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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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Service, in 2012 a total of 36,052 people died in nursing homes, a
60 percent increase compared to that in 2009.
There have been task force discussions to promote early screening of
frailty in nursing homes. The FRAIL-NH scale has been developed to
identify frail persons in nursing homes. It is comprised of 7 items; energy,
transferring, mobility, continence, weight loss, feeding and dressing. In
Korea, there has been a study that measured frailty with the FRAIL-NH
scale which used data obtained from the inpatient's data set in long-term
care hospitals.
Given a highly prevalence of frailty and disability in nursing homes,
intervention trials to reverse frailty status or physical function are limited.
Rather, most trials are mainly focused on preventing further functional
decline or maintaining quality of life. Also nutritional interventions such
as protein supplement to prevent functional decline in nursing home
patients are in progress. However, intervention trials for nursing homes are
still lacking and need more evidence and programs.
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5. STEPS FOR CONDUCTING
A COMPREHENSIVE GERIATRIC ASSESSMENT
At the first stage conducting a geriatric assessment is carried out by
studying the patient's medical history. The following information must be
taken into account: diagnosis, stage of the disease, the presence of
treatment, whether the treatment is adhered to. In geriatric practice, a
subjective health questionnaire (Health Questionnaire) is often used to
identify complaints about somatic and mental health. The questionnaire
was developed by B. Levin to study the features of depression in old age
and allows a specialist to collect information about chronological
(passport) age, gender, ethnicity, education, social employment, marital
status.
The subjective complaints of a geriatric patient are evaluated:
• Do you have any health problems?
• Do you have any vision problems?
• Do you have any hearing problems?
• Do you have any mood changes?
• Have you had health problems before?
The patient's preferences regarding their condition are also assessed.
Second phase. Along with chronological age, the concept subjective
age. Subjective age integrates biological and social factors (in our case,
those that ensure the aging process). It can be considered as an integrative
indicator of changes in cognitive, mental and physical functioning.
Differences in the assessment of subjective age may affect the
maintenance of health and social activity in later ages. Thus, it can be
assumed that subjective age can be considered as one of the factors of
psychological and physical well-being in later ages.
From a clinical point of view, subjective age can be an effective
means of identifying individuals with an increased risk of adverse
reactions to the onset of maturity and aging, as well as providing timely
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therapeutic assistance and influencing the somatic, cognitive and
psychological components of health. For the study of subjective age is
used cognitive scale for assessing subjective age or the Age-of-Me
questionnaire (Cognitiveage-decadescale, V. Barak).
The scale allows you to analyze a person's ideas about how old he
looks, feels, acts, and what age his interests correspond to. In general, in
order to assess what ideas a person has about his resources, opportunities
and interests, R. Kastenbaum proposed a multidimensional age-of-Me
model of age identity, consisting of subjective and ideal ages. This model
includes the following components of subjective age:
- cognitive-emotional (feel-age);
- subjectively biological (look-age);
- social (do-age);
- intellectual (interest-age) age.
Emotional age is perhaps most closely associated with physical,
mental and social change. Based on this model, a scale was developed that
consists of four questions that assess subjective age (table 1).
Table 1
Questions and evaluation of the components of subjective age
in the cognitive scale age estimates
Question
Components
Description
Do you feel like you think
how old?
Biological objective age
Assessment of the
functional state of the body
How old do you think you
look?
Emotional age
Assessment of body
image, appearance.
Attitude to age-related
changes in appearance
Your behavior corresponds
to a person of what age
social age
The ability to understand
and manage one's own
state, behavior
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Question
Components
Description
Your interests correspond
to the interests of a person
of how many years?
Intellectual (cognitive) age
Functioning, state of
memory, attention,
presence of fatigue. The
desire for knowledge,
interests, the availability of
mental resources
The presence of a tendency to estimate one's subjective age closer to
the chronological one is assessed: to overestimate it (that is, the negative
cognitive illusion of age) or to underestimate it (that is, the positive
cognitive illusion of age, subjective youth (cognitively younger)).
Third stage. A feature of elderly and senile people is the presence of
polymorbidity, predominantly chronic course of diseases, atypical clinical
manifestations, as well as the presence of various geriatric syndromes.
Syndromic analysis is performed using the Cumulative Illness Rating
Scale for Geriatrics, abbr. CIRS-G. The scale is a system for screening the
presence of chronic diseases (morbidity), taking into account the degree of
chronic diseases in individual body systems — for example, diseases of
the heart, blood vessels, blood, kidneys, etc. Assessment of the presence of
somatic diseases by organ systems and their severity (from mild to
extremely severe) in order to solve a specific set of problems of an elderly
person. It also includes an assessment and the degree of presence of mental
disorders.
Fourth stage. One of the criteria for assessing the effectiveness of
medical care and subjective well-being in the elderly and senile age is the
assessment quality of life. The most important components of assessing the
quality of life are considered to be the determination of the patient's
functional capabilities, the assessment of his subjective perception of his
state of health, and the patient's subjective assessment of the severity of the
symptoms of the disease.
This integrative indicator of physical, psychological and social wellbeing evaluates the components associated and not associated with
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diseases, and allows you to differentiate the impact of somatic and
psychosocial problems on the psychological, emotional state of an elderly
person, his social status.
The quality of life of the elderly can be assessed using World
Health Organization quality of life questionnaire (WHOQOL-BREF).
The questionnaire allows assessing the following components of the
quality of life:
- physical health;
- psychological health (self-perception);
- sphere of social relations (microsocial support);
- sphere of the environment and its safety (social well-being).
The use of this questionnaire is dictated by the age and nosological
characteristics of elderly and senile people, since some patients could not
cope with filling out the full version of the questionnaire.
The prenosological definition of somatic health — the viability of the
body of an aging person — is carried out by assessing the functioning and
tension of adaptive-regulatory mechanisms.
For prenosological diagnostics, it is recommended to calculate the
adaptive potential (AP) of the circulatory system:
AP = 0.011 × CHP + 0.014 × AD s + 0.008 × BP d + 0.014 × V +
0.09MT – (0.009 × P + 0.27),
where AP — adaptation material;
B — age;
BW — body weight, kg;
BP c — systolic blood pressure (mm Hg);
BP d — diastolic blood pressure (mm Hg);
PR — pulse per minute.
AP equal to 2.1 or less corresponds to satisfactory adaptation,
2.11–3.20 — to stress — adaptation mechanisms, 3.21–4.30 —
unsatisfactory adaptation and 4.31 and above — failure of adaptation
mechanisms.
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Patients with identified disorders or disruption of adaptivecompensatory mechanisms require a more in-depth clinical assessment of
their health status and appropriate therapeutic and preventive measures.
To assess the energy reserve of the cardiovascular system, a double
product (DP) or Robinson index characterizing the systolic work of the
heart is used:
DP = (HRС ) / 100
The higher this indicator at the height of the load, the greater the
functional capacity of the heart muscle. The lower the RP at rest, the
higher the maximum aerobic capacity and, consequently, the level of
somatic health. The Robinson index changes little with age.
Fifth stage. A number of neurodegenerative disorders and depression
are the most common diseases in people over 65 years of age. Most forms
of dementia are accompanied by symptoms of depression, and with
depression in elderly and senile people, as a rule, symptoms of cognitive
deficits are observed. Signs and symptoms of depression in the elderly and
senile are often atypical and blurred. In this regard, in the differential
diagnosis of depression and dementia in the elderly and senile age, first of
all, cognitive functions should be assessed, and then the severity of
affective symptoms.
Dementia is a syndrome caused by an organic lesion of the brain,
characterized by impairments in mnestic and other cognitive areas,
including speech, orientation, abstract thinking, and praxis. These
violations must be so pronounced as to lead to difficulties in everyday life
and / or professional activities. Often dementia is accompanied by
emotional and affective disorders, but the level of consciousness remains
unchanged until the terminal stage of the process. The presence of
dementia does not always imply the irreversibility of the defect, its
progression, global impairment of intellectual functions, or the presence of
some specific cause of cognitive impairment. The onset of dementia is
usually imperceptible (with the exception of post-traumatic, post-anoxic,
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and post-stroke disorders), and the course is often progressive, although in
some cases it can be stationary and even reversible.
The incidence of dementia increases with age: from 2 % in the
population up to 65 years old to 20 % in people aged 80 years and older.
Among people over 65, about 9 % have mild or moderate dementia, and
5 % have severe dementia. It is often quite difficult to distinguish between
the initial stages of dementia and forgetfulness in normal aging, and the
wrong solution to this problem leads to overdiagnosis of dementia in older
people. Age-related cognitive impairments are manifested by mild
memory impairments and some slowing down of the rate of mental
processes. At the same time, there are no significant restrictions in
everyday and professional activities due to cognitive impairment. These
individuals are often classified as having “benign senile forgetfulness” or
“age-related memory impairment”. However, their follow-up often reveals
the presence of progressive dementia. Therefore, dynamic observation
with re-examination, usually after 6–12 months, is indicated for this
category of patients, which helps to objectify cognitive impairment.
The first step is to diagnose dementia, the second is to find its cause.
A syndromic diagnosis of dementia cannot be made if the patient has an
impaired level of consciousness or the patient's condition does not allow
an adequate assessment of his mental status. It is necessary to distinguish
between dementia and organic syndromes, accompanied by an isolated
memory impairment or aphasia. Dementia implies an acquired impairment
of cognitive functions, so mental retardation (oligophrenia) does not apply
to dementia. The main difference between delirium and dementia is a
violation of the level of consciousness, which in delirium is not always
easy to diagnose. In addition, with delirium, there is an increase in body
temperature, the speech of patients is often dysarthric, and the EEG reveals
a diffuse increase in slow-wave activity. Cognitive impairments while
maintaining the level of consciousness in patients with toxic or metabolic
disorders are characterized by impaired attention, hallucinations, a state of
arousal, motor and speech disorders and may present certain difficulties in
differential diagnosis with delirium.
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The main causes of dementia are Alzheimer's disease and vascular
lesions of the brain (vascular dementia), much less often — dysmetabolic
disorders, alcoholism, brain tumors, traumatic brain injury, Parkinson's
disease, infectious diseases of the central nervous system, etc.
Identification of the cause of dementia is important, since in a number of
situations adequate treatment can lead to the reverse development of
disorders or slow down the progression of the pathological process. In
addition, prediction of the course of the disease based on the correct
diagnosis allows the patient and his family members to plan their actions.
Multi-infarct dementia develops in patients with cerebrovascular
disease and poorly controlled arterial hypertension.
Multi-infarct dementia has a relatively earlier onset (age
70–75 years), more often males, smokers, with arterial hypertension,
diabetes mellitus and coronary artery disease in history, who have had
strokes and have focal neurological symptoms. In order to facilitate the
recognition of multi-infarct dementia, V.S. Khachinsky et al. (1975)
proposed a scale for quantifying signs of cerebral ischemia characteristic
of multi-infarct dementia (table 2).
Table 2
Hachinski ischemia score for recognition
of multi-infarct dementia
Signs
Possible scores
Sudden onset of dementia symptoms
0 or 2
gradual deterioration
0 or 2
Undulating current
0 or 2
Night disorientation
0 or 1
Relative safety of personality
0 or 1
Depression
0 or 1
Somatic complaints
0 or 1
Emotional disorders
0 or 1
Arterial hypertension in history or at present
0 or 1
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Signs
Possible scores
History of stroke
0 or 2
Signs of concomitant atherosclerosis
0 or 1
Neurological symptoms
0 or 2
Focal neurological signs
0 or 2
Sum
A total score of 7 or more suggests multi-infarct or mixed dementia.
Due to the fact that cognitive impairment considered as the core of
the clinical picture of the development of dementia, the assessment of
cognitive status according to the recommendations of N.N. Yahno is
recommended to be carried out using Montreal Cognitive Assessment
Scale (Montreal Cognitive Assessment, abbr. MoCA). The scale is used to
screen for the diagnosis of mild cognitive impairment (MCI) and early
symptoms of dementia.
MoCA is more sensitive than the Mini Mental Status Scale (abbr.
MMSE) to manifestations of vascular dementia, Parkinson's disease, and
moderate forms of cognitive deficit. The test is not a clinical diagnostic tool
for cognitive impairment. The decision on the presence of cognitive disorders
should be based on a thorough assessment of complaints, clinical
examination and results of neuropsychological examination. According to
Z. Nasreddin, moderate cognitive deficit is < 26 points according to MoCA
(more detailed clinical and neuropsychological examination is required).
C. Louis recommends scoring mild cognitive deficits starting at 23.
Identification of a disorder of cognitive function
Among the various tests used to diagnose and assess cognitive
dysfunction, the most famous is the Mini-test for assessing mental
abilities, proposed by M.F. Folstein et al. (1993).
A score of less than 24 suggests dementia but may be associated with
severe depression or delirium.
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Those who scored low in the study have a low level of physical
health and take more medication than those who have a higher overall
score (table 3).
Orientation in time: the maximum score (5) is given if the patient
independently and correctly names the day, month and year. If you have to
ask additional questions, 4 points are given. Each mistake or lack of
answer reduces the score by one point;
Orientation in place: each mistake or lack of answer reduces the
score by one point;
Perception: the correct repetition of the word by the patient is
estimated at one point for each of the words;
Attention concentration: each mistake reduces the score by one point;
Memory: each correctly named word is worth one point;
Speech: each correct answer is worth one point;
3-stage team: each action is worth one point;
Reading: each mistake reduces the score by one point;
Draw a picture: each mistake reduces the score by one point.
The test results may have the following meaning:
28–30 points — no cognitive impairment;
24–27 points — predementia cognitive impairment;
20–23 points — mild dementia;
11–19 points — moderate dementia;
0–10 points — severe dementia.
Table 3
Mini Intelligence Test (maximum score 30)
(according to William B. Arams, et al., 1995)
Measures of Cognitive Ability
Points
Orientation
What is now:
year;
season;
the date;
day of the week;
month
0–1
0–1
0–1
0–1
0–1
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