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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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- functional diagnostics: assessment of the state of stability and the
degree of age-related changes in gait; identification of functional potential
using questionnaires and scales, for example, Activity of Daily Life
(ADL); identification of the degree of involutive changes in the main
organs and systems;
- assessment of mental status: identification of age-associated
changes in mental status (cognitive deficit, dementia or depression);
identification of age-associated psychological characteristics of a person
(the presence of a syndrome of maladaptation in a nursing home, a
syndrome of violence against the elderly, the presence of chronic stress);
nosological diagnostics, that is, the identification of mental pathology;
assessment of a psychiatric history in relation to the course of somatic
pathology, for example, the development of a state of delirium during
decompensation of somatic pathology;
- study of social status: identification of the social role and nature of
social relationships of a person of elderly and senile age; the nature (in
particular, safety) of the environment, the need for various types of social
assistance.
CGA is based on the use of questionnaires and scales, the main of
which are: “Assessment of the risk of developing malnutrition syndrome”,
“Assessment of motor activity in the elderly”, “Mini-study of mental
state”, “Assessment of depression (Beck Scale)”, “Assessment of
independence in Everyday life”.
Senile index
The Frailty Index (ISA) is often used to diagnose and determine the
severity of frailty. To determine it, it is necessary to evaluate the following
positions:
- self-assessment by a patient of elderly and senile age of their own
health level (0 points — very good; 0.25 — very good; 0.5 — average;
0.75 — bad; 1.0 points — very bad);
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- the presence, according to the patient, of at least one of the
following diseases: arthrosis, a history of stroke, coronary heart disease
(angina pectoris), diabetes mellitus, chronic obstructive pulmonary
disease, bronchial asthma, anxiety-depressive syndrome, arterial
hypertension, cataract (0 points — no, 1 point — takes place);
- assessment of the functional state (the ability to sit without
assistance; walking 100 meters; the ability to get up from a chair
independently; long standing; independence in housekeeping; social
activity; the ability to stretch your arms forward and hold them; the ability
to concentrate, walk for a long time; the ability to independently wash,
dress, work, take a bath, use the toilet, carry objects; safety of the
emotional sphere (0 points — no problems; 0.25 points — slight decrease
in abilities; 0.5 — moderate decrease; 0.75 — pronounced; 1 point — the
impossibility of independently performing the listed operations and
actions);
- body mass index (0 points — body mass index > 18.5; 1 point —
< 18.5);
- muscle strength during carpal dynamometric test (0 points — no
weakness; 1 point — weakness);
- the ability to walk quickly (0 points — saved; 1 point — not saved).
The higher the ISA, the more pronounced the deficiency of functions
and, accordingly, the increased need for care. In particular, 0–0.2 points is
regarded as the absence of frailty; 0.2–0.4 points — moderately
pronounced frailty; 0.4 points and above — severe frailty.
Frailty and care
Frailty corresponds, first of all, with the concept of care.
Identification of frailty and its leading symptoms allows us to develop an
individualized plan for caring for an elderly and senile person, which
allows us to maximize longevity in the most active form possible.
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Pharmacological care support is as follows:
- it is important to avoid polypharmacy and high doses of drugs;
- in case of sleep disturbance, it is advisable to use trazodone or
zolpidem, hygienic measures to restore sleep are important;
- in anxiety-depressive syndrome, it is advisable to use serotonin
reuptake inhibitors;
- it is necessary, with a decrease in body weight, to use enteral
mixtures;
- correction of vitamin D deficiency, if present, is necessary.
Kinesiotherapy in frailty is important and should be aimed at training
balance in order to prevent falls, the maximum possible restoration of
muscle strength and endurance at a given age and with the patient's
pathological background.
Frailty and other pathology
Above, we pointed out that the very concept of frailty is
characterized by a decrease in the reserve capacity of the body due to agerelated changes and multipathology, which dictates the need to develop
individualized care tactics. Diseases such as myocardial infarction, stroke,
tuberculosis, chronic heart failure and others can manifest frailty or worsen
its course, as well as the prognosis for the restoration of functions and life.
Frailty and disability
Frailty and disability are, in fact, different concepts. Frailty is a
condition or clinical syndrome in which, due to polymorbidity, many
organs and systems are affected, which leads to a decrease in the reserve
capacity of the body and the onset of disability or death due to minimal
internal or external influences. At the same time, the restriction of daily
activity (ADL) characteristic of persons with disabilities due to damage, as
a rule, to one leading system and a decrease in one leading function may
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be absent in frailty, when there is a decrease in many functions due to
multiorgan age-related and pathological processes. According to different
authors, with frailty, only 60 % of people have restrictions on daily
activity, and frailty itself is diagnosed in 28 % of patients with life
limitations and social insufficiency, that is, disability. Frailty, thus,
pathogenetically is a manifestation of the polymorbidity characteristic of
the elderly and senile age, and the organizational basis for providing care
for this syndrome is geriatric care.
Frailty and medical care
Frailty is largely a prognostic factor. For example, in the stage of preasthenia, the probability of death over the next five years averages 20.4 %,
and with a developed clinical picture of frailty, this figure increases to
44.5 %.
When ISA is above 4, against the background of normal cholesterol
and albumin levels, there is an extremely high risk of surgical mortality.
With the rapid progression of frailty, there is a high degree of resistance to
the treatment of its complications.
Data on the epidemiology of frailty are important when planning
specialized types of care, such as oncology. If 30 % of elderly and senile
people in the population are relatively healthy, then in relation to them,
with the development of oncological disease, traditional chemotherapy
will be required; but for those who have pre-asthenia or asthenia, special,
adapted schemes are needed, since aggressive chemotherapy can
accelerate the development of advanced manifestations of frailty. It is
believed that age-oriented chemotherapy regimens should consist in
reducing the doses of chemotherapy drugs, using less toxic therapy
regimens, the beginning of such therapy must be in the hospital, and it is
important to carefully assess the patient's condition in the immediate and
long-term period after the end of chemotherapy.
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Prevention of the development of frailty
The most important direction of medical care in the elderly and
senile age is the prevention of frailty. According to the first letters of the
English term “frailty” — FRAILTY — we can say that the prevention of
this syndrome should be as follows:
F (food) — control of food intake and regulation of the diet;
R (resistance exercises) — physical activity;
A (atherosclerosis prevention) — prevention of atherosclerosis;
I (isolation avoidance) — avoid social isolation;
L (limit pain) — stop pain;
T (tai-chi or other balance exercises) — doing physical exercises;
Y (yearly functional checking) — regular medical examinations.
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APPENDIX
COMPREHENSIVE GERIATRIC ESSASSMENT PATIENT CARD
Passport data and social status
Name of the patient
Gender: Male
Female
Date of birth
(d.m.y.)
(____/____/_______)
Disability
No
Family status
married
unmarried (not married)
widower (widow)
divorced
Education
average _____
classes
secondary special
higher
Who lives with
with wife/husband
with kids
one
other:
Profession
Works
Not really
Not working since
____ years
Address
Telephone
Is there someone the patient(s) can turn to for help if needed?
Yes
Not
Does the patient have a guardian?
Yes
Not
Name, telephone
number of the
guardian
Name, telephone
number of the
caregiver
Full name, position
of the person who
filled out the card
Date of
completion
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Functions of the pelvic organs
Does involuntary leakage of urine occur
during coughing, laughing, sneezing,
lifting heavy objects?
Never; once a week or less;
2–3 times a week; once a day;
several times a day; all time;
Is there involuntary leakage of urine on
the way to the toilet?
Never; once a week or less;
2–3 times a week; once a day;
several times a day; all time;
How much urine is leaking?
Small amount (a few drops)
moderate amount
A large number of
Concomitant chronic diseases and conditions
(with indication of duration)
Arterial
hypertension
Bronchial
asthma
Ischemic heart
disease
COPD
Postinfarction
cardiosclerosis
Oncological
diseases
CHF
Urolithiasis disease
A history of stroke
peptic ulcer
Diabetes
Trophic ulcers
bedsores
Osteoarthritis
Anemia
Problems with
chewing food
Other diseases
Do you have difficulty emptying your
bladder?
Yes
Not
How often does the patient get up at night
to urinate?
Do incidents of fecal incontinence occur?
Never; once a week or less;
2–3 times a week; once a day;
several times a day; all time;
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Vision/hearing problems
Diseases of the organ of vision
Cataract
Glaucoma
Increasing macular degeneration
Other
Surgical treatment
Do you have difficulty reading
newspapers/books even with glasses?
Yes
Not
Are faces difficult to recognize even
when wearing glasses?
Yes
Not
Diseases of the organ of hearing
Does the patient have to ask his
interlocutor again? (including when using
a hearing aid)
Not
Rarely
Often
Drug therapy (indicating the dose, frequency of administration,
missed doses, for example: takes the drug every day; skips a dose less
than 1 time per week, 1–2 times a week, 3 or more times a week)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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Risk factors for chronic noncommunicable diseases
Smoking:
I do not smoke
Smoked in the past for _____ years per _____ packs/day
Smokes: < 1/2 pack/day
½–1 pack/day for _________ years
> 1pack/day
Alcohol:
No Yes: < 1; 1–3; ≥ 3 units¹ per day
Physical
activity
shortness
daily, 2–3 times a week, 1 time per week, < 1 time per week,
< 1 time per month
duration
< 30 min, 30–60 min, 1–4 hours, > 4 hours
options
hiking, swimming, dancing, other activities
(_______________________________________________)
What is the
physical
limitation?
activity?
memory problems, arthritis, shortness of breath, chest pain,
injuries, fractures, consequences of stroke, chronic pain, loss of
vision, unsteady gait, other:
Age at menopause
(years)
Fracture of the
femoral neck in
parents
Not really
¹1 unit alcohol = 45 ml of vodka or 150 ml of wine or 330 ml of beer.
Numerological pain rating scale
0 1 2 3 4 5 6 7 8 9 10
No pain Unbearable
pain
Chronic pain
Yes, constantly experiencing
Yes, periodically
No, not experiencing
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Taking painkillers
Doesn't accept
Accepts (name)_________________
< 1 time per week
1 time per week
2–3 times a week
daily
Frequency of doctor's house calls (last
year)
Frequency of calls to the EMS (for the
last year)
Frequency of hospitalizations (last year)
indicating the reason for hospitalization
emergency
Planned
Falls in the
last year
Quantity
Circumstances (at home / on the street),
the reason
Exodus
(fracture,
injury,
TBI)
Fractures
Age
Circumstances, reason
Localization
Hip fracture in parents: No Yes
Densitometry
the date of
the
(__/__/___)
Hip
T-test
Total
Neck
MPC (BCM),
g/cm²
Total
Lumbar
spine
T-test
Total
(L 1–L 4)
Worst result
MPC (BCM),
g/cm²
Total
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