Utilization of Comprehensive Geriatric Assessment ( P 3 G ) in Primary Health Center at Medan City and Deli Serdang District of North Sumatera Province Indonesia 2018

Introduction: The Ministry of Health of the Republic of Indonesia has issued a guide to Comprehensive Geriatric Assessment (P3G) in 2017, but there is few data regarding its use in health care institutions. The primary primary health center as the spearhead of primary services always receives geriatric patients and should have taken advantage of CGA. Objective: To find out the results of using a comprehensive assessment guide for geriatric patients in Medan City Primary health center and Deli Serdang District Primary health center in 2018. Methods: Descriptive study with cross sectional design, respondents were elderly who sought treatment in three primary health center such as Sukaramai Primary health centers in Medan City, Bandar Khalipah Primary health center and Tanjung Rejo Primary health center Deli Serdang District from 27 August to 20 September 2018 by determining the number of respondentss using the Slovin method, data collection by questionnaire interviews and data analysis using SPSS. Results: A respondents of 120 people were obtained, with an advanced category elderly aged 60-74 years at 90.8%, old aged 75-90 years at 8.3% and very old aged > 90 years at 0.9%. With ADL examination, respondents experienced mild-moderate dependence 60.8%, 37.5% independent, 1.7% heavy dependence. By examining the respondents’ IADL 89.2% independently, 0.8% was done by others, 0.8% needed help all the time, and 9.2% needed occasional assistance. By checking the risk of falling, 57.5% of the respondents experienced a low risk, 35% high risk and 7.5% there was no risk. With GDS examination 67.5% of 1respondents had no depression, 32.49% were most likely to have depression. With the MiniCog examination 78% of normal respondents, 21.7% suspected cognitive function decreased. With MMSE examination 80.8% of normal respondents, 16.7% of mild cognitive function disorders, and 2.5% of severe cognitive dysfunction. With AMT examination 73.3% of normal respondents and 26.7% of moderate memory disorders. With MNA screening screenings, 66.7% of respondents had no risk, and 33.3% might experience malnutrition and further study was needed. Based on the assessment of advanced MNA 95% risk of malnutrition, and 5.0% malnutrition. Conclusion: Elderly people who came to the primary health center most were elderly aged 60-74 years at 90.8%, the highest gender was women at 53.3%, based on the ADL examination, the respondents experienced the most mild-moderate dependence of 57.7%, IADL examination amounting to 89.2% independently did not need assistance, risk checking fell by 57.5% respondents experienced a low risk of falling, GDS examination amounted to 67.5% of respondents had no depression, MiniCog examination of 78% of respondents did not experience a decline cognitive function, MMSE examination of 80.8% of respondents did not experience cognitive impairment, AMT examination was 73.3% of respondents did not experience memory impairment, MNA examination of 66.7% did not experience malnutrition. Keyword: Geriatrics, Elderly, P3G, Primary health center, Ministry of Health Correspondence to: Elman Boy, Public Health Lecture, Faculty of Medicine, Muhammadiyah North Sumatra University, Indonesia. Gedung Arca Street No. 53 Medan, North Sumatra, Indonesia. Email:elmanboy@umsu.ac.id 1. Public Health Lecture, Faculty of Medicine, Muhammadiyah North Sumatra University, Indonesia. 2-11. Medical Student, Faculty of Medicine, Muhammadiyah North Sumatra University, Indonesia. Introduction To maintain the elderly to stayhealthy and productive socially and economically in accordance withhumandignity, health care for the elderly must beheld. The CommunityPrimaryhealth center as a first levelhealth care facilityisexpected to be able to carry out basic levelpromotive, preventive, curative and rehabilitative efforts for the elderly.1 Based on the 2017 National Socio-Economic Survey (Susenas) data, the number of elderly International Journal of Human and Health Sciences Vol. 03 No. 02 April’19 Page : 88-100 DOI: http://dx.doi.org/10.31344/ijhhs.v3i2.82


Introduction
To maintain the elderly to stayhealthy and productive socially and economically in accordance withhumandignity, health care for the elderly must beheld.The CommunityPrimaryhealth center as a first levelhealth care facilityisexpected to be able to carry out basic levelpromotive, preventive, curative and rehabilitative efforts for the elderly. 1 Based on the 2017 National Socio-Economic Survey (Susenas) data, the number of elderly   2 In treating and managinggeriatric patients, two important components are included : the team approach and the Comprehensive Geriatric Assessmentwhichis part of comprehensivegeriatric management (CGM).The geriatricpatient'scompleteapproachis a multidimensionalassessmentprocedure.Multidisciplinary diagnostic instruments are needed to collectmedical, psychosocial, functionalability, and limitations of elderly patients. 3he Indonesiangovernmentthrough the Minister of Health has issued a regulation on the implementation of elderlyhealth services at the helath center. 1 Research on the comprehensiveassessment of geriatric patients whichincludeseightassessment components isstill not widelydone in Indonesia, especially in Helath center. 3ased on the description above, the researcherisinterested in conductingresearch on the overview of the completestudy of geriatric patients in Medan City Primaryhealth center and DeliSerdang District in 2018.

Method
This type of research is descriptive research with cross-sectional design, with the determination of the number of respondentss using the Slovin formula and using the Comprehensive Geriatric Assessment questionnaire instrument.Based on the data above, most of the respondents in Medan Primary health center were categorized as elderly, ie 54 people (90.0%).While the majority ofrespondents in Deli Serdang District Primary health center were categorized as elderly, namely 55 people (91.7%).Total 120 100 In this study showed that most respondents were female, namely 64 people (53.3%), followed by male respondents was 56 people (46.7%).

Respondent Characteristics
This study discusses the socio-demographic characteristics of the elderly, including age and gender.From sociodemography, respondents in Medan City Primary health center and Deli Serdang District found a higher ratio of elderly women than men (53.3 versus 46.7%).The results obtained tend to be close to the data in the population where the ratio of women and men is 55% versus 45%.Statistics in Indonesia also state that the elderly population above 60 years is dominated by women because it relates to a higher life expectancy.In terms of age, the category of respondents with age 70 years or more is the age category with the highest number.This is in line with the average life expectancy of elderly in Indonesia in 2014 which is close to 72 years. 4n this study based on ADL examination of 120 respondents, the results of the data in the most category were mild-moderate dependence of 73 people (60.8%).This is in line with Kamila's research (2017), with 88 respondents as many as 37 people (42%) categorized as mild-moderate dependence.. 5 The results of this study are in line with Prihati's (2017) research where out of a total of 96 respondents, 41 respondents (43%) experienced mild-moderate dependence. 6he results of this study are also in line with Rohaedi's (2016) study, where out of a total of 21 respondents, 15 respondents (72%) experienced mild-moderate dependence. 7In general, the physical condition of a person who has entered the elderly has decreased.So that in general will affect the activities of daily life.This study shows that the level of dependence of the elderly is mostly mild.This condition shows that most need only a little help (minimum care) in fulfilling their care. 8hen viewed by age category, the elderly category with an age range of 75-90 years, both in Medan City Primary health center and Deli Serdang District Primary health center both show the results of more respondents experiencing mildmoderate dependence as many as 3 respondents (60%) at the helath center Medan city and as many as 3 respondents (60%) at the Deli Serdang primary health center.This is in line with Inayah's research (2017) from 53 respondents of old age, as many as 27 respondents (40.3%) categorized as mild-moderate dependence. 9According to research Suardana (2012) states that in the elderly with an age range of 75-90 years more experienced a significant decrease in the level of independence compared to the elderly category with the age range 60-74 years. 10ased on the IADL examination, it was found that Independent / Independent were 107 people (89.2%).While based on the age distribution, the most distribution is in the elderly category, which is 65-75 years.Frequency Distribution of instrumental activities of daily living (IADL) in Medan city primary health centers and Deli Serdang district primary health centers showed the highest distribution was independent of 53 people (98.1%) in the age range 60-74 years and independent as much as 47 people (85.5%) in the age range 60-74 years.Not much different from the research conducted by Kurniawan (2018) in his research showed that the highest distribution was independent of as many as 36 people (67%) and the remaining independent were 18 people (33%).The limited ability of elderly IADL is the limitation of the elderly in meeting their life needs and their care. 11ging can cause a decline in the ability of the elderly to meet their needs and care for themselves so that the ability of the IADL also decreases. 12esearch conducted by Jerson et al.Showed significant results between age and IADL.There is still a decline in executive functions that affect a person's decision making in carrying out activities of daily life even though his health status is good. 12,13ased on the examination of the risk of falling in this study, it was found that most of the elderly (60-74 years) were 65 people (54.2%) the risk of falling low.This is supported by Junior (2017)  study entitled the relationship between age and daily activities with the risk of falling geriatric outpatient patients where there is a significant low and direct relationship between age and risk of falls. 14According to Grundstorm, et al the risk of falling in the elderly increases with age where there will be a decrease in bone mass that will affect the function and strength of bones which results in a decrease in the ability to maintain the balance of the human body. 15n this study more low risk of falling because the respondents in this study were mostly elderly (60-74 years) and this study was conducted on patients who came to seek treatment at Medan and Deli Serdang primary health centers where the majority of patients were still able to walk alone to come seek treatment while in Junior's study (2017) more are at high risk for falls because the respondents in the study is the most aged (76-80 years). 14ased on the GDS examination, in this study found the most elderly age groups (60-74 years) as many as 75 people (62.5%) no depressive disorders.This high percentage is in accordance with Aryawangsa's research (2016) the incidence of depression-free elderly in Tampaksiring I Primary health center, Gianyar Regency, Bali (76.7%) 16 and Prabhaswari et al study of the incidence of depression in the elderly in the working area of Petang I Public Primary health center in Badung Regency, 2015 (75.6%). 17n general, the elderly begin to experience setbacks from various aspects, namely physical, psychological, economic and social, which can affect the psychosocial status of the elderly themselves.The discovery of 32.49% of respondents from the results of the study with the conclusion that there is a high likelihood that there is a depressive disorder may be caused by the respondent is an outpatient who came to the primary health center with the aim of treating the disease, because one of the risk factors for depression is the existence of the disease. 16,18ne of the factors that support the high number of elderly without depression in this study can be caused by the high number of social activities and interpersonal relationships among fellow citizens.
Where residents work together and interact in daily life.Getting high social and environmental support will make the elderly feel more comfortable and happy, so they can keep them away from the risk of depression. 17,18,19ased on the Mini-Cog examination in this study, the most respondents were the elderly (60-74 years) as many as 88 people (73.3%) did not experience a decrease in cognitive impairment.This study is in line with Mongonsidi (2012) that more respondents in the elderly category with the age range 60-74 years did not experience a decline in cognitive function by 25 respondentss (86.25) of 29 respondentss. 20nd the results of this study are also in line with the research conducted by Manurung (2016) that of 53 respondentss, more respondentss did not experience a decrease in cognitive impairment by 34 respondentss (64.2%). 21This is because during the study period, respondents who visited Medan City Primary health center and Deli Serdang District Primary health center during the study were more elderly with an age range of 60-74 years.But this is not in accordance with the theory, which according to theory with increasing age will cause changes in neurotransmitters and cause a decline in cognitive function. 22According to Kalaria, age is the most consistent factor causing a decline in cognitive function in previous studies around the world. 23nd this may occur because in addition to the age factor, there are other factors that can also affect cognitive function such as educational history and other comorbidities.Based on the MMSE examination, in this study found the most respondents in the elderly category (60-74 years) as many as 91 people (83.5%) did not experience cognitive impairment.This research is in line with the research of Ramadian (2012) that more respondents in the elderly category (60-74 years) did not experience cognitive impairment as many as 26 respondents (86.7%) of 30 respondents. 24owever, this research is not in line with Gusti's research (2014) where the highest age category is elderly with an age range of 75-90 years as many as 52 respondents (61.9%). 25This is because during the study period, respondents who visited Medan City Primary health centerand Deli Serdang District Primary health center during the study were more elderly with an age range of 60-74 years, and this may occur because in addition to the age factor, there are other factors that also can affect cognitive functions such as educational history and physical activity levels.According to research conducted by Rasyid (2017) where there is a significant relationship between the level of education and the occurrence of cognitive impairment, the p value <0.05. 26ased on AMT examination in this study, it was found that there were the most elderly age groups (60-74 years) as many as 84 respondents (77.1%) did not experience memory / normal disorders.This research is in line with research conducted by Lumbantobing (1995) In 2020, developing countries older than 80 years will increase by 65% and reach 138%.In these circumstances the incidence of a person becoming senile or dementia is 1% at the age of 75 years and increases to 10% at the age of over 85 years. 27ased on the examination of MNA, in this study were obtained from 120 respondentss included in the category of good nutrition as many as 80 elderly (66.7%) and the risk category of malnutrition as many as 40 elderly (33.3%) of the above results more elderly who belong to the normal nutritional category.this research is not in line with the research conducted by Oktariyani (2012) out of 143 elderly 68 normal nutrition elderly (47.6%) and 75 elderly may experience malnutrition / need further assessment (52.4%) this is based on the respondent's characteristics and the location of the different locations oktariyani research was in a social institution. 28he number of elderly people who are in normal nutrition due to the characteristics of respondents who are dominated by the elderly (60-74) as many as 109 elderly while elderly (75-90) and very old age (> 90) only 11 elderly, because based on the theory of aging can cause changes in intestinal function, ineffective metabolism, homeostasis failure and the presence of risk factors that affect the nutritional status of the elderly such as psychological factors, the presence of disease history and the amount and type of food intake. 28

Table 2 .Frequency distribution age group at Medan City Primary health center
and Deli Serdang District Primary health center.

Table 5 .Frequency distribution of ADL ADL
Based on the results of the study, the highest distribution of the level of independence of elderly is the age group of 60-74 years as many as 67 people (61.5%) categorized as mild mild-moderate dependence.

Table 7 .Frequency distribution of ADL Data in Deli Serdang District Primary health center ADL
Frequency Distribution of instrumental activities of daily living (IADL) at Deli Serdang district primary health centers showed the highest distribution was 47 people (85.5%) in the age range 60-74 years old.

Table 11 . Frequency distribution of falling risk
Based on the general data, the risk of falling was obtained by the most respondents in the elderly category with the age range of 60-74 years having a low risk of 65 respondents (54.2%).

Table 12 .Frequency distribution of risk of falls in Medan City Primary health center.
Based on risk data falling in Medan City Primary health center, most respondents in the elderly category with an age range of 60-74 years had a low risk of 33 respondents (55%).

Table 13 .Frequency distribution of the risk of falls in the Deli Serdang District Primary health center.
Based on risk data falling in Deli Serdang District Primary health center, most respondents in the elderly category with age range 60-74 years old had a low risk of 32 respondents (53.3%).

Table 14 . Frequency distribution of GDS Age GDS Total Normal Probable Depression
data, the GDS was found to be the most respondents of the elderly category with the age range of 60-74 years without depression, 75 respondents (62.5%)

Table 15 .Frequency distribution of GDS in Medan City Primary health center.
data in Medan City Primary health center, there were the most respondents in the elderly category with an age range of 60-74 years without depression, 41 respondents (68.3%)

Table 16 .Frequency distribution of GDS in District Primary health centers Deli Serdang.
data at the Deli Serdang District Community Primary health center, most respondents in the elderly category with an age range of 60-74 years were not depressed, as in 34 respondents (56.7%).

Table 17 .Frequency distribution of Mini-Cog
Based on the general data of the mini-cog, the most respondents in the elderly category with the age range 60-74 years did not experience a decline in cognitive function by 88 respondents (80.7%).

Table 18 .Frequency distribution of Mini-Cog in Medan City Primary health centers and Deli Serdang district Age Medan city primary health center Deli Serdang district primary health center
Based on the Mini-Cog data of respondents in Medan City Primary health center, most respondents in the elderly category with age range 60-74 did not experience a decline in cognitive function as many as 47 respondents (87%).And at Deli Serdang District Primary health center, most respondents in the elderly category with age range 60-74 years did not experience a decline in cognitive function by 41 people (74.5%)MMSE

Table 20 . Frequency distribution of MMSE in Medan City Health Care
data, respondents in Medan City Primary health center found that most respondents in the elderly category with the age range 60-74 did not experience cognitive impairment as many as 47 respondents (83.3%).

Table 22 . Frequency distribution of AMT
Based on the results of the AMT study, the highest number of respondents in the elderly category was 60-74 years, 84 people (77.1%) did not experience memory problems.

Table 23 .Frequency distribution of AMT in Medan City Primary health center
Based on the results of AMT research in Medan City Primary health center, the results of the most respondents were in the elderly category with a range of 60-74 years, as many as 43 people (79.6%) did not experience memory disorders.

Table 24 .Frequency distribution of AMT in Deli Serdang District Primary health centers
Based on the results of AMT research at Deli Serdang District Primary health center, the results of the most respondents in the elderly category with a range of categories (60-74 years) were obtained, as many as 41 people (74.5%) did not have memory disorders.

Table 26 . Frequency distribution of MNA Medan City Primary health center
Based on research conducted in Medan City Primary health center, the results of the most categorized respondents were obtained with 60-74 years of category, as many as 17 people (94.4%) may experience malnutrition.

Table 27 . Frequency distribution of MNA Deli Serdang District Primary health centers
,29 Conclusion Based on the results of research on the Utilization of Comprehensive Geriatric Assessment (CGA) at the primary health center of North Sumatra Province in the case study of 2018, conclusions can be drawn: 1. Respondents in the Medan city primary health center were 83.1% elderly and in Deli Serdang district primary health centers were 91.7%. 2. Respondents of Helath center in Medan City are more female by 49.2% and in Helath center Deli Serdang district by 53.3%.3. Respondents in the Medan city primary health center and deli serdang district primary health centers are mostly Muslim at 70%. 4. Results of Activity of Daily Living (ADL) with Barthel Modification Index Instruments on respondents in the urban field primary health centers are more likely to experience mild dependence in the elderly by 38.3% and in the Deli serdang district primary health center at 70.0%.5.The results of the instrumental activities of daily living (IADL) Lawton on respondents in the helath center in the field were more independent/ older baths were 88.3% and in the Deli District primary health centers were 78.3%.6. Results from Falling Risks of Elderly Patients in respondents in the Helath center Medan field experienced a lower risk in the elderly by 55.0% and in the primary health center Deli Serdang district by 53.3%.7. The results of the Geriatric Depression Scale (GDS) in respondents in the Medan city primary health center did not have a higher risk for depression in the elderly at 68.3% and in the Deli srdang district primary health center at 56.7%.8.The results of the Mini-Cog and Clock Drawing Test (CDT4) on respondents in the Medan city primary health center did not experience cognitive impairment in the elderly at 78.3% and in the Deli Serdang District primary health center at 68.3%.9.The results of the Mini-Mental State Examination (MMSE) on respondents in the Medan city primary health center were less likely to experience cognitive impairment in the elderly at 78.3% and in the Deli Serdang district primary health center at 73.3%.10.The results of the Abbreviated Mental Test (AMT) on respondents in the Helath center in Medan City were more likely to experience no memory impairment in the elderly at 71.7% and in the Deli Serdang District Primary health center Serdang at 68.3%.11.The results of the Mini Nutritional Assessment (MNA) in respondents in the Medan city primary health center had no more risk of experiencing malnutrition in the elderly 60.0% and in the Deli Serdang district primary health center at 66.7%.