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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
.pdf
111
3.5/6/7
At admission, was any
resuscitation therapy /
anesthesia allowance /
pain relief with narcotic
drugs
Was the patient isolated,
including the ICU
_Not really
Number of
hours/days spent in
the ICU
____hours/____
days
4
Confusion score
4.1
Acuteness and undulation of changes in mental
status:
Are there changes in mental status relative to baseline?
OR
Have there been undulating changes in mental status in
the last 24 hours?
If the answer to
both questions is
“no” →
DELIRIUM NO
If the answer to one
of the questions is
“Yes” → 4.2
4.2
Attention disorder:
“Squeeze my hand every time I say the letter A”
Read the following sequence of letters “L A M P A A L
A D D I N A”
BUGS: Doesn't compress on letter A and compresses
on other letters
\If he cannot complete the task with letters → Pictures
If 0-2 errors →
DELIRIIA NO
If ≥2 errors → 4.3
4.3
Changes in the level of consciousness Current level of
consciousness (according to RASS)
If RASS is other
than 0 →
DELIRIUM YES
If RASS = 0 → 3.4
4.4
Disorganized thinking :
1. Will the stone float on water?
2. Do fish live in the sea?
3. Does one kilogram weigh more than two?
If ≥ 2 error →
DELERIUM IS
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4. Can a hammer hammer a nail?
Command: “Show as many fingers” (show 2 fingers)
“Now do the same with the other hand” (do not
demonstrate) OR “Add another finger” (if the patient
cannot move both hands)
If 0-1 error →
DELIRIIA NO
4.5
Conclusion : DELIRIUM / no delirium
4.6
Test of consecutive, fivefold
subtraction of 7 from 100:
“Subtract 5 times
consecutively 7 out of
100”
Number of errors:
4.7
Time Orientation __ /5
Orientation in
space__/5
The Richmond Agitation-Sedation Scale (RASS)
+4 MILITARY: belligerent, aggressive, dangerous to others
+3 VERY ARRIVED: aggressive, trying to rip out tubes, IV or
catheter
+2 EXCITED: frequent aimless movements, resistance to procedures
+1 UNRESTORED: restless, non-aggressive movements
0 CALM AND ATTENTIVE
–1 Drowsy: inattentive, drowsy but always reacts to voice
–2 LIGHT SEDATION: wakes up briefly to voice
–3 MIDDLE SEDATION: moving or opening eyes to voice but no
eye contact
Results of laboratory studies
Hemoglobin (g/l)
LDL (mmol\l)
Creatinine (µmol/l)
Ca total (mmol\l)
Glucose (mmol\l)
Caionizer (mmol\l)
Total protein (g/l)
TSH (µIU\ml)
Albumin (g/l)
Vit B12 (pg\ml)
Cholesterol (mmol\l)
Folic acid (nmol/l)
113
Geriatrician's conclusion:
Additional examinations:
Expert advice:
Preventive and therapeutic measures:
– physiotherapy
– diet
– referral to schools for patients and their families
114
Drug therapy
Referral to the territorial center of social services:
Repeated consultation with a geriatrician
_______________________________________________________
Screening “Age is not a hindrance”
The date _____________
Full name of the patient
_______________________________________________________
Full years
Screening “Age is not a hindrance”
The date _____________
Full name of the patient
_______________________________________________________
Full years
115
Questions
Yes (1)
No (0)
1
Have you lost 5 kg or more in the last 6 months?
(in EU)
2 Do you experience any limitations in daily life due to
visual impairment or hearing loss?
3
Have you had a fall-related injury in the past year?
4
Have you been feeling depressed, sad or anxious
during the last weeks? (mood)
5 Do you have problems with memory, understanding,
orientation, or the ability to plan?
6
Do you suffer from urinary incontinence?
7
Do you have difficulty moving around the house or
outside? (walking up to 100 m / climbing 1 flight of
stairs)
TOTAL
The patient is considered “fragile” with 3 or more points
116
CONTROL TASKS
VARIANT 1
Test questions
1. Absolute indications for nutritional support in the form of
liquid oral nutritional supplements are:
a) The patient's initial signs of malnutrition: body mass index less
than 12 kg/m2, hypoproteinemia (< 30 g/l), hypoalbuminenmia (< 30 g/l);
b) The patient's initial signs of malnutrition: body mass index less
than 19 kg/m2, hypoproteinemia (< 60 g/l), hypoalbuminemia (< 30 g/l);
c) The presence of rapidly progressive and significant weight loss of
more than 10 % per week;
d) Presence of rapidly progressive and significant weight loss of
more than 2 % per week.
2. All drugs for the treatment of osteoporosis are recommended
to be prescribed in combination:
a) vitamin D with potassium preparations;
b) vitamin D with calcium preparations;
c) vitamin A with calcium preparations;
d) vitamin B with potassium preparations.
3. Vitamin D deficiency corresponds to the concentration
a) 15(OH)D3 < 10 ng/ml;
b) 25(OH)D3 < 20 g/ml;
c) 25(OH)D3 < 20 ng/ml;
d) 45(OH)D3 < 20 ng/ml.
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4. The duration of a comprehensive geriatric assessment of
patients with frailty is:
a) 1.5–2 hours;
b) 1–1.5 hours;
c) 30 minutes — 1 hour;
d) 30–45 minutes.
5. For secondary prevention of cardiovascular diseases, it is
recommended to take acetylsalicylic acid in the following doses:
a) 75–100 mg/day;
b) 75–200 mg/day;
c) 75–90 mg/day;
d) 85–150 mg/day.
6. For the correction of behavioral and mental disorders, it is
first of all recommended to apply:
a) neurocognitive drugs;
b) neuroleptics;
c) non-drug methods
d) tranquilizers
7. For the treatment of chronic pain syndrome, it is
recommended:
a) venflaxin;
b) duloxetine;
c) melipramine;
d) escitalopram.
8. To assess the cognitive functions of the patient, the following
are used:
a) Montreal Cognitive Assessment Scale;
b) battery of frontal tests;
c) Luria test;
d) Stroop test.
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9. For patients with frailty, the following types of physical
activity are recommended:
a) anaerobic loads;
b) strength exercises;
c) Balance exercises;
d) resistance exercises.
10. Long-lived is:
a) persons aged 75 years and over;
b) persons aged 80 and over;
c) persons aged 90 and over;
d) persons aged 100 years and older.
ANSWERS:
1 — b, d
3 — c
5 — a
7 — b
9 — d, c, d
2 — b
4 — b
6 — c
8 — a, b
10 — c
Task #1
A 68-year-old patient, accompanied by relatives, asked for medical
help. It is known that she has been suffering from hypertension for about
20 years, and has been taking beta-blockers (propranolol) for a long time.
About 3 years ago, for the first time at a height of blood pressure up to
200/120 mm Hg. dizziness, headache, vomiting, numbness in the left arm
and left leg appeared, there was a short-term loss of consciousness; after
taking antihypertensive drugs, the condition returned to normal, but the
patient began to complain of stupidity, periods of unmotivated depression,
tearfulness. A year later, the same condition recurred. After that, the
patient began to notice a significant deterioration in memory, difficulty
concentrating, she noticed that she hardly remembers the previous
episodes of her favorite television series, one day, leaving home, she did
not close the door, she began to notice fatigue, tearfulness, sometimes
119
causeless irritability. According to medical documentation, during a
neurological examination for about 2 months. there was an increase in
tendon reflexes on the right. About a month ago, there was a third episode
of worsening condition at the height of blood pressure, similar to the
previous ones. After that, she could not speak for several days, with
difficulty choosing words. Recently, I began to notice that “someone
snores and coughs in the toilet”, “strangers walk around the rooms at
night”, she began to be afraid to go to the toilet, she cannot be dissuaded.
On examination: BP — 140/90 mm Hg, pulse 84/min. Neurologically —
smoothness of the nasolabial fold on the right, slight deviation of the
tongue to the left. During a conversation, he cannot correctly name the
current date, his age. Thinking is concrete, the pace is slow. Intellectualmnestic functions are significantly reduced. On the EEG — diffuse
changes, on CT — foci of post-infarction changes on the right and left in
the cortical posterior frontal zones.
Questions:
1. What condition has developed in the patient?
2. What caused the development of this condition?
3. What are the principles of treatment and care for this disease?
Sample answers:
1. Multi-infarct vascular dementia
2. Several ischemic episodes that created an accumulation of infarcts
in the cerebral parenchyma
3. Therapy includes: treatment of the underlying vascular disorder
with the use of anticoagulants, vasodilators, angioprotectors; treatment of
hypertension; combating cognitive deficits through intensive training,
prescribing vitamins and nootropics. The principles of care include:
ensuring the safety of the patient (if possible, do not leave her alone, do
not let one go out of the house, remove piercing and other dangerous
objects); providing psychological assistance to the patient (affectionate,
gentle treatment, avoidance of rudeness, ridicule) and her relatives, who
120
bear the main responsibilities for care; to the extent necessary —
assistance to the patient in the implementation of self-care skills (dressing,
toilet, feeding).
Task #2
A 70-year-old patient applied for medical help. For a long time he
suffers from hypertension and coronary artery disease with sick sinus
syndrome. The last month keeps high blood pressure (up to 200/120 mm
Hg), dizziness, headaches, shortness of breath. At night, an attack of
severe weakness developed with dizziness, severe bradycardia. There was
a brief loss of consciousness and convulsions. Relatives called an
ambulance, the doctor of which did not give intelligible explanations,
made an injection of drugs, which the patient finds difficult to name, after
which the condition improved. The patient fell asleep, waking up in the
morning, noted weakness, dizziness, and therefore took 25 drops of
Zelenin, which had previously helped her in similar cases. About an hour
later, the condition deteriorated sharply: there was pain in the eyeballs,
visual acuity decreased significantly, a severe headache appeared , nausea
and vomiting. On examination: state of moderate severity, stupor, pale
skin, normal humidity. The eyelids of both eyes are edematous, the cornea
is cloudy, the pupils are dilated, the conjunctiva is injected. Heart sounds
are deaf, rhythmic, accent 2 tones over the aorta. Heart rate — 52/min.,
BP — 180/90 mm Hg. Breathing is hard, no wheezing, respiratory rate —
20/min. Abdomen without features. The liver is 1 cm below the edge of
the costal arch. Pastosity of legs. Neurologically: Focal symptoms, no
meningeal signs.
Questions:
1. What is the diagnosis of the underlying and concomitant disease
in this patient?
2. What condition developed in the patient at night and what — in
the morning?
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