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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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141
Task #4
An 86-year-old woman consulted a geriatrician. Complaints of
weakness, fatigue, heaviness after eating, frequent dizziness, hand tremors,
memory loss, gait disturbances, episodes of dizziness, frequent
constipation, a decrease in height by 2 cm
Disease history. In 2014, a resection of the stomach was performed
for cancer, a stump of 1/3 was left. With annual control according to the
EGDS, ultrasound of the abdominal pathology without negative dynamics.
He follows a diet, takes food mainly in liquid form.
The diet contains fruits, a spoonful of caviar in the morning, fruits
300–400 grams per day, vegetables 300–400 grams, 1–2 slices of bran
bread, 0.5 tablespoons of honey. Portions of 50–100 gr, meat 25 gr.
After eating, he is in a horizontal position for at least 30 minutes,
notes an increase in heart rate up to 90 beats per minute. For the last
3–4 months, she has been worried about weakness, drowsiness, severe
fatigue with minimal physical exertion, weight loss by 5 kg.
She is observed by a gastroenterologist, periodically takes
Pancreatin. Control of the level of B vitamins and indicators of iron
metabolism was not carried out.
For the last 7 years, she has noted a decrease in height by 2 cm, about
2 years ago she suffered a compression fracture of L 2 of the lumbar spine.
She is seen by an endocrinologist for senile osteoporosis, she constantly
takes calcium and colcalciferol preparations, and she received 3 injections
of denosumab. Densitometry was performed: osteoporosis in the lumbar
vertebrae (T-score –2.5), osteopenia in the femoral neck (T-score –2.0).
Anamnesis of life. For about 20 years, she has been observed by a
cardiologist with a diagnosis of “Ischemic heart disease. Hypertension 2 st
2 st 3 gr risk” takes periodically.
There is a history of arterial hypertension for a long time, more often
with self-measurement of 120–130 / 80–90 mm Hg. Small-focal AMI from
2000. Outpatient takes candesartan 8 mg 1 r/d, akatinol memantine 10 mg
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at night, concor 2.5 mg 2 r/d, vitamin D 5000 U every other day, calcium
D3 nycomed
As of 2021 survey: Blood hemoglobin (g/dL) 119, Blood creatinine
(µmol/L) 79.2, GFR-EPI (mL/min/1.73m2) 59.0, Blood potassium
(mmol/L) ) 3.7, Blood glucose (mmol / l) 7.99 (venous serum) — 6.4
(capillary blood) mmol / l on an empty stomach — elevated level, Total
cholesterol (mmol / l) 6.28, LDL cholesterol (mmol /l) 3.2, HDL
cholesterol (mmol/l) 2.8, Triglycerides (mmol/l) 0.5, Hva1c 5.8 %, glucose
5.38 mmol/l from 10/14/2021 According to home glycemic control data up
to 6 mmol\l.
Ultrasound of the OBP signs of biliary dyskinesia
According to the analysis of body composition, a deficiency of
muscle and fat body mass was determined.
Height — 163 cm. Weight Body weight — 43 kg. BMI — 15.8 kg / m2.
Objectively. 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 slightly reduced.
“Age is not a barrier”: 4 points (memory, falls, mood, weight loss)
Mobility: independently.
Barthel index: 100/100 points (no dependence).
Lawton scale: 8/8 points.
Screening MNA: 5/14 points.
MNA test: 22/30 points (Risk of developing malnutrition).
GLIM BEN high degree.
SPPB test: 6/12 points.
Falls for the previous year: in January 2020 with a hip fracture,
August 30, 2021 without a fracture.
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Dynamometry: right hand — 8.5 kg, left hand — 6.0 kg.
Orthostatic test is positive. Walking speed — 0.75 m/s,
Fall risk self-assessment scale: 5/10 — high risk of falls
CAM scale (delirium): no delirium.
Test “Mini-Cog”: 4/5 points (Low risk of cognitive impairment).
Test “Drawing clock”: 9/10 points.
MMSE test: 26/30 points.
PHQ-9: 7 points low risk of depression.
HADS: anxiety — 8 points, depression — 3 points
Questions:
1. List the phenotypic criteria for malnutrition for this patient.
2. List the most typical complaints in a patient with malnutrition
syndrome.
3. Criteria for the diagnosis of malnutrition are …
4. What instrumental diagnostic studies are used in patients with
malnutrition syndrome?
5. A feature of coding a disease or condition (a group of diseases or
conditions) according to the International Statistical Classification of
Diseases and Related Health Problems is …
6. What conditions require exclusion before making a diagnosis of
PEU in this patient?
7. It is recommended to calculate the energy value of the diet of an
elderly and senile patient, focusing on …
8. What amount of protein is recommended to focus on when
calculating the amount of protein in the daily diet of elderly and senile
people in order to reduce the risk of malnutrition or correct it.
9. The main options for enteral nutrition are …
10. What energy need should be provided by PEP?
11. When is tube feeding recommended?
12. What eating conditions are important in older age?
144
Sample answers
1. Low BMI — 15.8 kg / m2. Physical examination of a
malnourished patient may reveal the following: Body weight: BMI less
than 20 kg/m2 if the patient is younger than 70 years of age, or less than 22
kg/m2 if the patient is older than 70 years of age
2. Weakness, lethargy, decreased performance. Typical complaints
of patients are weakness, lethargy, lethargy, weight loss, thinning of the
limbs, and decreased performance. History of fasting, reduced food intake,
and other potential causes.
3. Minimal Nutritional Assessment (MNA), Universal Malnutrition
Screening (MUST), Nutritional Risk Screening NRS — 2002). The
diagnosis of malnutrition (malnutrition) in elderly and senile patients is
established on the basis of history, physical examination, laboratory tests,
as well as the results of screening for malnutrition syndrome using the
recommended tools. The results of assessment using validated screening
instruments indicate the risk or presence of malnutrition (Mini Nutrient
Assessment (MNA), Universal Malnutrition Screening (MUS ),
Nutritional Risk Screening NRS — 2002). Result: Screening MNA
5/14 points. MNA test 22/30 points (Risk of developing malnutrition).
BEN of a high degree.
4. Individual examination plan. Currently, there are no specific
instrumental diagnostic methods for establishing the diagnosis of
malnutrition. The use of instrumental diagnostic methods is dictated by the
clinical need to assess the etiological factors of malnutrition or differential
diagnosis with other conditions accompanied by a similar clinical picture.
Result: During the annual control according to the EGDS, ultrasound of
the abdominal pathology without negative dynamics.
5. BEN of a high degree. E.43 High PEI
6. Oncopathology. The use of other diagnostic methods is dictated
by the clinical need to evaluate the etiological factors of malnutrition or
differential diagnosis with other conditions accompanied by a similar
clinical picture.
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7. Level 30 kcal per kg of body weight per day. It is recommended
to calculate the energy value of the diet of an elderly and senile patient,
focusing on the level of 30 kcal per kg of body weight per day. This value
should be adjusted on an individual basis based on nutritional status,
physical activity level, disease status, and tolerance.
8. At least 1 g of protein per kg of body weight per day. It is
recommended to focus on the amount of at least 1 g of protein per kg of
body weight per day when calculating the amount of protein in the daily
diet of elderly and senile people in order to reduce the risk of malnutrition
or its correction. The amount of protein in the diet should be individually
tailored to the nutritional status, level of physical activity and comorbidity.
9. The use of combined oral enteral nutrition (PEP) with special
mixtures and dietary nutrition. combined oral enteral nutrition (PEP) with
special mixtures and dietary nutrition; OR only PEP with special blends;
OR tube enteral nutrition (ZEP): a tube into the stomach (including
through the stoma), a tube into the duodenum (including through the
stoma), a tube into the jejunum (including through the stoma).
10. At least 400 kcal / day and protein at least 30 g / day. It is
recommended to prescribe oral enteral nutrition preparations that provide
energy intake of at least 400 kcal/day. and protein at least 30 g / day. all
elderly and senile patients with malnutrition or the risk of its development.
11. When oral nutrition is not possible for three days, or covers less
than half of the energy requirement for more than one week. It is
recommended to use tube enteral nutrition (ZEN) in elderly and senile
patients in cases where oral nutrition is not possible for three days, or
meets less than half of the energy requirement for more than one week,
despite interventions to support oral nutrition, with the purpose of meeting
nutritional needs and maintaining or optimizing nutritional status.
12. Nice homely atmosphere while eating. It is recommended to
stimulate sufficient food intake by creating a pleasant home environment
during meals for elderly and senile patients in specialized settings in order
to increase food intake and maintain quality of life.
146
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