3

3
1.5 Diagnosis
Diagnosis of COPD should be considered in any patient who has symptoms
of dyspnea, chronic cough or sputum production, and/or a history of exposure to risk
factors for the disease. The diagnosis should be confirmed by spirometry. The
presence of post bronchodilator FEV1/FVC < 0,70 and FEV1 < 80% predicted
confirms the presence of airflow limitation that is not fully reversible.3,4

1.5.1 Spirometry Classification

Spirometry is essential for diagnosis and provides a useful description of the
severity of pathologic changes in COPD.3
Stage I (mild COPD)
• Characterized by mild airflow limitation (FEV1/FVC: 0.70, FEV1 > 80%
predicted).
• Symptoms of chronic cough and sputum production may be present, but not
always.
• At this stage, the individual is usually unaware that his or her lung function
is abnormal.

Tabel 1. Key indicators for considering a diagnosis of COPD3

4
Stage II (moderate COPD)
• Characterized by worsening airflow limitation (FEV1/FVC: 0.70, 50% <
FEV1 , 80% predicted)
• Shortness of breath typically developing on exertion and cough and sputum
production sometimes also present.
• This is the stage at which patients typically seek medical attention because
of chronic respiratory symptoms or an exacerbation of their disease.

Stage III (severe COPD)

• Characterized by further worsening of airflow limitation (FEV1/FVC , 0.70,
30% < FEV1 , 50% predicted)
• Greater shortness of breath, reduced exercise capacity, fatigue, and repeated
exacerbations that almost always have an impact on patients’ quality of life.

Stage IV (very severe COPD)

• Characterized by severe airflow limitation (FEV1/FVC: 0.70, FEV1: 30%
predicted or FEV1 , 50% predicted plus the presence of chronic respiratory
failure).
• Respiratory failure is defined as an arterial partial pressure of O2 (PaO2) less
than 8.0 kPa (60 mm Hg), with or without an arterial partial pressure of CO2
(PaCO2) greater than 6.7 kPa (50 mm Hg) while breathing air at sea level.
Respiratory failure may also lead to effects on the heart such as cor
pulmonale (right heart failure).
• Clinical signs of cor pulmonale include elevation of the jugular venous
pressure and pitting ankle edema.
• Patients may have stage IV COPD even if their FEV1 is greater than 30%
predicted, whenever these complications are present.
• At this stage, quality of life is very appreciably impaired and exacerbations
may be life threatening.

5
 Severity of pathologic changes in COPD may decrease functional capacity.
Functional capacity in COPD can be predicted by functional capacity classification:
Class A: Full functional capacity
No dyspnea on level walking
Dyspnea on climbing 2 flights of stairs
Insignificant COPD symptoms
No restrictions imposed on the patient by his disease
Class B: Slightly diminished functional capacity
No dyspnea on level walking
Dyspnea on climbing 1 flight of stairs
Mild COPD symptoms
Slight restrictions with respect to sternuous activities and stresses
Class C: Significantly diminished functional capacity
Dyspnea on walking 1,5 level city blocks at own pace
Dyspnea on climbing 0,5 flight of stairs
Dyspnea on some of the ADL
Moderate COPD symptoms
Considerable restrictions with respect to sternuous activities and stresses;
prolonged walking and standing are contraindicated, as well as lifting objects
greater than 5 lbs
Class D: Minimal remaining functional capacity
Dyspnea on walking 0,5 level city block at own pace
Dyspne on minimal stair climbing
Dyspnea on most of the ADL
Marked COPD symptoms
Severe activity and environmental restrictions, limiting patient to sedentary
activities and the less demanding aspects of self-care
Class E: No remaining functional capacity
Dyspnea at rest
Unable to carry out any of the ADL
Severe COPD symptoms

6
 Maximal restrictions; patients is confined to wheelchair or bed, is completely
dependent on others, and can tolerate no environmental and emotional
stresses.

1.6 COPD Management

An effective COPD management plan includes four component: (1) assess
and monitor disease, (2) reduce risk factors, (3) manage stable COPD, and (4)
manage exacerbations. Although disease prevention is the ultimate goal, once COPD
has been diagnosed, effective management should be aimed at the following goals:
- relieve symptoms
- prevent disease progression
- improve exercise tolerance
- improve health status
- prevent and treat complications
- prevent and treat exacerbations
- reduce mortality
Pulmonary rehabilitation, as an adjunct to standard medical therapy, may result
in improvement in some of these areas.3,4

1.7 Pulmonary Rehabilitation

7
 Pulmonary rehabilitation has been defined as ‘a multidimensional continuum
of services directed to persons with pulmonary disease and their families, usually by
an interdisciplinary team of specialists, with the goal of achieving and maintaining
the individual’s maximum level of independence and functioning in the community.
Pulmonary rehabilitation result in improvement in multiple outcome areas of
considerable importance to the patient, including dyspnea, exercise ability, health
status and healthcare utilization. These positive effects occur despite the fact that it
has a minimal effect on static pulmonary function measurements.
Component of a rehabilitation program are individualized based on a
thorough assessment of the patient, not limited to lung function testing. This
assessment must address distressing symptoms, functional limitation, and emotional
disturbance, knowledge of the disease, cognitive and psychosocial functioning and
nutritional assessment. Furthermore, this assessment must be an ongoing process
during the whole rehabilitation process.2,7
Candidates for pulmonary rehabilitation are:5,8
 All patients with stable chronic pulmonary disease
 Not in acute phase (exacerbation) and have motivation

1.7.1 Component of Pulmonary Rehabilitation

Education
Education is considered an important component of comprehensive
pulmonary rehabilitation and is integrated into virtually all programs. Each and
every rehabilitation program begins with indoctrination of the patient as to the nature
of his disease and the goals of his specifics rehabilitation plan. The topics for an
education program include the following: smoking cessation, basic information
about COPD and pathophysiology of the disease, general approach to therapy and
specifics aspects of medical treatment, self management skills, strategies to help
minimize dyspnea, advice about when to seek help, self management and decision
making during exacerbations and advance directives and end of life issues.3

Psychosocial and behavioral intervention

8
 Anxiety, depression and difficulties in coping with chronic disease are
common in COPD patients and contribute to morbidity. Psychosocial and behavioral
intervention in pulmonary rehabilitation may include educational sessions or support
groups focusing on specifics problems such as stress management, or instruction in
progressive muscle relaxation, stress reduction and panic control. Informal
discussions during rehabilitation sessions of symptoms, concern and problems
common to COPD patients may be beneficial. Participation by family members or
friends in pulmonary rehabilitation support groups is encourage. Motivation for
pulmonary rehabilitation, which may be suboptimal at the onset, might improve
during therapy.3,4

Nutritional Therapy
Weight loss and muscle wasting, which are present in 20 – 35 % of patients
with stable COPD, contribute to morbidity and mortality in COPD, independent of
the pulmonary physiological abnormality. Nutritional intervention should be
considered for these individuals, especially under conditions of increased exercise-
related energy expenditure. Based on BMI, patients are divided into underweight
(BMI <21 kg·m-2, age >50 yrs), normal weight (BMI 21–25 kg·m-2), overweight
(25< BMI <30 kg·m-2) and obese patients (BMI ≥30 kg·m-2).
Dietary fat has a lower level of carbon dioxide production per kilocalorie of
energy extracted. This is evident in the respiratory quotient, which is 0,7 for fat and
1,0 for carbohydrate.9

Exercise
Patients with COPD stop exercising because of shortness of breath or muscle
fatigue. Thus, physical exercise training is a universal component of pulmonary
rehabilitation programs. As previously stated, physical training results in improved
exercise tolerance, measurable changes in the physiological response to exercise,
and improvements in health status.
There are two types of exercise testing, incremental exercise test (treadmill,
ergocycle) and field test (6 minute walk test, shuttle walk test). The measurement

9
taken includes the following: work rate, 12-lead ECG, blood pressure, pulmonary
gas exchange (V’O2 and carbon dioxide production (V’CO2)), ventilation,
transcutaneous oxygen saturation and symptom scores (Borg scale).
In general, two types of exercise training can be given: endurance (or
aerobic) training and strength training.12
Before we make an exercise program to a patient, we ought to know his basic
functional capacity. Exercise tolerance testing used to determine the functional work
capacity, which in turn can be used to determined disability as well as guide cardiac
or pulmonary rehabilitation.4,10,11 Contraindications for doing exercise tolerance
testing show in this table.12

Chest Physical Therapy

Chest therapy is one of the major contributions of rehabilitation medicine. It
is involve relaxation exercise, postural drainage, breathing exercise (pursed lip

10
breathing and diaphragmatic breathing), thoracic expansion exercise and coughing
exercise.5,13

Energy Conservation
Since work capacity reduced, patients with COPD benefit from instruction
in work simplification and energy conservation. The patients whose functional
capacity is seriously impaired will also required evaluation of his performance of
activities daily living. The purpose of this evaluation is to determine how he can
reduce the energy needed to perform activity and how his home environment can be
modified to assist him in carrying out these tasks. Energy conservation is a planning
method and activity in order to perform work with minimal energy. This include
breathing control, avoid useless activity, asking for help, time management, control
step in walking, control posture, relaxation, use adaptive living properly.7,11,12

2. Coronary Artery Disease (CAD) in COPD Cases

COPD and coronary artery disease share common risk factor profiles and
potentially mechanistic pathways. Tobacco use and old age contribute to elevated
risk for both of these disease entities. Patients with COPD are also at increased risk
for CAD and other smoking-related illnesses. In a recent large cohort of nearly
400,000 veterans with COPD admitted to a Veterans Administration (VA) hospital
or VA clinic, the prevalence of CAD was 33.6%, significantly higher than the 27.1%
prevalence seen in a matched cohort without COPD. Others have also confirmed a
high prevalence of CAD in COPD.13,14

2.1 Pathogenesis
Various studies have reported a strong link between the occurrence of COPD
and the presence of CAD. The causal link between these diseases has historically
been cigarette smoking, but the exact mechanisms have only recently been studied.
Epidemiologic evidence supports the importance of systemic inflammation in the
pathogenesis of atheroma formation and ischemic heart disease, and recent studies
have indicated that patients with COPD have a prominent systemic inflammatory

11
response. C-reactive protein (CRP), a known marker of systemic inflammation, for
example, has been shown to be elevated in patients with both stable COPD and
during exacerbation. Because elevations in CRP have been linked to CAD, it appears
as though the pathogenesis of both COPD and CAD may stem from enhanced
systemic inflammation. Although data supporting the use of statin therapy for
primary prevention of CAD are currently lacking, there are data showing that the
use of statins reduces systemic inflammation as evidenced by reductions in CRP. In
addition, the observation that the use of statin therapy is associated with a significant
reduction in respiratory related mortality after a COPD exacerbation further
underscores the likely importance of inflammation in this disease.14

2.2 Management
There is a recommended approach to patients with chronic obstructive
pulmonary disease (COPD) presenting with dyspnea. An atypical presentation of
myocardial infarction (MI) should be considered in every patient presenting with
COPD exacerbation with the understanding that MI may coexist with another acute
illness in these patients. Patients with COPD and MI should be urgently assessed for
revascularization via percutaneous coronary intervention and started on guideline-
based therapy. Any hospitalization in a patient with COPD, even in the absence of
an MI, should be considered an opportunity to assess and optimize the coronary risk
factors.13

12
 Figure 3. The recommended approach for patient with COPD and MI13

The role of cardiopulmonary rehabilitation merits consideration. Current

guidelines recommend cardiopulmonary rehabilitation as an evidence-based,
multidisciplinary and cost-effective intervention that leads to improved health in
patients with COPD and MI. pulmonary rehabilitation has been shown to improve
exercise capacity, reduce dyspnea and fatigue, improve healthcare quality of life and
reduce hospitalizations with the greatest benefit derived in GOLD stages II–IV.13
Persons with COPD may have co-existing cardiovascular abnormalities such
as high blood pressure or coronary artery disease. A medically monitored exercise
evaluation is highly recommended to assess the patient’s cardiac risk as well as
physiological and subjective responses. Patients then can be stratified according to
their need for medical support and surveillance during exercise. A symptom limited
exercise tolerance test is very helpful for determining the appropriate range of
exertion and the optimal training heart rate. Medical supervision is recommended at
least twice a week (especially at the beginning of the program) in order to develop
the patient’s understanding and self-confidence in how hard to exercise, as well as
to individualize the training intensity, duration and frequency.12
Since breathlessness is often the primary determinant of exertional tolerance,
ratings of shortness of breath can be used to monitor the patient’s exercise intensity.
Ideally, the exercise intensity will not be limited by shortness of breath before the
patient experiences moderate exertion. Intermittent exercise (i.e., short intervals of
exercise alternating with regular rest periods) usually permits higher intensities.
After the initial weeks of training, patients may be able to sustain a high
percentage of their peak work capacity for 30 to 40 minutes per training session. The
benefits of exercise typically increase as the training load is gradually progressed.
Moderate exercise on a daily basis has been shown to decrease the sensation of
breathlessness and produce the greatest improvements in functional capacity and
health status. For most patients, 15 minutes of moderate physical activity, 3 days per
week is probably the minimum amount for ensuring the exercise benefits.12

13
 Aerobic training should involve the major muscle groups of the lower
extremities, as these are used in everyday tasks such as walking and climbing stairs,
for a total of 20 to 30 minutes. Improved walking endurance, activity tolerance and
quality of life have been reported after programs using either stationary cycling,
ground-based and treadmill walking, or a combination of all three. Since numerous
daily activities require use of the upper extremities, endurance and strength training
of the upper body can also provide practical benefits. It is advisable to combine
resistance training with an aerobic training program to help increase endurance.
Exercises for strengthening should include all major muscle groups. The resistance
should be prescribed for each person and allow for completion of at least one set of
8 to 12 repetitions of the exercise. As muscular strength and endurance improve,
more sets can be added to each exercise.12

3. Geriatric Syndrome
Solomon et al from California University divide to “The 13/14 I” .15
- Immobility - Isolation - Impaction
- Instability - Impotence - Iatrogenic
- Intellectual - Immunodeficiency - Insomnia
impairment - Infection - Impecunity
- Incontinence
- Inanition
- Impairment of hearing, vision, smell etc

Brocklehurst et.al also named the clinical syndromes in elderly with the
“Geriatric’s Giants” that consist of: cerebral syndromes, autonomics disorders, falls,
mental confusion, incontinence, bone disease and fractures, and pressure sores.15

3.1 Giants of Geriatrics

14
 Dr.P.Srinivas describes about giants of geriatric on 1st World Congress on
Healthy Ageing in Kuala Lumpur Malaysia, March 2012. Giants of geriatrics was a
term coined by the late Prof. Bernard Isaacs to highlight the major ilnessess
associated with ageing.16
Giants of geriatrics are :
 Immobility
Defined as impairment of the ability to move independently which results in the
limitation of lifespace. Functional assesment of elderly patients is very important
in a comprehensive geriatric assesment and management of the patient in a
holistic manner
 Instability / falls
Falls defined as a subject unintentionally coming to rest on the ground, not as
result of a major intrinsic event (ag. Stroke, syncope) or overwhelming hazard.
Falls are common and preventable source of mortality and morbidity in the
elderly. Most falls multifactorial in origin resulting from stability impairment
features of the host (intrinsic) and extrinsic causes in the environment.
Risk factors affecting stability :
a. Sensory : vision, hearing, vestibuler function and proprioception
b. Central Nervous System – problems in central integration
c. Dementia – cognitive function decline
d. Musculoskeletal
e. Medications
 Incontinence
A condition of involuntary loss of urine that is a social or hygienic problem and
is objectively demonstrable. Ageing causes smaller bladder capacity and more
nocturia.
 Intellectual impairment / dementia
Dementia is a syndrome which progressive deterioration in intellectual abilities
is so severe that it interferes with the person’s usual social and occupational
functioning.
 Iatrogenic

15
 Average elderly in community consume 4,5 medications. Elderly at risk for
excessive prescribing / polypharmacy because there are change in drug
distribution and metabolisme, multiple symptoms leading to multiple drugs and
multiple factors that affect drug adherence in the elderly.

Hypertension
The incidence of hypertension rises with age, so it is very important to screen
blood pressure with every patient. Hypertension is an independent risk factor for
cardiovascular and renal disease. The Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure is urging the health
care field to focus not only on treating. Hypertension, defined as a blood pressure of
140/90 mmHg, but to also address pre-hypertension, blood pressure of 120/80 to
139/89 mmHg, with the goal being to decrease the incidence of Coronary Artery
Disease, stroke, and renal disease. Physiatrist make the proper referral for medical
management but they can also assess the effectiveness of antihypertensive
medications. Evaluation for hypertension should be assessed on at least two to three
consecutive sessions, and if the patient is found to have either resting or exercise
hypertension, he or she should be referred for medical management.17, 18

Cardiovascular Changes
The aging cardiovascular system has decreased arterial compliance,
increased systolic blood pressure, left ventricular hypertrophy, decreased
baroreceptor sensitivity, and decreased sinoatrial node automaticity. The exercise
induced adaptations that occur in younger people, such as increased peripheral
arteriovenous oxygen difference and increased cardiac size, stroke work, cardiac
output, and left ventricular function, are not as available to the elderly. Older patients
with coronary artery disease have age-related increases in left ventricular and arterial
wall stiffness and thickening, which limit some adaptations with conditioning. 17, 18

Decreased Vision in Elderly

16
 Vision is important in identifying environmental cues and distinguishing
environmental hazards. As people age, changes in vision and visual perception may
lead to misinterpretation of visual cues and result in functional dependence. Slight
diminution of visual acuity has been documented to occur between the ages of 50
and 70 years and at a greater rate after age 70 years. Factors responsible for
decreased visual acuity include increased thickness of the lens, which affects the
amount of light allowed to reach the retina, and the loss of elasticity of the lens.
These changes result in decreased ability to see clearly and particularly affect near
objects. In addition, changes in the iris and pupil may decrease acuity. As one ages,
the iris loses its ability to change width, and pupil size remains small in both dim
and bright light. One specific consequence is decreased night vision. It is likely that
optical factors alone are insufficient to account for acuity loss and that age-related
changes in the retina and brain are also contributing factors.19

Hearing Loss in Elderly

Age-related hearing loss or presbycusis, is the slow loss of hearing that can
occurs as people getting older. About one-third of Americans between the ages of
65 and 74 have hearing problems. There is no cure for age-related hearing loss.
Treatment is focused on improving function. Hearing aids, telephone amplifiers and
other assistive device, speech reading or cochlear implant may be helpful. Age-
related hearing loss most often get worse slowly. The hearing loss cannot be reserved
and may lead to deafness. Hearing loss can result both physical (not hearing a fire
alarm) and psychological (social isolation) problems.19

Impaired Aerobic Capacity in Elderly

In older adults, aerobic capacity impairments may be related to a number of
issues, including deconditioning, age-related physiological changes, and specific
pathology. Deconditioning, or decreased physical activity, is common in older adults
and often associated with illness, functional limitations, restricted activity, and
cognitive limitations. Many age-related physiological changes, such as reduced

17
maximal oxygen consumption because of decreased cardiac performance and
skeletal muscle endurance, directly impact aerobic capacity. Aerobic capacity
limitations are associated with declining functional mobility, disability, and loss of
independence in older adults. Long-term physical activity is related to postponed
disability and longer independent living in older adults, including those with chronic
disease.19

Depression in Elderly
Depression is not a normal part of aging. Although brief periods of sadness or
grief normally occur when a person experiences loss or disappointment, depression
differs from sadness. It is a serious illness with persistent symptoms that affect every
day functioning. Up to one in four older adults who live in the community have
significant symptoms of depression. The illness of major depression occurs in more
than 5 percent of older adults who receive care in primary care clinics, and up to 15
percent of older adults in nursing homes. Untreated depression may lead to serious
problems. It affects functioning, health, and quality of life. One of the most common
depression screening tools is the Geriatric Depression Scale. It is designed
specifically for older adults who may need further evaluation for depression.22

Comprehensive Geriatric Assessment

Comprehensive geriatric assessment involves the evaluation of the physical,
psychosocial and environmental factors that impact on the well-being of older
individuals. The use of an organized approach with objective measurements helps
target key areas of functional status. Important areas include the evaluation of
activities of daily living, cognition, mood, social supports, gait and falls, nutrition,
sensory impairments, incontinence, polypharmacy, elder abuse, pressure sores, pain,
and advance directives. The provision of primary and secondary prevention is also
increasingly important for older individuals. The components of a successful
geriatric assessment program are outlined, with suggestions to improve
compliance.23

18
Adapting the Environment
The process of adapting to environment or adapting the environment to edge
person is especially important in geriatric rehabilitation. The purpose of
rehabilitation providers is to manipulate the environment to make it safer. Assistive
walking devices or modifications of the home may be recommended. Because the
home is the hub of most activity for older individuals, creating an environment to
support sensory loss and enhance maximum functional independence is critical.
Incorporating the previously outlined design principles that accommodate losses in
vision, hearing, taste, smell, and touch will not only facilitate independence but may
also minimize the occurrence of accidents leading to death or disability. Examples
of accommodations that should be considered include use of enhanced lighting and
provision of contrast in personal living space to deter falls that result from decreased
vision and the use of smoke detectors with visual cues to decrease vulnerability to
death from fires in older individuals with decreased ability to hear and smell.
Another examples are push-button controls placed at the front of a range assist aged
individuals with low vision, doors may need to be widened, ramps installed, bath
handle or additional carpet in bathroom to decrease a slippery floor.24

19
 CHAPTER 2
CASE REPORT

Mr. H, 71 years old, Indonesian, lives in Ciwastra, Bandung, is referred from

Internal Department with diagnosis Chronic Obstructive Pulmonary Disease +
Coronary Artery Disease DC Left-Right Functional Class II + Hypertension.

ANAMNESIS (July 20th 2016)

Chief Complaint:
Shortness of breath

History of Present Illness:

Since about 13 days ago, the patient has been complaining shortness of
breath. The shortness of breath was accompanied by cough, sometimes with whitish
sputum. The complaint is worsening in four days, he felt breathless from 2 times a
day into 4 times a day especially at morning and at night, and also when he is walking
about 20 meters. The breathless was slightly relieved when he is resting by sitting
down. There is no fever, night sweat, bloody sputum, chest pain, swelling at his
feet/eyes or fainting. He was come to internal department in Soreang Regional
Public Hospital and he was referred to Hasan Sadikin General Hospital. The doctor
said that he had pulmonary disease and send him to check his breathing by
spirometry. He was diagnosed chronic obstructive pulmonary disease and
medication such as ventolin inhaler and seretide twice a day. Now he still feels the
same after consume the medication.
The patient has been feeling shortness of breath since about 4 years ago
(2012) but the patient didn’t really aware about his condition. He’s still doing
activities just like his used to do every day. He still do a gardening, helping his wife
in house works, and swimming. Two years later (2014), he suddenly felt heavy in
his chest and cannot breathe when he’s swimming in the swimming pool for 5 hours.
He was taken to hospital and diagnosed with coronary artery disease. Since that day,

20
he was stopped doing his regular activities and always stays at home. After two years
of heart medication, the shortness of breath is still persisted. The doctor suspected
the complaint is not from the heart condition and he was referred to Hasan sadikin
general hospital. The patient had been easy become fatigue while working on
strenuous activities such as walking up stairs, but he still do all his daily activities
independently and even still do some housework like washing and cleaning the
house. He still controlled regularly to the heart department of Hasan Sadikin General
Hospital once a month and given Nitrokaf Retard 2x1, Furosemide morning 2 tab
day 1 tab, and kandesartan 1x2.
When it is time to sleep at night she has no difficulty to fall asleep. He doesn’t
have sleeping disturbance, but he uses 2 pillows to sleeps. He sometimes wake up at
midnight because feels not comfortable, but he fall asleep again very easy. He sleeps
about 8 hours per day.
He has smoking history for 22 years with 2-3 pack per day, but he already
stopped smoking since 1993. He stopped smoking because he want to save the
money for his children later. Today he feels that he is allergic to smoke from
cigarette, he will feel not comfortable and dizzy if he smell the smoke. There’s no
history of smoking in his family members.
There are no complaint for bowel and bladder. He usually defecate once a
day.
The patient has sports history since he retired from government employee.
Since 2002 – 2005, he regularly exercises in fitness center once a week. He exercises
to increase strength of upper body such as weight lifting, sit ups, and other exercise
using dumbbell. He also regularly swims for exercise three times a week since he
still working until 2012. He stops exercising because he felt pain in his chest while
exercise and forbidden to do it by the doctor.
He has to wear glasses to see far things. He uses a minus 3.5 for right eye
and minus 4 for left eye. If he wants to read, he just take off the glasses. He already
uses glasses since age 38 years old.

21
History of Past Illness
 History of hypertension (+) since 4 years ago, control regularly to RSHS and
given amlodipine 1x10mg
 History of heart disease (+) since 4 years ago, control regularly to RSHS.
 History of dyslipidemia and hyperuricemia was denied
 History of asthma was denied
 History of athophy was denied
 History of tuberculosis was denied
 History of diabetes mellitus was denied
 History of falls was denied

History of Nutrition
He doesn’t feel tired or fell difficulty when eating. He does not lose his appetite.
He eats a many varieties of food three times a day. He always steamed the vegetable,
tofu and also fried the chicken using free cholesterol oil. He drinks about 5 x 350
ml of water a day. He seldom to eats snack between mealtimes.

History of Family Illness

 No family’s history of respiratory and cardiovascular disease.

History of Habits
His daily routines begins by waking up at 4.00 a.m. and do Morning Prayer.
He usually take a morning walk about 20 – 30 minutes at 6.00. After that he is taking
a bath at 6.30 and has breakfast at 7.00. Then he is doing a laundry for his very own
cloths manually. After that he is just sitting reading a book or seeing the TV
programs. At 12.00 he goes do dzuhur prayer. At 13.00 a.m., he has another meal.
After that he always looks for an activity to fill his time such as cleaning, sweeping
or other housework. He has Ashar prayer at 4.30 p.m. After have maghrib and Isya
prayer, then have a dinner with his family. He likes watching TV and has
conversation with his family before night sleep at 20.00 p.m.

22
History of Social Situations
He graduated from college, working as government employee in pharmacy
section RSHS, RSUD Cibabat, work in licensing department in public health office
and retired at 2001. He was married and has 3 children, all already married. He now
lives with his first child and family. The other were lived at bogor and bandung. He
is very happy because his children is really care and helpful. He uses BPJS as
medical insurance. He would use public transportation to Hasan Sadikin Hospital
with his wife.

House and Evironment

He lives at ciwastra Bandung for 2 years now. He lives in a part of his son’s
house. There’s no industries in his neighborhood, but pretty dense neighborhood.
There’s only one living room, bed room, kitchen, storage room and bath room.
Before, he lives in soreang. He said that he can live more comfy and more quite that
in Bandung. In soreang, he lives besides the main road.

Activity of Daily Living

Barthel Index : 20
Lawton IADL : 8 (maximum score 8)
Geriatric Depression Scale
Total score: 4 (normal)

PHYSICAL EXAMINATION (July 20th 2016)

The patient was come walking alone without assistive device.

General Status
Posture : kyphosis (details on trunk examination)
Consciousness : compos mentis
Contact : adequate, cooperative
Cognitive :
 MMSE : 30 (normal)

23
Communication : receptive and expressive good
Vital sign :
 Blood Pressure : 100/70 mmHg
 Heart Rate : 80 bpm
 Respiratory Rate : 20x/m
 Saturation : 95%
 Temperature : Afebris

Nutrition status : Body weight: 68 kg; body height: 154 cm

BMI= 28.7 kg/m2 (overweight)
Mini Nutritional Status: 23

Mobilization
Balance :
Functional Reach Test : 30 cm
Time Up and Go test :6s
Berg balance scale : 56

Gait:
Head, Arm, Pelvis/Hip Knee Ankle/Foot
trunk
Sagital Head Straight Hip flexion +/+ Knee Flexion Heel strike +/+
Arm swing +/+ Toe off +/+
minimal
Trunk slight
kyphosis
Frontal Head midline Slightly wide base

General Examination
Head and neck region
Head : conjunctiva non anemic, sclera non icteric
Isochoric pupil θ 3mm/3mm, light response reflex +/+
Nasal flare (-), nasal discharge (-)
Perioral cyanosis (-)

24
 Good oral hygiene, false teeth (+): incisor teeth and canine
teeth (-)
Neck : Suprasternal retraction (-)
JVP (5 + 2) cmH2O
Enlargement of lymph nodes (-)
Hypertrophy of sternocleidomastoids muscle -/-
Accessories muscles contraction during inspiration -/-

Deformity (-); ROM full; MMT 5

Thorax region
Shaped and movement symmetrical
Deformity: (in standing position kyphosis posture)
Wall Occiput Distance: 7 cm
MMT functional

Breathing pattern: thoracoabdominal

Barrel chest (-), intercostal retraction -/-
Lungs : vesicular breathing sound, right = left: rhonchi -/-, wheezing -/-,
slem -/-, vocal resonance right = left, vocal fremitus right = left,
percussion sonor right = left
Heart : S1 S2 normal, S3 -, S4 -; Heart border: left: 5th ICS, 1.5 cm to the
left midclavicular line, right: right sternal line, top: 2th ICS,
bottom: 5th ICS, No other additional heart sound
Chest expansion 3 / 3.5 / 3.5 cm

Abdominal region
Epigastric retraction (-), Flat, flexible on palpation, enlargement of liver and spleen
(-), tenderness (-), normal bowel sound

Extremity region
Clubbing -/-, cyanosis -/-, edema -/-

25
Upper Extremities region : Deformity -/-, inflammation sign -/-
ROM full / full (active), pain -/-
MMT 5 / 5
Resting tremor -/-, Intentional tremor -/-
Spasticity -/- , Rigidity -/-
Physiological reflexes ++/++
Pathological reflexes - / -
Sensibility normal/normal, proprioception
good/good
Cordination good/good
Hand prehension good/good
Lower Extremities region : Deformity +/- (Hallux valgus), inflammation sign -
/-
Pain on movement -/-, ROM full / full
MMT 5 / 5
Spasticity -/- Rigidity -/-
Physiological reflexes ++/++
Pathological reflexes -/-
Sensibility normal/normal, proprioception
good/good
Cordination good/good
Leg Length Discrepancy (-)

Additional Examination
COPD assessment
CAT : 10
MMRC :2
SGRQ : Symptom : 52.42
Activity : 59.46
Impact : 27.99

26
 Total : 41.92
BODE index : 10

Cardiopulmonary test
6MWT:
Walking distance : 200.4 m
VO2Max : 11.325
METs : 3.24

Senior Fitness Test:

Not Yet Examined
Result Normal Range Interpretation
30-Second Chair 10-15
Stand
Arm Curl 11-17
6 Minute Walk 430-585
2 Minute Step Test 68-100
Chair Sit-and -1,5- +3,5
Reach
Back Scratch -5,0- +0,5
8 foot up and go 7,4-5,2

Risk of Fall Evaluation

Time Up and Go test :6s
Berg balance scale : 56 (Low risk)
Falls Efficacy Scale : 26 (Moderate)

Functional Assessment:
Barthel Index : 20 (independent ADL)
Geriatric Depression Scale : 4 (normal)
Katz Index : 6 (independent)

Risk Stratification of Coronary Artery Disease

Thrombolysis in Myocardial Infarction (TIMI) Score : 2 (Low Risk)
Global Registry of Acute Coronary Events (GRACE) Score : Not Applicable

27
SUPPORTING EXAMINATION
Spirometry (July 13th 2016)
Predicts Without bronchodilator
Value %
FVC 3.06 1.29 42
FEV1 / FVC 55.0
FEV1 1.99 0.71 36
PFR 535 100 18
Interpretation: Severe Obstructive

Laboratory (July 14th 2016)

Cholesterol HDL 40
Cholesterol LDL 145

WORKING DIAGNOSIS
- Clinical Diagnosis :
Chronic Obstructive Pulmonary Disease GOLD 3, patient group D (J.44)
Geriatric Syndrome : (R.54)
a) Imobility : Chronic disease (COPD), low cardiopulmonal
endurance, low musculoskeletal endurance, environment
b) Isolation : immobility factor, decrease relationship with
neighbor, depression
c) Impairment of vision and hearing
d) Iatrogenic
Hypertension stage 2 (I.10)
Coronary artery disease Functional Class 2 (I25.1)

- Etiological Diagnosis :
Chronic disease
Degenerative
- Location Diagnosis :
Cardiopulmonal system, musculoskeletal system, sensory system

28
FUNCTIONAL DIAGNOSIS
 Impairment : Cardiorespiratory system (COPD, coronary artery
disease, low cardiopulmonal endurance,
hypertension)
Geriatric syndrome
 Disability : Mobilization
 Handicap : Avocational and Psychosocial

PROGNOSIS
- Quo ad vitam : dubia ad bonam
- Quo ad sanationam : dubia ad bonam
- Quo ad functionam : ad bonam

PROBLEMS INVENTORY
Medical Problem :
COPD
CAD
Hypertension stage 2

Rehabilitation Problem :
Cardiopulmonal endurance
Mobilization
Avocational and psychosocial

GOAL
1. Short term :
- Understand with his condition
- Decrease episode of shortness of breath
- Prevent exacerbation
2. Mid term :

29
 - Improve cardiopulmonary endurance
- Improve exercise tolerance
- Prevent exacerbation
3. Long term :
- Maintenance avocational and psychosocial activity
- Help the patient return to the highest possible functional capacity
- Maintain cardiopulmonary endurance
- Prevent exacerbation
- Slowing down COPD progression

REHABILITATION MANAGEMENT
1. Chronic Obstructive Pulmonary Disease
S : Shortness of breath, decrease activity
O:
SGRQ: 41.92 %, CAT: 10, MMRC: 2
Spirometry test: severe obstructive
G: Decrease recurrent of dyspnea
Patient knowledge about the management of dyspnea
Improve cardiopulmonal endurance
Prevention of exacerbation
P:
o Education about COPD and the progression of the disease, to take
medication and control regularly, not to contat to any pollutant, risk
of respiratory infection, and make adequate ventilation at house
o Education about signs and symptoms of exacerbation, and
management during exacerbation for patients and family, exercise
and benefit of exercise
o Exercise and postural training
o Breathing exercise during standing, walking, climbing stairs, and
other functional activities: chest expansion exercise, controlled
breathing exercise: diaphragmatic breathing with minimal upper

30
 chest movement, pursed lip breathing (careful to avoid forced
expiration), inspiratory muscle training, preventing and relieving
episodes of dyspnea.
o Deep and effective cough
o Exercise to mobilize the chest emphasizing movement of the lower
rib cage during deep breathing
o Positioning for relaxation :
 Relaxed head up position in bed: trunk, arms, and head are
well supported.
 Sitting: leaning forward, resting forearms on thighs or on a
table.
 Standing: leaning forward on an object, with hands on the
thighs or leaning backward against a wall.
o Relaxation exercise for shoulder musculature: active shoulder
shrugging followed by relaxation; shoulder and arm circles;
horizontal abduction and adduction of the shoulders.
o Endurance exercise with initially low intensity of exercise within 30
minutes (symptom limited or borg scale)
o Advise to have immunization to prevent respiratory infection
o Plan to monitoring / evaluation: check for CAT, MMRC, 6MWT and
SGRQ regularly.
o Energy conservation: symptoms limited activities, proper body
mechanic, control plan, time and distance of work.
o Control to pulmonology department regularly

2. Hypertension Stage 2
S -
O Current Blood Pressure 100/70 mmHg controlled with
antihypertensive drug
G Stable and normal blood pressure achieved

31
 P -. Education : about the disease and risk factor; regular check for
hypertension and medication; exercise monitoring
-. Diet modification  low salt and fat/cholesterol intake, high
fiber intake
-. Environmental modification

3. CAD
S -
O Dyslipidemia
G Slow Progression of CAD
Increase cardiopulmonal endurance
P -. Educate the patient about the disease, risk factors and management
-. Exercise with walking (cardiopulmonal endurance exercise), same
as pulmonary rehabilitation program
-. Dietary

4. Mobilization, avocational and psychosocial

S Shortness of breath 2 times every day
Decreased his activities outside of home
Easily fatigue if do moderate activities (walking in longer distance
and ascending-descending stairs)
House environment with small alley and crowded population
O Instability: kyphotic posture, wall-occipital distance: cm, balance
impaired (TUG, BBS, FES)
Low cardiopulmonal endurance
Katz Index :
Inaniation and risk of malnutrition
G Improve cardiopulmonal endurance
Prevent of fall and safe mobilization
Maintain proper posture and prevent further deformity
Maintain nutrition status with proper composition of food

32
 P -. Education to patient and family: about risk of fall, fall prevention,
do the exercise at home, energy conservation,
-. Modification of environment: proper light and diminished
obstacles at surrounding area
-. Energy conservation technique: symptom limited activities,
proper body mechanic, control plan, time and distance of activities
-. Proper posture in all activity
-. Balance and coordination exercises
-. Flexibility exercise of trunk, upper and lower extremities
-. Evaluate polypharmacy (interfere with inaniation)
-. Consult to nutrition department for food composition progam
-. Cardiopulmonal endurance exercise
-. Plan to give resistance exercise
-. Join the COPD community

5. Hearing and visual problem

S He hear louder voices when communicating and use glasses to see
far things
O Hearing acuity impaired bilaterally, Visual impairment
G Improvement of communication
P Control and use medication regularly to Eye and ENT department

6. Geriatric Syndrome
S Immobility, Isolation, Iatrogenic, Impairment of Vision and
Hearing
O Hearing acuity impaired bilaterally, Visual impairment
Decrease of cardiopulmonal endurance
G Improvement Quality of Life
P Same as Above
Plan to assess Full assessment for geriatric syndrome and Senior
Fitness

33
 Plan to assess regularly once a month

Follow Up

July 25th 2016

S: Home Visit
House and Environment Assessment
He lives at his son’s house. He just moved in for two years because he must
control regularly to RSHS. It has a living room, one bed room, a kitchen, store
room and a bathroom. It has minimal ventilation especially in the bed room and
store room. He lives in densely populated area and far from main road. There are
no industries around the area.
O:

34
A: Mild Risk of Environmental Hazard for COPD condition
P: -. Educate to open the bedroom’s door often to increase the ventilation
-. Modified by clean up and organized the bed room and storage room.

35
 DISCUSSION

This patient was referred with diagnosis Chronic Obstructive Pulmonary

Disease + hypertension on therapy + Coronary artery disease functional class 2. His
chief complaint was shortness of breath. Based on anamnesis, physical examination
and supporting examination, the COPD was categorized in COPD GOLD 3 in
patient group D.25 This mean that he included in severe obstructive pulmonary
condition. He also diagnosed with CAD with history of chest pain on 2014. Today
he already control regularly to cardiac department and got medicine for his cardiac
problem. He included in low stratification of cardiac condition. In some of literature
said that many COPD patient will have a risk to get a cardiac problem such as
myocardial infarction. The pathogenesis is still under study but some of them already
stated that inflammatory marker and lung function is one of the link between COPD
and CAD. COPD is a state of systemic inflammation and high levels of inflammatory
markers are associated with severity of airflow obstruction and cardiac injury.
Inflammatory process in airways parenchyma and pulmonary vasculature may
spillover into systemic circulation promoting a generalized inflammatory reaction.
This inflammation was seen in COPD persons who were noncurrent smokers; and
once COPD develops, cessation of smoking may not fully attenuate the
inflammatory process associated with this condition. Inflammatory markers set the
stage not only for COPD but also for atherosclerosis and thus CAD. So COPD is
responsible for systemic inflammation along with possibility of reverse causation,
i.e., systemic inflammation causing injury to airways. Inflammatory markers cause
accelerated decline in lung function, repeated hospital admissions, and acute
coronary events as airflow limitation doubles the risk of cardiovascular mortality
independent of smoking.14, 26
Poor lung function also associated with risk of
developing diabetes, high Blood Pressure, and fatal stroke.26
In this case, author is still looking for the risk that cause the pulmonary
problem. There is no history of infection when the first time he got the shortness of
breath. He already stopped smoking in 1993. So I assume that environment is the
cause of his complaint. I didn’t know the environment condition when he stays in

36
Soreang. He only said that he can live more comfy and quite at soreang. When I
explore his house in Bandung, I found some risk that can exacerbate the COPD such
as disarrangement stuff in kitchen and storage room, no partition between rooms,
small ventilation in bedroom. This kind environment will make a moist air and
increase chance of bacterial growth thus will increase chance in pulmonary
infection. Because of this condition, I try to modified the environment by educate to
arrange the stuff in the kitchen and storage room using boxes and throw up the
unused stuff, and also educate to open the bedroom’s door very often to increase the
ventilation helped by a electric fan.
From the examination patient has multiple exacerbation episode, decreased
cardiopulmonary endurance and shortness of breath when doing activities. He
sometimes has productive cough. Because of his condition, he limited his activities
not only in the house but also limited his interaction with community. He is not an
active smoker. The patient have a hope that he want to back swimming and have a
place to socialize beside in his neighbor. With this, I can set a goal to for his quality
of life. The goal is to prevent exacerbation of COPD, decreasing progression of
COPD, improve and maintain cardiopulmonal endurance and also create an
opportunity to socialize.
Education about patient’s condition is important, like the ability to avoid
exacerbation like reducing the probability of getting influenza by getting influenza
vaccine, managing the acute dyspnea before she got to the hospital, compliance and
importance of drug as long as it advised by the pulmonologist. The other thing that
is important energy conservation, make a plan when want to do something,
controlled breathing when do the activities, taking a deep breath before getting
dyspnea or stopping every 20 m walking before getting dyspnea, relaxation
technique, management of medication and exacerbation, exercise and benefit of
exercise.
In GOLD 2015 exercise is an important part of COPD management.
Sedentary patient will have decrease cardiopulmonal endurance, more severe
breathlessness and muscle wasting which will begin the viscous cycle in COPD
patient. The exercise is an aerobic exercise which took 8 weeks because at this

37
duration of time there will be a neural and muscular adaptation from the exercise.
The frequency is 5x/weeks with 2x hospital based and 3x home based, with low to
moderate intensity. The duration of exercise is 30 minutes.12, 25
Diagnostic of geriatric syndrome is made by isolation, impairment of
hearing,and vision, immobility, and iatrogenic condition in this patient. The most
problem in this patient are compounded by aging process. The aging process cause
a change of body structure and function. This patient undergo a change in the
neuromuscular system, muskuloskeletal, cardioavascular and metabolic system.
Within all those problem mentioned above, she is predicted vitally good
(with good treatment and prevention of metabolic problem), recurrency is predicted
as doubtful into a good way due to complex multifactorial involvement that may
cause any impending critical complications and functionally predicted as doubtful
yet in a good way since all his geriatric syndrome present not in severe ways and his
motivation is quite good to encourage him self to do the exerrcise, medication and
other programs. I plan to take him to a COPD community in bandung to encourage
him about his condition and hoping he will have a motivation to back to community.
Dealing with elderly problems need a thorough examination and re-
evaluation in the whole process and stage of illness and this definately needs a
holistic approach in physical medicine and rehabilitation.
The prognosis at vitam on this patients is dubia ad bonam. This patient has
COPD GOLD 3 and have dyspnea two times a day, but he has a good motivation to
exercise and very cooperative to undergo rehabilitation program. He already
understand how to control breathing when doing activities.
The prognosis at sanactionam is dubia ad bonam because the dyspnea occurs
almost every day. Patient looks dyspnea when he do an activities. His environment
does not really support his health condition, but I try to modify his environment. I
also give education to him and his wife about management of exacerbation. I give
him chest flexibility exercise, controlled breathing exercise: pursed lip breathing,
relaxation techniques: progressive muscle relaxation exercise, and energy
conservation: symptoms limited activities, proper body mechanic, control plan, time
and distance of work.

38
 The prognosis for functionam is ad bonam. The patient can still independent in
doing activity of daily living. He has good motivation to become healthier. The
exercise I give to him is to return him become as active as possible, stabilize physical
and psychosocial function, help him return to the highest possible functional
capacity, we give him education about physical and psychosocial consequences of
COPD, aerobic exercise, flexibility exercise and plan to give resistance exercise,
which is prescribed based on his physical capacity.

39
 CASE ANALYSIS

Smoking/Occupational
Respiratory Inflammation
Hazard/Pollution/
(Chronic)
Environmental Condition

Small airway disease Parenchymal destruction

Airway inflamation Loss of alveolar attachments
Airway remodelling Decrease of elastic recoil

Airflow limitation

Systemic Inflammation

Oxygenation ↓
C - reactive protein ↑

Coronary Artery Syndrome

Iatrogenic
Male, 71 years old
COPD + CAD + Hypertension

Isolation

Dyspnea
(Exacerbation)
Cardiopulmonal Impairment of
Immobility
Endurance↓ Hearing & Visual

Restricted Lung

Muscle Flexibility ↓
Avocational Disturbance:
-. Cannot go swim or hiking
Psychosocial Disturbance
-. Doesn’t interact with
Mobilization Disturbance: community
-. Easy Fatigue
-. Short of breath after
walking or activities

40
 MINI MENTAL STATE EXAMINATION (MMSE)
Patient’s Name : Mr. H / 71 years old, Date: , 2016
Patient’s
Question Maximum
score
“what is the year? Season? Date? Day of the week? Month?” 5 5
“where are we now: state? Country? Town/city? Hospital? Floor?” 5 5
The examiner names three unrelated objects clearly and slowly, then asks the
patient to name all three of them. The patient’s respone is used to scoring. The
3 3
examiner repeat them until patient learn of them, if possible. Number of
trials:............
“I would like you to count backward from 100 by sevens”
5 5
(93,86,79,72,65,...........) stop after the answer.
“Earlier I told you the names of three things. Can you tell me what those were?” 3 3
Show the patient two simple objects, such as a wristwatch and a pencil, and ask
2 2
the patient to name them.
“Repeat the phrase : “No ifs, ands, or buts.” 1 1
“Take the paper in your right hand, fold it in half, and put it on the floor.” (the
3 3
examiner gives the patient a pice of blank paper).
“Please read this and do what I says”. (written instruction is “Close your eyes”.) 1 1
“Make up and write a sentence about anything”. (this sentence must contain a
1 1
noun and a verb).
“Please copy this picture”. (the examiner gives the patient a blank piece of paper
and asks him/her to draw the symbol elow. All 10 angles must be present and two
must intersect).
1 1

TOTAL 30 30

Skor : 0 – 22 (ada gangguan fungsi luhur)

23 – 30 (normal)

THE BARTHEL INDEX

Patient Name: Mr. H Rater Name: dr. Luthfi
20/07/2016

41
FEEDING 2
0 = unable
1 = needs help cutting, spreading butter, etc., or requires modified diet
2 = independent
BATHING 1
0 = dependent
1 = independent (or in shower)
GROOMING 1
0 = needs to help with personal care
1 = independent face/hair/teeth/shaving (implements provided)
DRESSING 2
0 = dependent
1 = needs help but can do about half unaided
2 = independent (including buttons, zips, laces, etc.)
BOWELS 2
0 = incontinent (or needs to be given enemas)
1 = occasional accident
2 = continent
BLADDER 2
0 = incontinent, or catheterized and unable to manage alone
1 = occasional accident
2 = continent
TOILET USE 2
0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)
TRANSFERS (BED TO CHAIR AND BACK) 3
0 = unable, no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent
MOBILITY (ON LEVEL SURFACES) 3
0 = immobile or < 50 yards
1 = wheelchair independent, including corners, > 50 yards
2 = walks with help of one person (verbal or physical) > 50 yards
3 = independent (but may use any aid; for example, stick) > 50 yards
STAIRS 2
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent
TOTAL (0–20): 20

0–4 very severe disability

5–9 severe disability
10 – 14 moderate disability
15 – 19 mild disability
20 independent in ADL

FORMULIR UJI JALAN 6 MENIT

42
 AMERICAN THORACIC SOCIETY
Nama : No. Reg :
Jenis Kelamin : Dokter :
Umur : y.o Tanggal :
Berat Badan : kg Obat-obatan :-
Tinggi badan : cm
Pemberian O2 selama tes :
Baseline Setelah Tes
Tekanan darah mmHg mmHg
Denyut nadi x/menit x/menit
Dyspneu (Borg scale)
Fatigue (Borg scale)
Effort (Borg scale)
Sp O2 % %
Berhenti atau istirahat sebelum 6 menit : Alasan :
Gejala setelah latihan :
Jarak total dalam 6 menit : meter
Jarak yang diperkirakan : meter
Persentase jarak yang diperkirakan : %

INTERPRETASI
VO 2 max = 0,006 x (jarak) + 7,38 = 0,006 x + 7,38 =
0,3048 0,3048

MET = =
3,5

Jenis Aktivitas :

43
 Berg Balance Scale

Name: Date of Test:

1. Sit to Stand

Instructions: “Please stand up. Try not to use your hands for support”

Grading: Please mark the lowest category that applies

( ) 0: Needs moderate or maximal assistance to stand

( ) 1: Needs minimal assistance to stand or to stabilize

( ) 2: Able to stand using hands after several tries

( ) 3: Able to stand independently using hands

( )4: Able to stand with no hands and stabilize independently

2. Standing unsupported

Instructions: “Please stand for 2 minutes without holding onto anything”

Grading: Please mark the lowest category that applies

( ) 0: Unable to stand 30 seconds unassisted

( ) 1: Needs several tries to stand 30 seconds unsupported

( ) 2: Able to stand 30 seconds unsupported

( ) 3: Able to stand 2 minutes without supervision

( ) 4: Able to stand safely for 2 minutes

If person is able to stand 2 minutes safely, score full points for sitting unsupported (item 3)
. Proceed to item 4.

3. Sitting with back unsupported with feet on floor or on a stool

Instructions: “Sit with arms folded for 2 minutes”

Grading: Please mark the lowest category that applies

( ) 0: Unable to sit without support for 10 seconds

( ) 1: Able to sit for 10 seconds

( ) 2: Able to sit for 30 seconds

( ) 3: Able to sit for 2 minutes under supervision

( ) 4: Able to sit safely and securely for 2 minutes

44
4. Stand to sit

Instructions: “Please sit down”

Grading: Please mark the lowest category that applies

( ) 0: Needs assistance to sit

( ) 1: Sits independently but had uncontrolled descent

( ) 2: Uses back of legs against chair to control descent

( ) 3: Controls descent by using hands

( ) 4: Sits savely with minimal use of hands

5. Transfers

Instructions: “Please move from chair to chair and back again” (Person moves one way to
ward a seat with armrests and one way toward a seat without armrests) Arrange chairs for
pivot transfer

Grading: Please mark the lowest category that applies

( ) 0: Needs two people to assist or supervise to be safe

( ) 1: Needs one person to assist

( ) 2: Able to transfer with verbal cueing and/or supervisionTransfers

( ) 3: Able to transfer safely with definite use of hands

( )4: Able to transfer safely with minor use of hands

6. *Standing unsupported with eyes closed

Instructions: “Close your eyes and stand still for 10 seconds”

Grading: Please mark the lowest category that applies

( ) 0: Needs help to keep from falling

( ) 1: Unable to keep eyes closed for 3 seconds but remains steady

( ) 2: Able to stand for 3 seconds

( ) 3: Able to stand for 10 seconds without supervision

( )4: Able to stand for 10 seconds safely

7. *Stand unsupported with feet together

Instructions: “Place your feet together and stand without holding on to anything”

Grading: Please mark the lowest category that applies

( ) 0: Needs help to attain position and unable to hold for 15 seconds

45
( ) 1: Needs help to attain position but able to stand for 15 seconds with feet together

( ) 2: Able to place feet together independently but unable to hold for 30 seconds

( ) 3: Able to place feet together independently and stand for 1 minute without supervision

( )4: Able to place feet together independently and stand for 1 minute safely

The following items are to be performed while standing unsupported

8. *Reaching forward with outstretched arm

Instructions: “Lift you arm to 90⁰ . Stretch out your fingers and reach forward as far as yo
u can” (Examiner places a ruler and end of fingertips when arm is at 90⁰ . Fingers should n
ot touch the ruler while reaching forward. The recorded measure is the distance toward tha
t the fingers reach while the person is in the most forward lean position)

Grading : Please mark the lowest category that applies

( ) 0: Needs help to keep from falling

( ) 1: Reaches forward but need supervision

( ) 2: Can Reaches forward more than 2 inches safely

( ) 3 : Can Reaches forward more than 5 inches safely

( )4: Can Reaches forward confidently more than 10 inches

9. *Pick up object from the floor from a standing position

Instructions: “Please pick up the shoe/slipper that is placed in front of your feet”

Grading: Please mark the lowest category

( ) 0: Unable to try/needs assistance to keep from losing balance or falling

( ) 1: Unable to pick up shoe and needs supervision while trying

( ) 2: Unable to pick up shoe but comes within 1-2 inches and maintains balance independe
ntly

( ) 3:Able to pick up show but needs supervision

( )4:Able to pick up show safely and easily

10. *Turn to look behind over left and right shoulders while standing

Instructions: “Turn you upper body to look directly over your left shoulder. Now

try turning to look over you right shoulder”

Grading: Please mark the lowest category that applies

( ) 0: Needs assistance to keep from falling

( ) 1: Needs supervision when turning

46
( ) 2: Turns sideways only but maintains balance

( ) 3: Looks behind one side only; other side shows less weight shift

( )4: Looks behind from both sides and weight shifts well

11. *Turn 360

Instructions: “Turn completely in a full circle. Pause, then turn in a full circle in the

other direction”

Grading: Please mark the lowest category that applies

( ) 0: Needs assistance while turning

( ) 1: Needs close supervision or verbal cueing

( ) 2: Able to turn 360 safely but slowly

( ) 3: Able to turn 360 safely to one side only in less than 4 seconds

( )4: Able to turn 360 in less than 4 seconds to each side

12. *Place alternate foot on bench or stool while standing unsupported

Instructions: “Place each foot alternately on the bench (or stool). Continue until each foot
has touched the bench (or stool) four times”. (Recommended use of 6- inch-high-bench.)

Grading: Please mark the lowest category that applies.

( ) 0: Needs assistance to keep from falling/unable to try

( ) 1: Able to complete fewer than two steps; needs minimal assistance

( ) 2: Able to complete four steps without assistance but with supervision

( ) 3: Able to stand independently and complete eight steps in more than 20 seconds

( )4:Able to stand independently and safely and complete eight steps in less than 20 second
s

13. *Stand unsupported with one foot in front

Instructions: “Place one foot directly in front of the other. If you feel that you can’t place y
our foot directly in front, try to step far enough ahead that the heel of your forward foot is
ahead of the toes of the other foot” (Demonstrate this test item)

Grading: Please mark the lowest category that applies

( ) 0: Loses balance while stepping or standing

( ) 1: Needs help to step but can hold for 15 seconds

( ) 2: Able to take small step independently and hold for 30 seconds

( ) 3: Able to place one foot ahead of the other independently and hold for 30 seconds

47
( )4: Able to place feet in tandem position independently and hold for 30 seconds

14. *Standing on one leg

Instructions: “Please stand on one leg as long as you can without holding onto

anything”

Grading: Please mark the lowest category that applies

( )0: Unable to try or needs assistance to prevent fall

( ) 1: Tries to lift leg, unable to hold 3 seconds but remains standing independently

( ) 2: Able to lift leg independently and hold up to 3 seconds

( ) 3: Able to lift leg independently and holds for 5 to 10 seconds

( )4: Able to lift leg independently and hold more than 10 seconds

Total Score : 56 (low risk fall)

Note: Perform only items 6 thorough 14 (*) in the modified version of the scale. Maximu
m score for modified version is 36 points.

Score : 41 - 56 : low risk fall

21 – 40 : moderat risk fall

0 – 20 : high risk fall

48
49
MINI NUTRITIONAL ASSESSMENT

PART I. ANTHROPOMETRIC ASSESSMENT

Instructions: Complete this questionnaire by writing the number of points scored in the
boxes at the right of the questions.
Add the numbers in the boxes and compare the total assessment to the Malnutrition Indicator
Score on pg 4.

1. Body Mass Index(weight in Kg)/(height in m) = 20,65 Points

a. BMI < 19 = 0 points
b. BMI 19 to < 21 = 1 point
c. BMI 21 to < 23 = 2 points
d. BMI > 23 = 3 points _______

2. Measure of Mid –arm circumference (MAC) in cm.= 21 cm

a. MAC < 21 cm. = 0.0 points
b. MAC 21 < 22 cm. = 0.5 points ______
c. MAC >22 cm. = 1.0 points

3. Measure of Calf circumference (CC) in cm. = 30 cm

a. CC < 31 cm = 0 points ______
b. CC > 31 cm =1 point

4. Have you had a weight loss during the last 3 months

a. weight loss greater than 3 kg(6.6 lbs.)
= 0 points
b. does not know = 1 point
c. weight loss between 1 and 3 kg.
(2.2 lbs. and 6.6 kg.) = 2 points ______
d. no weight loss = 3 points

Total points for this section I = _______

MINI NUTRITIONAL ASSESSMENT

PART II. GENERAL ASSESSMENT

Instructions: Complete this questionnaire by writing the number of points scored in the
boxes at the right of the questions.
Add the numbers in the boxes and compare the total assessment to the Malnutrition Indicator
Score on pg 4.

1. Do you live independently? (not in Nursing home or Assisted living)

a. No = 0 points
b. Yes = 1 point _____
2. Do you take more than 3 prescription drugs per day?
a. Yes = 0 points ______
b. No = 1 point
3. Have you suffered from Psychological stress or an acute illness in
the past 3 months?
a. Yes = 0 points ______
b. No = 2 point
4. Mobility:
a. You use a wheel chair = 0 points
b. You are able to get out of a bed /chair

50
 but does not go out alone = 1 point ______
c. You go out independently = 2 points
5. Neuropsychological Problems:
a. has severe dementia or depression = 0 points
b. mild dementia = 1 point ______
c. no psychological problems = 2 points
Mini Mental State Score ___28_____/30
6. Skin condition:
Do you have any sores or ulcers (body check)
a. Yes = 0 points _____
b. No = 1 point

PART III. SELF ASSESSMENT

1. Do you view yourself as having nutritional problems?

a. Yes -major problems with malnutrition = 0 points
b. Does not know or has moderate problems = 1 point ______
c. NO –do not have nutrition problems = 2 points
2. In comparison with other people of the same age, how do you compare
your health status?
a. Not as good = 0.0 points
b. Do not know = 0.5 points
c. As good as others = 1.0 points ______
d. Better than most = 2.0 points

PART IV DIETARY ASSESSMENT

1. How many full meals do you eat daily?

a. 1 full meal daily = 0 points
b. 2 full meals daily = 1 point
c. 3 full meals daily = 2 points ______

2. Selected consumption markers for protein intake

 At least one serving of dairy products (milk, cheese, yogurt) per
day? Yes____ No____
 Two or more servings of legumes or eggs per week?
Yes___ No ____
 Meat, Fish, or Poultry every day?
Yes____ No____
a. If 0 or 1 Yes responses = 0.0 points
b. If 2 Yes responses = 0.5 points _______
c. If 3 yes responses = 1.0 points
3. Do you consume 2 or more servings of fruits or vegetables per day?
a. No = 0 points _____
b. Yes = 1 point
4. Has your food intake declined over the past three months due to loss of
appetite, digestive problems, chewing or swallowing problems?
a. severe loss of appetite = 0 points
b. moderate loss of appetite = 1 point ______
c. no loss of appetite = 2 points
5. How much fluid (water, juice, tea, milk …)do you consume daily?
(1 cup = 8 ounces)
a. less than 3 cups = 0.0 points
b. 3 to 5 cups = 0.5 points ______

51
 c. More than 5 cups = 1.0 points
6. Ability to feed self
a. requires assistance with meals/feeding = 0 points
b. able to feed self, but has some difficulty = 1 point ______
c. able to feed self independently (no problems) = 2 points

Total points for Section IV Dietary Assessment = ____

Add to Section I Anthropometric Assessment Points = ________
Section II General Assessment Points = _______
Section III Self Assessment Points = ________
ASSESSMENT TOTAL POINTS (maximum 30 points)) TOTAL =________

MALNUTRITION INDICATOR SCORE

> 24 points = Well nourished ________
17 to 23.5 points = at risk for malnutrition__________
< 17 points = malnourished _________ ***Consult nutritionist

52
53
 REFERENCES

1. Alba AS. Concept in pulmonary rehabilitation. In: Braddom RL. Editor.

Physical medicine and rehabilitation. 2nd ed. 2007. Philadelphia, WB
Saunders Company. p 710-17, 739-52.
2. Bach JR. Rehabilitation of the Patients with Respiratory Dysfunction. In :
DeLisa. Physical Medicine and Rehabilitation. 4th ed. 2005. Philadelphia,
Lippincott William and Wilkins. p 1843-62.
3. Global Strategy for the Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease (updated 2009). 2009. Medical
Communications Resources.
4. American Thoracic Society and European Respiratory Society. Standards for
the diagnosis and management of patients with COPD. 2004. Available at
http://www.thoracic.org/sections/COPD/resources/COPDdoc.pdf
5. Cuccurullo SJ. Editor. Physical medicine and rehabilitation board view. 1st
ed. 2004. New York. Demos Medical Publishing. p 585-610.
6. Kottke/Lehmann. Kruesen’s handbook of physical medicine and
rehabilitation. 4th ed. 1990. USA, W.B. Saunders Company. p 858-73.
7. Hass A et al. Pulmonary therapy and rehabilitation: principles and practice.
1st ed. 1979. Baltimore, The Williams and Wilkins Company. p 57-82.
8. Rogayah R. Pulmonary rehabilitation. In: Up date on respiratory care. 2000.
Jakarta, Persahabatan Hospital.
9. Tan JC. Practical manual of physical medicine and rehabilitation diagnostics,
therapeutics, and basic problems.2nd ed. 1998. St. Louis, Mosby. p 60, 650,
670-72.
10. Pulmonary Rehabilitation. BTS statement. Thorax 2001; 56: 827-834.
11. Tamin TZ. Manfaat latihan relaksasi dan konservasi energi pada penderita
penyakit paru obstruktif kronik. In: Pelatihan tim rehabilitasi medik
kardiorespirasi wilayah indonesia timur. 2002. Bandung.
12. American College of Sports Medicine. ACSM’s guidelines for exercise
testing and prescription. 7th ed. 2000. Philadelphia, Lippincott Williams &
Wilkins. p 227-29.
13. Sinha S, Gurm H. The double jeopardy of chronic obstructive pulmonary
disease and myocardial infarction. Open Heart. 2014. doi: 10.1136/openhrt-
2013-000010.
14. Falk JA, et al. Cardiac Disease in Chronic Obstructive Pulmonary Disease.
Proc Am Thorac Soc. 2007. Volume 5. doi: 10.1513/pats.200708-142ET.
15. Pranarka K. Tinjauan Umum Sindroma Geriatri. In : Rahayu RA, Karjono
itors. Simposium Geriatric Syndromes: Revisited. Semarang Badan Penerbit
Universitas Diponegoro; 2011. h. 1-22

54
16. Srinivas,P. Giants of Geriatrics-Current Issues and Challenges. 1st World
Congress on Healthy Ageing “Evolution: Holistic Ageing in an Age of
Change. Kuala Lumpur Malaysia; 19-22nd March 2012
17. Kissner C, Colby L. Management of pulmonary conditions. In: Therapeutic
exercise foundation and techniques. 5th ed. 2002. Philadelphia, F.A. Davis
Company. p 851-880.
18. Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, et all. Harrison’s
Principles of Internal Medicine. 17th ed. 2008. United States, McGraw-Hill
Companies. Chapter 241 and 338.
19. Brown, Marybeth. The Physiology of Age-Related and Lifestyle-Related
Decline. In Geriatric Physical Therapy. 4th edition. St. Louis, Missouri;
Elsevier Mosby. 2012; Page 34-45
20. Bloch, Rina M. Geriatric Rehabilitation. In Braddom Physical Medicine and
Rehabilitation. 4th edition. Philadelphia; Elsevier.2011. Page 1482-95.
21. Lewis CB, Bottomley JM, Geriatric rehabilitation, a clinical approach, 3th
edition, New jersey, Pearson Prentice Hall, 2008
22. Older Adult, Family, and Caregiver Guide on Depression. US Department
of Health and Human Services. 2011. P 1-5.
23. Devon CA. Comprehensive geriatric assessment: making the most of the
aging years. Curr Opin Clin Nutr Metab Care. 2002;5:19-24
24. Lewis CB, Bottomley JM, Geriatric rehabilitation, a clinical approach, 3th
edition, New jersey, Pearson Prentice Hall, 2008
25. Decramer M, et al. Global Initiative for Chronic Obstructive Lung Disease:
pocket guide to COPD diagnosis, management, and prevention. GOLD Inc.
2015.
26. Hasan A, et al. Understanding the relation between COPD and Coronary
artery disease. JIACM. 2014. 15(2): 120-4.

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