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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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(Samara, Volgograd, Voronezh, Kaluga, Belgorod, Perm regions, the
Republic of Bashkortostan) in the pilot project “Territory of care” for
2017–2019. The purpose of the pilot project is to organize a geriatric
service in the regions of the Russian Federation, including in the Samara
region, in accordance with the order of the Ministry of Health of the
Russian Federation dated January 29, 2016 № 38n “On approval of the
procedure for providing medical care in the profile “Geriatrics”. According
to the “Roadmap” for the implementation of the pilot project “Territory of
care” in the Samara region for 2017–2019, the formation of the geriatric
service went through the following stages:
1. Analytical I (preanalysis). Analysis of forces (personnel) and
means (network, equipment) in the region.
2. Organizational and methodological. Creation of a regulatory
framework (an interdepartmental agreement on joint work between the
Ministry of Health and the Ministry of Social, Demographic and Family
Policy of the Samara Region; routing of patients for medical care in the
Geriatrics profile, development of educational programs).
3. Educational. Training of specialists (medical personnel, social
workers, nurses in the field of “Geriatrics”).
4. Practical (creation of geriatric rooms in the outpatient network,
geriatric inpatient departments, interdepartmental and interdisciplinary
interaction to provide assistance in the field of “Geriatrics”).
5. Analytical II (post-analysis). Summing up the results of the
implementation of the pilot project “Territory of care” in the Samara
region. for 2017–2019.
In the region, an Agreement between the Ministry of Health and the
Ministry of Social, Demographic and Family Policy of the Samara Region
was approved as part of interdepartmental cooperation, further training of
medical personnel (doctors, nurses), social workers, and nurses in the
Geriatrics profile is being carried out. As of September 30, 2022, a
geriatric center operates in the region (the head is the chief freelance
geriatrician of the Ministry of Health of the Samara Region, MD
S.V. Bulgakova), 40 geriatric rooms in primary health care, 165 geriatric
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beds in round-the-clock hospitals (at GBUZ “Samara Regional Clinical
Geriatric Hospital” — 105 beds, in GBUZ “Samara Regional Clinical
Hospital of War Veterans” — 60 beds).
In terms of routing at the stage of primary outpatient care, general
practitioners screen all patients over 60 years of age for the syndrome of
frailty according to the questionnaire “Age is not a hindrance”, consisting
of seven questions. Each positive answer is assigned one point. With a set
of three or more points, the patient is necessarily sent for a consultation
with a geriatrician. According to the order of the Ministry of Health of the
Russian Federation dated January 29, 2016 № 38n “On Approval of the
Procedure for Providing Medical Care in the Geriatrics Profile”, primary
specialized health care in the Geriatrics profile is carried out by a
geriatrician in cooperation with doctors of various specialties
(interdisciplinary interaction) and a social work specialist
(interdepartmental interaction). If necessary, specialized inpatient medical
care in the “Geriatrics” profile for persons of older age groups can be
obtained in geriatric departments on the basis of the Samara Regional
Clinical Geriatric Hospital and the Samara Regional Clinical Hospital for
War Veterans. In order to provide social assistance and social adaptation
of patients with frailty, a social work specialist determines their further
routing. One of the achievements of the region in 2018. was the
introduction of such items as “a visit to a geriatrician with a
comprehensive geriatric assessment” — 90 minutes, “a consultation with a
geriatrician with a comprehensive geriatric assessment” — 90 minutes.
Currently, federal standards are in place for outpatient and inpatient
medical institutions: a 45-minute consultation with a geriatrician.
There is a sufficient supply of geriatricians in the region. At the
Department of Endocrinology and Geriatrics of the Samara State Medical
University of the Ministry of Health of Russia, geriatricians regularly
undergo PC cycles, residents are trained in the specialty “Geriatrics”.
There is a sufficient supply of nursing staff working in geriatric centers,
geriatric rooms and geriatric departments.
Electronic comprehensive geriatric assessments have been developed
and put into operation, work has been organized to provide palliative care
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to patients with geriatric psychiatry, the work of multidisciplinary field
teams has been established to provide medical care in the Geriatrics profile
to the population of the Samara region, and constant work has been
organized with the media.
The region is fulfilling the targets stipulated by the National Project
“Demography” and the regional level of hospitalization for a
gerontological (geriatric) bed of the “Older Generation” component:
- the level of hospitalization for a gerontological (geriatric) bed;
- coverage of citizens older than working age with preventive
examinations, including clinical examination;
- the proportion of people older than working age who have diseases
and pathological conditions under dispensary observation;
- delivery of citizens 65 years and older to medical organizations.
Meeting these targets carefully monitored monthly by the chief
freelance geriatrician of the Ministry of Health of the Samara Region, the
information is sent to the Ministry of Health of the Russian Federation and
the Federal National Research Center for Geriatrics.
Established interagency cooperation. In 2021, the region entered the
pilot project “System of long-term care for the elderly and disabled.” The
project is an integral part of activities aimed at developing and maintaining
the functional abilities of older citizens, including balanced social services
and medical care at home, in a semi-residential and stationary form, with
the involvement of patronage services and carers, as well as support for
family care. A road map has been approved in the region. The Geriatric
Center, together with the chief freelance geriatrician of the Ministry of
Health of the Samara Region, makes visits to boarding houses and
complex centers of social services for the population to monitor ongoing
activities, carry out on-site consultations, and educational activities. The
issue is controlled by the Ministry of Health of the Russian Federation and
the Federal National Research Center for Geriatrics. There are no
complaints.
Within the framework of interdepartmental cooperation, the
Department of Endocrinology and Geriatrics conducts training for
employees of the Ministry of Social, Demographic and Family Policy
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involved in the implementation of the pilot project (extrabudget) according
to the original program developed by the department's employees.
Comprehensive geriatric assessment: “Age is not a hindrance” and a
block of neuropsychological tests for the early diagnosis of “frailty” and
neurodegenerative diseases “Vascular Dementia, Alzheimer's Disease,
etc.” are formed in EMIAS (the main freelance geriatrician, together with
the employees of the geriatric center of the GBUZ SOKGB, developed an
interface), then in the discharge summary and will be available in
information interdepartmental interaction with the GIS SOG (an analogue
of the information system of the Ministry of Social-Demographic and
Family Policy). This allows , in 100 % of cases, after discharge from the
hospital, to transfer information to comprehensive social service centers
for the population, followed by interdepartmental interaction between
outpatient departments of medical organizations in the Samara region, to
work with autonomous non-profit organizations social service centers for
the population (ANO TsSON) for medical and social support and
provision of social services, incl. and at home.
On the basis of the Geriatrics Center of the State Budgetary
Healthcare Institution of the SOKGB with the RGNCC (Moscow) and
medical organizations of the Samara region.
The region is implementing a program to introduce a set of measures
aimed at preventing falls and fractures in the elderly and senile.
The Department of Endocrinology and Geriatrics of the Samara State
Medical University of the Ministry of Health of Russia (Head of the
Department, Doctor of Medical Sciences S.V. Bulgakova), together with
the State Budgetary Healthcare Institution of the Specialized Clinical
Hospital, the State Budgetary Healthcare Institution of the Specialized
Clinical Hospital, in order to increase life expectancy in the region and
active longevity, conducts the following scientific work:
1. The study of age-associated, metabolic diseases and the
development of methods for early diagnosis, comprehensive measures for
their prevention and treatment.
2. Identification of factors, pathogenetic mechanisms that determine
the processes of aging, including premature, and the development of
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methods for early diagnosis, comprehensive measures for the prevention
and treatment of premature aging.
3. Basic and applied research in the field of gerontology, studying the
mechanisms of aging and ways to extend life in order to:
studying the mechanisms of aging;
prevention of development and progression of frailty;
optimization of prevention, diagnosis and treatment of age-related
diseases in the elderly;
IT-geriatrics;
deprescribing of drugs in the treatment of age-associated
diseases.
In 2022, employees of the Department of Endocrinology and
Geriatrics entered the working group of the United Russia Party project
“Older Generation”. A number of documents have been prepared. Party
project coordinator, First Vice Speaker of the Samara Provincial Duma,
Ph.D. M.J. Antimonov.
In 2022, the implementation of paragraph 10 of the Decree of the
Government of the Russian Federation dated June 23, 2021 № 1692-r
“Implementation of the prevention of cognitive impairment in older
citizens” is implemented on the basis of the Regional Action Plan for the
implementation in 2021–2025 in the Samara Region of the Action Strategy
in the interests of older citizens until 2025, includes holding joint events
between the Geriatric Center and Samara State Medical University of the
Ministry of Health of the Russian Federation:
1. Implementation of measures to prevent cognitive disorders in older
citizens.
2. Implementation of the method of therapeutic functionally balanced
nutrition of the brain.
3. Introduction of combined and hybrid methods for the diagnosis,
treatment and prevention of cognitive disorders in older citizens.
4. A neural network algorithm for the early detection of cognitive
chronobiological differences with a functional technology for the
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prevention and treatment of neurodegenerative diseases in middle-aged
and elderly people.
5. Functional technologies for the prevention of early cognitive
deficit in middle-aged and elderly people based on digital neurovirtual
technologies.
From 12/15/2021, the Cooperation Agreement between the State
Budgetary Healthcare Institution “SOKGB” and the Samara State Medical
University of the Ministry of Health of the Russian Federation “On
conducting research to develop successful practices for active longevity
and healthy human aging” is being implemented. Conducting research,
incl. on the prevention of cognitive impairment and neurodegenerative
diseases (Alzheimer's disease, dementia), scientific, methodological and
design work.
The joint work of the departments of Samara State Medical
University: physiology with the course of BJD and MC, medical physics,
mathematics and computer science, endocrinology and geriatrics,
psychiatry, narcology, psychotherapy and clinical psychology open up
prospects for the clinical implementation of modern neurotechnologies.
In addition, with the active participation of the chief geriatrician of
the Ministry of Health of the Samara Region, MD. S.V. Bulgakova,
schools of memory, schools of rehabilitation and care for patients with
vascular dementia and Alzheimer's disease are being opened on the basis
of medical facilities; for the prevention of bedsores, for the care of patients
with frailty with cognitive impairment of varying severity.
Samara Regional Clinical Hospital for War Veterans in 2017 became
the winner in the nomination “Leader in the implementation of the pilot
project “Territory of Care”.
In 2020 according to the results of the work of the federal forum
“Strong ideas for the new time” — the chief geriatrician of the region,
MD. Bulgakova S.V. was awarded the “Silver Medal” — “Choice of the
Community”, and on September 14, 2022 — a diploma of the finalist for
replication in medical organizations and social institutions of the “Best
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Practices for ACTIVE LONGEVITY 2021”. These are high marks for the
achievements of Samara geriatrics.
In the prospects for the development of the geriatric service in the
Samara region, I would like to highlight the following points:
1. In connection with the continuing aging of the region's population
and an increase in the proportion of people over 60, it is necessary to
annually monitor the region's need for geriatric rooms and beds, followed
by the correction of these indicators in accordance with Order No.
2. Maintaining a register of patients with a diagnosis of “frailty”.
3. Continue the implementation and monitoring of target
indicators — provided for by the National Project “Demography” and the
regional component “Older Generation”.
4. Continue the implementation of pilot projects “The system of
long-term care for the elderly and disabled”, “Introduction of a set of
measures to prevent falls and fractures in the elderly and senile”,
“Introduction of prevention of cognitive impairment in older citizens”.
5. Strengthen innovative work in gerontology and geriatrics with the
introduction of developments into practice.
In our rather rapidly changing age, the age of the aging of the
population, geriatrics remains a sought-after medical specialty. The
development of geriatrics is a requirement of the times.
Aging can be viewed in many ways, but it must be prepared: at
different stages of human development, lifelong health, safe environments,
older-centred health care and long-term care systems, strengthening the
evidence base and scientific research in the field of gerontology.
Humanity looks at the problems of old age in a new way. The
healthcare paradigm is also changing. If the main problem of medicine at a
young age is the prevention, detection and treatment of diseases, then for
people over 75 it is slowing down the aging process, maintaining
independence and a high quality of life. Thus, we can say that the Samara
region has become one of the leading centers in the study of gerontology
and geriatrics, contributing in every possible way to the thesis put forward
by the outstanding scientist I.V. and must be made useful to society.
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Therefore, science is closely studying the medical aspects of aging in order
to make life easier for an elderly person. In our opinion, knowledge of
gerontology, geriatrics, social assistance to people who have crossed a
certain age limit is needed by everyone. The need for a broader education
of the whole society within the framework of gerontology and geriatrics is
dictated not only by the aging of the population, but also by the progress of
mankind, which is not seen without the active participation of older people
in it, who are able to pass on their experience and knowledge to
subsequent generations.
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3. COMPREHENSIVE GERIATRIC ASSESSMENT:
A BACKGROUND
A comprehensive assessment of the health status of an elderly person
has historically gone through three phases of development. This process
was first carried out in 1935 at the West Middlesex Infirmary, in the UK,
where Marjorie Warren, the “mother of geriatrics”, established a system of
rehabilitation for elderly patients based on a complete comprehensive
assessment of their condition. She and her team found that bedridden and
long-term hospitalized elderly patients have many disorders, but it is
possible to restore independence, the ability to self-care, and improve the
quality of life through various targeted rehabilitation measures.
The integrated assessment model developed and improved until the
1970s in each country. From the mid-seventies to the mid-90s, many
randomized trials were performed to evaluate the clinical and costeffectiveness of various models of geriatric care, which were based on a
comprehensive assessment of the health status of the elderly patient. A
1993 meta-analysis of 28 studies culminated in a meta-analysis
of 28 studies that examined the effectiveness of five different types of
services for older patients: inpatient emergency department, inpatient
geriatric counseling service, geriatric home counseling service, and special
assessment service. patient after discharge from the hospital, as well as an
outpatient system for a comprehensive assessment of an elderly patient.
The analysis showed that, despite the advantages of some programs,
especially those that included assessment of patients at home and in a
hospital, they all contributed to an 18 % reduction in mortality, and also
increased the likelihood of patients returning to independent living at home
by 25 %. Moreover, there was a 41 % increase in the likelihood of
improving cognitive functions, and a 12 % increase in the risk of
readmissions. Comprehensive evaluation programs have continued to be
studied since the publication of these impressive results, but one of the
universally accepted conclusions remains fundamental: these programs
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must target specific groups of older people if they are to be clinically and
economically effective. They should be used primarily for patients with
frailty. As mentioned above, for many patients over 60, only preventive
measures are needed — nutritional advice, increased physical activity,
timely treatment of chronic diseases. These tasks can be performed by
primary care, general practitioners, together with nurses. For many other
patients — those who are frail, or those over 75 years of age, or who will
be placed in a nursing home or residential facility — not only a
comprehensive assessment is needed, but, most importantly, follow-up to
improve their condition, with ongoing monitoring, home visits,
rehabilitation. Another group can be identified as a result of such a
comprehensive assessment — those who do not yet need special
rehabilitation measures, but have unsatisfactory, borderline health
indicators. If such evaluations remain mere evaluations, they are neither
clinically nor economically effective. An example is services that only
conduct examinations and give recommendations, but do not support
further monitoring of the patient, do not engage in his rehabilitation.
The third phase of development and improvement of a
comprehensive assessment of the health status of an elderly person began
in the mid-90s and continues to the present. Its main goal is approval and
adaptation to the characteristics of different countries, different
populations, different health care systems. It should be noted that
adaptation takes place everywhere with discussion at the level of national
and international medical communities, but the main role belongs, of
course, to national geriatric communities and associations. An important
question that emerged from these discussions is who should carry out the
assessment and follow-up?
In 2001, the study “Dutch Easy care” was started in the Netherlands
and completed in 2007. The reason for organizing this study was that
general practitioners are faced daily with the growing needs of an aging
population suffering from numerous diseases and problems caused by old
age and disease. At the same time, despite a significant decline in
functions and quality of life, loss of independence, ability to self-service,
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