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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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131
it became difficult to count money, attention decreased, instability when
walking, dizziness of a non-systemic nature. For about 7 years he has been
suffering from hypertension, while for the last 2 years the patient has been
observed by a cardiologist with chronic heart failure.
History of life. Lives alone, living conditions are satisfactory,
occasionally drinks alcohol (once a week, soft drinks), smokes
(3 cigarettes a day). Suffers from hypertension III st, 3 tbsp. risk 4, CHF II
B. He worked as the head of the economic department, resigned about
2 years ago due to the difficulty of performing professional duties.
Allergological anamnesis is not burdened. Hereditary history is not
burdened.
Objective status. The condition is satisfactory. The constitution is
normosthenic. Height 170 cm, weight 78 kg. BMI = 26.9. The skin is of
normal color and moisture. There are no peripheral edema. Breathing is
vesicular, no wheezing. NPV 18 in 1 min. Arrhythmic heart sounds, mitral
valve murmur on auscultation. HR 59 in 1 min, BP 110/75 mm Hg. Art.
The abdomen is soft and painless. Liver on the edge of the costal arch.
Urination is frequent, painful. The symptom of tapping is negative on both
sides. The chair is regular, decorated.
Neurological status:
There are no meningeal signs. Consciousness is clear, criticism of
one's state is preserved, thinking is safe, memory is reduced. The palpebral
fissures are D = S, the pupils are D = S. Photoreactions are preserved.
There is no nystagmus. Tongue in the midline. Swallowing, phonation,
speech are not disturbed. Tendon reflexes from the hands are high: D = S,
knee reflexes are high: D = S, Achilles reflexes are reduced. Sensitivity is
not broken. There is slight instability in Romberg's position. Performs
coordinating tests with a miss on the left.
Questions:
1. The methods of examination necessary for making a diagnosis are …
2. Instrumental methods of examination necessary for making a
diagnosis include …
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3. Based on the identified clinical data, the patient can be diagnosed …
4. The 3 leading clinical manifestations of the diagnosis necessary
for making a diagnosis are …
5. Symptom observed in this patient, which is included in the group
of main clinical signs of sleep apnea syndrome …
6. One of the manifestations observed in the patient, which refers to
the main signs of sleep apnea syndrome …
7. What is the severity of apnea observed in this patient …
8. The most effective treatment for this patient is …
9. A hypnotic that may improve sleep in this patient …
10. A group of drugs that is not recommended for this patient due to
possible respiratory depression during sleep is …
11. The main factor in the development of central apnea syndrome
in this patient is …
12. An additional treatment that may improve the condition of a
patient with central sleep apnea is …
Sample answers:
1. Analysis of the main clinical manifestations. To make a diagnosis
of sleep apnea, it is necessary first of all to assess the leading clinical
manifestations.
2. Polysomnography. Polysomnography is the “gold standard” for
sleep research and allows differential diagnosis of a wide range of sleep
disorders. Respiratory sensors that are used in polysomnography make it
possible to detect respiratory disorders during sleep of various origins.
Result: Pattern of multiple episodes of central sleep apnea and hypopnea.
Apnea + hypopnea index = 35.5 per hour. Snoring was recorded
throughout the night. Respiratory disorders were accompanied by episodes
of mild to moderate desaturations. 304 episodes of desaturations over 3 %
were registered. The minimum saturation value was 68 %. The average
indicators of blood oxygen saturation during the course are within the
normal range — 80 %. SLEEP: Sleep latency increased — 20 min. (with
the norm < 15 min.). The sleep efficiency index was reduced — 75.7 %
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(with a norm of > 90 %) due to macro-awakenings during the night
(2 hours 21 minutes). The macrostructure of sleep is significantly
disturbed: the duration of the 1st stage of sleep is increased (54.6 % at a
norm < 10), the variability of sleep stages is increased, the representation
of deep stages of sleep is significantly reduced — 10.4 % (at a norm of
20–30 %) and REM sleep — 7.6 % (at a rate of 20–25 %). The sleep
microstructure is significantly disturbed due to an increase in the
frequency of microactivations (index 48 per hour, with a norm of < 10).
3. Central sleep apnea syndrome. The patient has leading clinical
signs of sleep apnea syndrome. And also, according to the
polysomnographic study, signs of sleep apnea of a central nature are
revealed.
4. Frequent nocturnal awakenings. 12 main clinical signs of sleep
apnea syndrome have been identified: snoring, pathological motor activity
during sleep, increased daytime sleepiness, hypnagogic hallucinations,
enuresis, morning headaches, arterial hypertension, decreased libido,
personality changes, decreased intelligence. In order to suggest the
presence of sleep apnea, the presence of a triad is sufficient: snoring
during sleep, insomnia with frequent episodes of awakenings, and daytime
sleepiness.
Daytime sleepiness . Included in one of the three leading clinical
manifestations of sleep apnea syndrome
Snoring . Included in the triad of leading clinical manifestations of
sleep apnea syndrome
5. Morning headaches. There are 12 main clinical signs of sleep
apnea syndrome: severe snoring, abnormal motor activity during sleep,
increased daytime sleepiness, hypnagogic hallucinations, enuresis,
morning headaches, arterial hypertension, decreased libido, personality
changes, decreased intelligence.
6. Decreased intelligence. Decreased intelligence is one of the
12 major clinical features of sleep apnea that have been identified.
7. Severe degree. The assessment of the severity of respiratory
disorders during sleep is carried out using the apnea/hypopnea index,
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which provides a quantitative assessment of episodes of apnea and
hypopnea per hour of sleep. Mild course: 5 to 14.9 episodes per hour.
Course of moderate severity: from 15 to 29.9 episodes per hour. Severe:
≥ 30 episodes per hour.
8. Non-invasive ventilation of the lungs with the creation of two-
level positive airway pressure (BIPAP therapy). This method is indicated
for the treatment of central sleep apnea, medicinal approaches have not
been proven. The essence of the method lies in the fact that during a
night's sleep, breathing air is supplied to the patient's respiratory tract and
creates pressure of various levels during the patient's inhalation and
exhalation.
9. Drug therapy is not indicated. Hypnotics and other psychotropic
drugs can depress breathing during sleep and are not indicated for sleep
apnea.
10. Benzodiazepines. Drugs from the benzodiazepine group are not
used in patients with acute and chronic respiratory failure or respiratory
depression.
11. Chronic heart failure. In many patients, central apnea is
secondary to congestive heart failure (CHF). It can be confidently assumed
that central apnea in patients with CHF contributes to an increase in the
sympathetic effect on the heart and thus has a secondary negative effect on
the underlying disease.
12. Oxygen therapy. Taking into account the fact that the patient
develops nocturnal hypoxemia due to apnea, it can be stopped with the
help of additional administration of oxygen.
Task #2
An 81-year-old female patient, living on her own, came to see a
geriatrician with her son. The son is concerned that recently the patient has
become much less active, less likely to go outside for walks and for
groceries, she began to move around the house with difficulty, and lost
weight.
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Anamnesis of the disease: a gradual decrease in activity is observed
during the last 3.5 months after the flu, when the patient was forced to
spend about 10 days practically on bed rest at home. During the illness,
she lost 4 kg, then gained 1.5 kg.
History of life: lives alone in a 2-room apartment on the 3rd floor of
a 5-storey building without an elevator, a widow for 7 years, a former
teacher at the Faculty of Physics and Mathematics of the University,
stopped working at 72, a long history of arterial hypertension, for which he
is taking amlodipine 5 mg/day, enalapril 20 mg/day, no myocardial
infarction, no stroke, no smoking, no drinking alcohol objective status. The
result of screening for frailty on the scale “Age is not a hindrance” is
3 points. The condition is satisfactory. Height 165 cm, body weight
66.2 kg. The skin is of normal color and moisture. There are no peripheral
edema. Vesicular respiration, respiratory rate 14 in 1 min. Rhythmic heart
sounds, murmurs over the region of the heart, carotid arteries are not
auscultated. Heart rate 72 in 1 min. BP lying 142/74 mm Hg. Art., standing
after 1 minute 133/70 mm Hg, after 2 minutes 137/72 mm Hg, after
3 minutes 145/73 mm Hg. The abdomen is soft and painless. Liver on the
edge of the costal arch. Central nervous system: no focal symptoms.
Vision is reduced. Hearing is not reduced.
Questions:
1. Mandatory examination to establish the diagnosis of frailty at this
stage includes …
2. Based on the data obtained, further examination includes …
3. Required laboratory research methods for frailty include …
4. Interpret the results of a brief battery of physical functioning tests.
5. Assess the degree of dependence of the patient on outside help
based on the assessment of basic functional activity on the Barthel scale.
6. Assess the degree of the patient's dependence on outside help
based on the assessment of instrumental functional activity according to
the Lawton scale.
7. Assess the risk of malnutrition on the Mini Nutrition Rating Scale.
136
8. Assess cognition based on the Montreal Cognitive Assessment
Scale.
9. At this stage, the recommended types of physical activity include …
10. Nutritional advice for this patient should include …
11. Recommended measures to prevent falls in a patient include …
Sample answers:
1. Screening for cognitive impairment using the Mini-Cog test.
Patients with a score of 3–4 on the screening questionnaire “Age is not a
hindrance” are recommended to be referred to a geriatric office for a MiniCog test to clarify their geriatric status and determine indications for a
comprehensive geriatric assessment. Result: Word recall: 3 out of 3, Clock
drawing test: 2 points, Test result: 5 points. In addition, a short battery of
physical functioning tests must be performed. Patients with scores of
3–4 on the “Age Is Not a Barrier” Screening Questionnaire are
recommended to be referred to a geriatric office for a Brief Battery of
Physical Functioning Tests to clarify geriatric status and determine
indications for a comprehensive geriatric assessment. Result: Balance test:
semi-tandem foot position 8.5 s, Walking speed for 4 m: 0.72 m/ 5-sit-up
test: 13.6 s, 5-sit-up test: 13.6 s.
2. Conducting a comprehensive geriatric assessment. The result of a
short battery of physical functioning tests of 7 points is an indication for a
comprehensive geriatric assessment. Result: Mini Nutrition Scale 22/30,
Lawton Instrumental Activity 7/8, Barthel Baseline Functional Activity 95/100,
Montreal Cognitive Assessment 27/30, Geriatric Depression Scale 3/15.
3. Frailty. Result of a short battery of tests of physical functioning
7 points.
4. Determination of thyroid-stimulating hormone (When conducting
a comprehensive geriatric assessment, it is recommended to evaluate the
concentration of thyroid-stimulating hormone in order to differentially
diagnose frailty and thyroid dysfunction), determination of the
concentration of vitamin 25 ( OH ) D 3
in
serum marker of the course and
outcomes of the syndrome of frailty), determination of hemoglobin.
137
5. Slight degree of dependence. 95 points on the Barthel scale
correspond to a mild degree of addiction.
6. Mild addiction.
7. 22 points on the Brief Nutritional Assessment Scale correspond to
the risk of malnutrition.
8. Norm. The patient's result of 27 points corresponds to the normal
values of the test.
9. Balance exercises should be recommended to all patients with
frailty to reduce the risk of falls. Muscle strength exercises should be
recommended to all patients with frailty to reduce the risk of falls,
prevent/correct sarcopenia, and progression of frailty.
10. Protein intake with food at least 1.0–1.5 g per 1 kg of body
weight for the treatment and prevention of sarcopenia.
11. Performing physical exercise for balance training is a Level A
measure of evidence for reducing the risk of falls.
Task #3
A 74-year-old man consulted a geriatrician. Complaints of weakness,
fatigue, pain in the bones, large joints and lower back, decreased height by
10 cm, occasional heartburn.
Disease history. For the last 7 years, he has noted a decrease in
height, a gradual increase in pain in the area of large joints and the lower
back. Repeatedly applied to the place of residence to the therapist,
according to the survey noted a moderate increase in the level of
creatinine, urea, uric acid. Electrolyte levels were not monitored.
Diagnosis: osteochondrosis, scoliosis of the thoracic spine. The course of
physical therapy is recommended. Then, pain in the back and small joints
gradually joined, periodically calf cramps began to disturb muscles. Over
the past 5 years, there have been 2 fractures (radius, phalanx of the fingers)
with minor or no injuries. The patient was consulted by an endocrinologist;
for the first time, an increase in the level of total calcium against the
background of low phosphorus values was revealed. Diet is not followed.
138
Anamnesis of life. For about 10 years, she has been seen by a
urologist with a diagnosis of “Urolithiasis, stones in both kidneys”,
periodically taking Allopurinol 100–200 mg under the control of uric acid
levels.
In the anamnesis there is hr. gastroduodenitis, over the past 5
years — two episodes of exacerbation of peptic ulcer of the 12th intestine.
According to the survey, the level of total calcium is 2.9 mmol /
l (2.15–2.5), albumin 38 g / l (35–50) ionized calcium 1.35 mmol / l
(1.15–1.32), parathyroid hormone 130 pg / ml (9.5 to 75), Creatinine
88.3 µmol/l (50–98), GFR 57 ml/min (over 90), 25(OH) vitamin D
10 ng/ml (over 30), urinary calcium 12 mmol / day (2.5–7.5) objective
status. Height — 170 cm. Weight Body weight — 60 kg. BMI —
20.8 kg / m2.
Consciousness is clear. Body temperature — 36.6 oC. There is no
shortness of breath when talking. The skin is pale. Pastosity of legs and
feet. Breathing is vesicular, no wheezing. NPV — 16 / min. Heart sounds
are rhythmic, muffled. Pulse — 62/min satisfactory filling and tension.
Heart rate — 62 / min. BP — 134/90 mm Hg. Art. Pulsation in the
peripheral arteries is preserved. The abdomen is soft and painless. Liver at
the edge of the costal arch. Chair prone to constipation with words. The
symptom of tapping is negative on both sides. Urination free, painless.
Stop sensitivity: temperature saved; pain saved; tactile is reduced.
Questions:
1. The laboratory methods of examination necessary for monitoring
the condition of this patient with hyperparathyroidism are …
2. The necessary instrumental methods of examination in the
framework of monitoring patients with hyperparathyroidism include …
3. The most common complaint of patients with
hyperparathyroidism is …
4. What is the diagnosis?
5. What conditions require exclusion before making a diagnosis of
PHPT?
139
6. The main treatment for hyperparathyroidism is …
7. What indications for surgical treatment of PHPT are considered
absolute?
8. What drugs are used to treat acute hypocalcemia?
9. What drugs are used to treat chronic hypocalcemia?
10. How often should calcium levels be monitored in case of mild
PHPT?
11. Against the background of what conditions can a hypercalcemic
crisis develop?
Sample answers:
1. Re-determination of the level of total calcium, albumin (with the
calculation of albumin-corrected calcium) and / or ionized calcium in order
to exclude false positive laboratory results. Patients with newly diagnosed
hypercalcemia are recommended to re-determine the level of total calcium,
albumin (with the calculation of albumin-corrected calcium) and / or
ionized calcium in order to exclude false positive laboratory results.
Result: total calcium level 2.9 mmol/l (2.15–2.5), albumin 38 g/l (35–50)
ionized calcium 1.35 mmol/l (1.15–1.32). The study of the level of
parathyroid hormone in the blood (iPTH) is included in the mandatory
monitoring of patients with hyperparathyroidism. Result: Parathormone
130 pg/ml (9.5 to 75). In order to assess the filtration function of the
kidneys and determine indications for surgical treatment, as well as to
exclude secondary causes of an increase in the level of iPTH, patients with
suspected PHPT are shown to determine the level of creatinine with the
calculation of GFR, to determine the level of 25(OH) vitamin D in order to
diagnose its insufficiency/deficiency , the study of calcium and creatinine
levels in the urine (daily analysis) with the calculation of renal calcium
clearance to creatinine clearance. Result: Creatinine 88.3 µmol/l (50–98),
GFR 57 ml/min (over 90), 25(OH) vitamin D 10 ng/ml (over 30), urinary
calcium 12 mmol/day (2, 5–7.5).
2. Ultrasound and radionuclide studies (scintigraphy, SPECT,
SPECT-CT) of the parathyroid glands. The methods of the first line of
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instrumental diagnostics in PHPT are ultrasound and radionuclide studies
(scintigraphy, SPECT, SPECT-CT). Methods of the second line of
diagnostics — MSCT with contrast enhancement, MRI, 4D CT, PET,
PET-CT. Result: Ultrasound of the parathyroid glands: behind the lower
third of the left lobe of the thyroid gland and below, a formation with
dimensions of 5.6 × 2.2 × 1.5 cm is determined, with clear contours,
reduced echogenicity. According to scintigraphy, signs of the formation of
the left parathyroid gland with high functional activity were revealed.
X-ray densitometry of 3 departments. To determine the spectrum and
severity of bone disorders in patients with PHPT, an examination is
recommended, including a quantitative assessment of bone mineral density
of 3 sections using X-ray densitometry, X-ray assessment of skeletal
integrity in case of suspected fractures, including X-ray of the thoracic and
lumbar spine in a lateral projection with loss of growth by 4 cm from
youth or loss of height by 2 cm in the last year. Result: A decrease in bone
mineral density was revealed T-criterion –7.4 SD in the lumbar spine,
–6.1 SD in the proximal femur, –4.9 SD in the radius.
3. Pain in the bones.
4. Primary hyperparathyroidism of severe course, mixed form.
Adenoma of the left parathyroid gland. Hyperparathyroid osteodystrophy
with multiple compression fractures of the vertebral bodies, a decrease in
height by 10 cm, grade III kyphoscoliosis. Urolithiasis, bilateral
nephrolithiasis, cysts of the left kidney. Duodeno-gastric reflux.
5. Vitamin D deficiency, malabsorption syndrome, nutritional
deficiency of magnesium and potassium.
6. Removal of the pathologically altered PTG is the only radical
treatment for PHPT. Follow-up and drug therapy are less cost-effective
even in asymptomatic PHPT.
7. Age less than 50 years.
8. Gluconate and calcium carbonate and vitamin D preparations.
9. Calcium carbonate and vitamin D preparations.
10. 2–4 times a year.
11. Infectious diseases, fractures, prolonged immobilization, taking
antacids.
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