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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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3. What is the tactics at the stage of first medical aid in relation to
this patient?
4. What are the principles of nursing care for this disease?
Sample answers:
1. IHD, sick sinus syndrome, sinus bradycardia. Sop.: GB II Art.,
decompensated course; CHII Art.
2. At night — Morgagni-Adams-Stokes attack on the background of
sinus bradycardia, hypertensive crisis. In the morning — an acute attack of
glaucoma, probably provoked by the introduction of atropine.
3. The introduction of diuretics, glycerin (1 tsp), pilocarpine
(2 % eye drops), hot foot baths, emergency hospitalization in an
ophthalmic hospital.
4. Ensuring physical and mental rest, talking with the patient in
order to explain to her the features of the disease, calming the patient,
providing nutrition in accordance with the principles of diet therapy
(restriction of salt, liquid, exclusion of extractives, spices, alcohol, addition
of coarse vegetable fiber, nutrition 5–6 r / day), if necessary, assistance to
the patient in the implementation of self-care skills, monitoring the
patient — monitoring blood pressure, heart rate, general condition,
administration of drugs prescribed by the doctor, sampling of biological
materials for analysis and preparation for examinations.
Task #3
Patient A., 57 years old, accompanied by relatives, is at the reception
in the family outpatient clinic. Complaints of relatives about the
inappropriate behavior of the patient, individual statements of a delusional
nature. History without features. There were no serious illnesses, injuries,
operations during her life, she did not abuse alcohol. Divorced, has no
children. Lives with sister's family. She has a specialized secondary
education, throughout her life, until relatively recently, she worked at an
electric lamp plant. About three years ago, she began to notice increased
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fatigue, weakness, an unreasonable decrease in mood, labor productivity
dropped sharply, she began to allow marriage, was transferred to a simpler
job, but soon stopped coping with it. Hasn't worked for about a year. At
home, relatives gradually began to notice oddities in the patient's behavior:
She began to forget where everything lay, once she forgot to turn off the
electric stove, which almost caused a fire, she denied her guilt. Gradually
she stopped leaving the house, did almost nothing at home, looked out of
the windows, asked her sister what kind of people were walking around
the house, began to get annoyed for no reason, sometimes crying. On
examination: Somatically satisfactory. BP — 130/85 mm Hg, heart rate —
86/min. Neurologically: Focal symptoms, no meningeal signs. In a
conversation, he cannot accurately name his age, the current date, correctly
list with whom he lives, does not quite understand where he is (“like some
kind of sanatorium”). The pace of thinking is slowed down, intellectualmnestic functions are significantly reduced. The patient does not consider
himself. She says she needs some rest and she can go back to work.
Questions:
1. Probable diagnosis?
2. What are the stages of the disease?
3. Principles of treatment?
4. Features of nursing care?
Sample answers:
1. Alzheimer's disease, stage of moderate dementia.
2. During the course of the disease, 3 main stages are traditionally
distinguished: initial, stages of moderate and severe dementia. In some
works, the initial stage is divided into the stage of preclinical
manifestations, or dubious dementia, and the stage of mild dementia, and
the stage of severe dementia is divided into the stage of severe and very
severe (final stage) dementia.
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3. The currently existing strategies for therapeutic intervention are
represented by the following main areas:
1) compensatory (replacement) therapy aimed at overcoming
neurotransmitter deficiency;
2) protective therapy — the use of neuroprotectors and neurotrophic
factors; correction of violations of free radical processes, as well as
calcium metabolism;
3) anti-inflammatory therapy;
4) psychopharmacotherapy of productive psychopathological
disorders;
5) psychological correction (cognitive training).
4. Care areas are:
psychological support for patients and their relatives, tolerance
and benevolence;
patient safety — elimination of piercing and cutting objects,
weapons, complex equipment, etc.;
care for the maximum activity of patients, incl. occupational
therapy;
in some cases — assistance in the implementation of hygiene and
other skills.
Task #4
Patient B., 56 years old, military man, at the reception in the family
outpatient clinic. Delivered by relatives due to ridiculous disinhibited —
behavior. From the anamnesis it is known that in childhood and
adolescence he developed without special features, following the example
of his father he entered the Higher Military School . Married for over
30 years, two adult sons live separately. He was always a good,
hardworking husband, helped a lot around the house, knew how to craft.
Progressed well. In recent years, with the rank of colonel, he worked as a
teacher at the Military Academy. Smokes, drinks alcohol moderately.
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During the last year, the wife notes a change in the character of the patient:
he became smiling, restless, stupid. He tells the same jokes over and over
again, criticizes her work, but he does not do anything around the house.
Correctly fulfills all her requests, but refuses to work at the slightest
obstacle. He drives a car well, but once at full speed he threw the steering
wheel and began to carefully study the map. Could not understand why his
wife scolds him when they were in a ditch. On examination: Somatically
without severe pathology. BP — 130/90 mm Hg, heart rate — 80/min.
Smiling, especially perks up when communicating with women, tries to
kiss them, makes compliments. He correctly names the current month, day
of the week, year of his birth, name of the doctor, but in a conversation he
is easily distracted from the topic of the conversation. One type begins to
recall how “when he was young he looked after the granddaughter of
Count Sandunov .” He regrets: “It's a pity there is no guitar — I would
sing for you.” Willingly sings the same ditty even without accompaniment,
not embarrassed by unprintable expressions. Does not recognize
inappropriate behavior. On the EEG — a decrease in voltage in the frontal
leads, on CT — signs of atrophy of the frontal parts of the left hemisphere.
Questions:
1. Probable diagnosis?
2. How to conduct a diff. diagnosis of this disease with the disease
described in the previous task?
3. Principles of treatment?
4. Features of nursing care?
Sample answers:
1. Dementia in Pick's disease.
2. Alzheimer's disease begins with amnestic disorders, which are
preceded by initial disorders, usually of an affective and neurotic range,
and Pick's disease begins with impaired social functioning and a symptom
of unmotivated actions at a later age (symptoms of E. Robertson).
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3. The principles of treatment are the same as for Alzheimer's
disease and include the following areas:
1) compensatory (replacement) therapy aimed at overcoming
neurotransmitter deficiency;
2) protective therapy — the use of neuroprotectors and neurotrophic
factors; correction of violations of free radical processes, as well as
calcium metabolism;
3) anti-inflammatory therapy;
4) psychopharmacotherapy of productive psychopathological
disorders;
5) psychological correction (cognitive training).
4. Directions of care, as in Alzheimer's disease, include
psychological support for patients and their relatives, ensuring the safety
of patients (do not leave alone, remove dangerous items from everyday
life, etc.), if necessary, help patients in the implementation of self-care
skills.
Task #5
House call. Woman, 79 years old. Complaints of decreased vision,
the appearance of a veil before the eyes
Disease history. Notes a decrease in vision for several years. I did not
visit an ophthalmologist. Also many years of hypertension. He takes
antihypertensive therapy, against which he does not notice fluctuations in
blood pressure. Myocardial infarction, strokes — denies
Anamnesis of life: She grew and developed according to her age.
Higher education: English teacher. She worked until the age of 70 at
school. Previously, she was actively involved in sports: skiing, swimming.
Currently, he notes difficulties in moving, frequent falls due to decreased
vision. Lives with her husband. 2 children. Allergic history without
features objective status. The condition is satisfactory. Height — 164 cm,
weight — 66 kg. BMI — 24.5 kg / m2. Body temperature 36.6 оC. Build:
correct. Skin and mucous membranes: clean, physiological color. The
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tongue is clean and moist. Lymph nodes are not enlarged. The thyroid
gland is not enlarged, displaceable, painless, soft elastic consistency,
homogeneous. Peripheral edema — no. With comparative percussion of
the lungs, a clear pulmonary sound is heard. Breathing in the lungs is
vesicular. NPV 18 in 1 minute. Rhythmic heart sounds, heart rate 66 in
1 min, rhythmic. BP 130/80 mmHg Art. The abdomen is soft and painless.
Liver on the edge of the costal arch. Chair — daily. Urination free,
painless.
Comprehensive Geriatric Assessment Results:
Scale Age is not a hindrance: 3 points
SPPB: 9 points
Barthel: 95 points;
Lawton: 1 point.
MNA: 27 points
Orthostatic test is negative.
Questions:
1. What is recommended to clarify the decrease in vision in elderly
patients recommended?
2. What confirms the presence of frailty/preathenia?
3. Who should manage patients over 65 years of age with pre-frail
older adults and visual impairment?
4. Routing for this patient.
5. The main treatment for cataracts is …
6. The replacement of the lens is …
7. Recommended for the prevention of cataracts.
8. Decreased vision increases the risk of developing.
9. Glaucoma is characterized.
10. Age-related macular degeneration is …
11. The main treatments for age-related macular degeneration are …
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Sample answers:
1. Using the Rosenbaum table. The Rosenbaum table is used to
determine near visual acuity. The table is used in good light at a distance
of 36 cm from the eyes. The test result is recorded separately for each eye
with and without glasses. Farsighted people should read with near glasses.
Nearsighted people are examined only with glasses.
2. Brief battery of tests of physical functioning — 9 points.
–9 points on a short battery of physical activity tests indicates the presence
of pre-frail older adults.
3. Geriatrician. Ophthalmologist.
4. Scheduled consultation with an ophthalmologist.
5. Surgical replacement of the lens. Removal of the clouded lens
with IOL implantation is recommended for all patients with an established
diagnosis of senile cataract as the only effective and radical method of
cataract treatment in the absence of contraindications.
6. Elective surgery requiring preoperative preparation.
7. Wearing sunglasses with a UV filter and wide-brimmed hats,
especially in regions characterized by high insolation. It is recommended
that all patients wear sunglasses with a UV filter and wide-brimmed hats in
order to prevent the development of cataracts, especially in regions
characterized by increased insolation.
8. Cognitive impairment, falls, social isolation.
9. Violation of the hydrodynamics of the eye with an increase in
intraocular pressure and the development of optic neuropathy with the
corresponding irreversible changes in the optic nerve and visual field.
10. This is a chronic progressive multifactorial disease
characterized by a degenerative process in the pigment epithelium (PE),
Bruch's membrane and choriocapillaries of the central zone of the fundus
with a secondary lesion of the neuroepithelium (NE) and is the main cause
of loss of central vision among people of the older age group.
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11. Prescribing multivitamins + other drugs, the composition of
which is optimized for retinal diseases (including those containing lutein
and zeaxanthin. Laser treatment, including focal laser coagulation of the
fundus under local anesthesia or photodynamic therapy. Surgical
treatment, including intravitreal administration of special drugs.
VARIANT 2
Test questions
1. According to the screening questionnaire “Age is not a
hindrance”, patients are sent to the geriatric office with the result:
a) ≥ 3 points;
b) ≥ 4 points;
c) ≥ 5 points;
d) ≥ 6 points.
2. Old age according to the 2012 WHO age group classification is:
a) 55–74 years old;
b) 60–74 years old;
c) 75–80 years;
d) 80–85 years old.
3. When detecting depression, it is preferable:
a) neuroleptics;
b) selective serotonin reuptake inhibitors;
c) tranquilizers;
d) tricyclic antidepressants.
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4. For warfarin treatment, the target values for the international
normalized ratio are
a) 1.0–3.0;
b) 2.0–3.0;
c) 2.0–5.0;
d) 2.0–7.0.
5. In the treatment of depression, the initial dose of Escitalopram is:
a) 10 mg/day;
b) 15 mg/day;
c) 20 mg/day;
d) 5 mg/day.
6. When prescribing antihypertensive therapy, the following level
of systolic pressure is recommended:
a) 120–130 mm Hg;
b) 140–150 mm Hg;
c) 140–160 mm Hg;
d) 160–170 mm Hg.
7. In the presence of aggressiveness in patients with frailty, it is
recommended to use:
a) antidepressants;
b) atypical antipsychotics;
c) nootropic drugs;
d) tranquilizers.
8. When conducting a comprehensive geriatric assessment of
patients with frailty, it is recommended to assess the 10-year risk of
osteoporotic fractures using an instrument:
a) FRAX;
b) STOP/START;
c) Morse Fall Rating Scales;
d) Empirical Risk Scale.
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9. In severe chronic pain syndrome, the dose of tramadol is
a) 100–200 mg;
b) 25–50 mg;
c) 5–10 mg;
d) 50–100 mg.
10. Carrying out a complex of non-drug measures for the
prevention of delirium has a level of persuasiveness of
recommendations
a) A;
b) B;
c) C;
d) D.
ANSWERS:
1 — с
3 — b
5 — d
7 — b
9 — d
2 — b
4 — b
6 — b
8 — a
10 — b
Task #1
A 78-year-old man consulted a geriatrician. Complaints about night
awakenings with a feeling of interruptions in the work of the heart, night
snoring, frequent nighttime urination, deterioration in the quality of night
sleep, general weakness, “brokenness” headaches in the morning, daytime
sleepiness, memory impairment for current events, problems with
counting, dizziness, unsteadiness when walking.
Disease history. According to the patient, during the last year he has
had a sleep disorder. During this period, the patient has nocturnal
awakenings (2–3 times) at night, during which he experiences a feeling of
interruptions in the work of the heart. In the morning the patient wakes up
with a feeling of “brokenness”, weakness, moderate daytime sleepiness is
noted. The patient also notes a deterioration in memory for current events,
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