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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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81
Position
Action
Points
Ability to maintain
balance when pushed
(patient stands with feet
as close together as
possible, examiner
lightly pushes him in the
sternum with the palm
of his hand 3 times)
Starts to fall
Staggers, seeks support, but stays on his feet
Sustainable
0
1
2
Ability to maintain
balance with eyes
closed (patient standing
with feet as close
together as possible)
Unstable
Sustainable
0
1
Rotate 360o
Intermittent steps
Smooth turn
Unstable (looking for support, staggering)
sustainable
0
1
0
1
Attempt to sit down
Uncertainty (incorrectly calculates the distance,
falls into a chair)
Uses hands
Reliable, safe driving
0
1
2
Table 9
Gait
Instructions: The patient stands and then walks down the hall or
crosses the room at a possibly fast but safe pace (using his usual walking
aids, such as a cane or a walker).
Movement initiation
(immediately after
command)
Any hesitation or multiple attempts to start
moving
No hesitation
0
1
82
Step length and height
Beginning right foot:
cannot start a step with the left foot;
can start with the left foot;
the right leg does not come off the floor
completely when stepping;
the right leg is completely off the floor.
Beginning left foot:
cannot start a step with the right foot;
can start with the right foot;
the left leg does not come off the floor completely
when stepping;
the left leg is completely off the floor
0
1
0
1
0
1
0
1
Symmetry of steps
Right and left steps of unequal length
Right and left steps are the same
0
1
Step Continuous
Stops or uneven steps
Continuous Steps
0
1
Trajectory (can be set by
deviation of one leg
more than 10 cm from a
straight line)
Noticeable deviation
Slight to moderate deviation or use of assisted
walking
Straight without assistance in walking
0
1
2
Torso
There is a noticeable wobble
No rocking, but knee or back flexion or arms
spread while walking
No rocking, no bending, no use of hands and
accessories
0
1
2
Leg position while
walking
Large distance between the feet
Heels almost touch each other when walking
0
1
A patient with a score of 28 does not experience difficulties in
moving and walking. The sum of points less than 26 indicates a violation
of a particular function, and the lower the sum of points, the more
pronounced balance and gait disorders.
A score below 19 is associated with a 5-fold increase in the risk of
falls.
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Table 10
Evaluation of the patient's ability to self-care in the hospital
FULL NAME. __________________________________________________________ Gender M / F
Age ___________
№
Name of questions
Score in points
Can the patient independently without outside help and supervision:
Before hospitalization
After hospitalization
1
Use public transport
0
0.5
1 0 0.5
1
2
Move around in the apartment
3
Get out of bed
4
Turn around in bed
5
Dress/undress (underwear, stockings/socks, outerwear, headwear)
6
Cook food
7
Warm up food
8
Buy groceries (go down/climb stairs, overcome other obstacles)
9
Eat (use eating utensils)
10
Bath / shower (wash the whole body, hair, use a washcloth)
11
Wash your face, brush your teeth, shave
12
Wash your crotch
13
Go to the toilet (use toilet paper)
14
Clean up a room, apartment, room, etc.
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№
Name of questions
Score in points
15
Use the phone
16
Take medication
17
Use a hearing aid
18
Orientation in time (year, month, day, place of stay)
19
Control urination
20
Name within 1 minute:
10 animals
10 fruits
10 cities
10 flower plants
(for answers it is charged: less than 15 = 1; 20 – 35 = 0.5;
35–40 = 0)
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The degree of dependence is calculated on the basis of the “Patient's
ability assessment card for self-care in a hospital” according to the formula
X % = N × 5,
where: X % — reduced ability to self-service;
N — the number of points the patient scored.
The degree of dependence of elderly patients
According to the degree of dependence, elderly patients in geriatric
practice are divided into 4 groups:
a. Decreased self-care ability by: 0 to 24 % — independent patients.
b. Decreased self-care ability by: 25 to 49 % — need help.
c. Decreased ability to self-care by: 50 to 74 % — “prisoners of the
apartment”.
d. Decreased ability to self-care by: 75 to 100 % — “prisoners of the
bed.”
The degree of patient dependence or reduced ability to self-care in
patients 60 years of age and older is assessed at an outpatient appointment
annually. When a patient is admitted to a day hospital or an inpatient
facility, the degree of patient dependence is assessed upon admission and
discharge. Based on the analysis of the degree of dependence of the
patient, a prognosis of the patient's condition is made and the quality of the
treatment and rehabilitation is assessed.
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7. SYNDROME OF FRAILTY
Definition.
Frailty is a characteristic of the health status of an elderly and senile
patient, which reflects the need for care. The most commonly used and
simplest definition of frailty is the definition of Fried et al., according to
which this clinical syndrome includes a combination of five positions:
weight loss (sarcopenia), dynamometrically proven decrease in hand
strength, severe weakness and fatigue, decreased speed of movement, a
significant decrease in physical activity. According to the same authors,
frailty occurs in the presence of three or more symptoms, while in the case
of the presence of one or two of them, pre-frail older adults occurs.
Epidemiology and risk factors
The average prevalence of frailty is 12.9 %, pre-frail older adults —
48.9 %. It is believed that in the absence of adequate measures of
treatment and rehabilitation, pre-frail older adults turns into an expanded
form within 4–5 years. The development of frailty is due to such main
factors as age, gender, level of education, socio-economic conditions of
life.
Age. There are two points of view regarding the causes of the
development of frailty: frailty as a genetically transmitted phenotype
(Fried-like) and as a combination of acquired functional deficiency against
the background of polymorbidity (Rockwood-like). At the same time,
apparently, the so-called acquired frailty against the background of
cumulation of diseases is more common: at the age of 65–70 years, it
occurs in 5–15 % of cases (genetically determined frailty — 3–6 %);
70–80 years old — 8–17 % of cases (genetically determined — 5–12 %).
At the age of 80–84 years, the frequency of occurrence of both forms of
frailty levels off and exceeds 16 %, but at the age of over 85 years, the
cumulative form of asthenia is about 26 %, and the genetically determined
form occurs in 50–56 % of cases. These patterns are easily explained by
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the lower life expectancy and higher polymorbidity index of those elderly
people who have various diseases leading to functional deficits [4].
Floor. It is known that frailty is significantly more common in
women of any age.
The level of education. It is more common in people with a lower
level of education.
Family status. Frailty is more common in divorced and widowers,
somewhat less often in people who have never been married, and even less
often in elderly people who are married. At the same time, at the age of
84–85 years, the second position in the prevalence of frailty is occupied by
the category of persons who are married.
Socio-economic conditions. The frequency of development of frailty
is influenced by socio-economic conditions of life. According to different
authors, the frequency of occurrence of elderly people with senile pre-frail
older adults and frailty in different countries is as follows: Belgium —
40 % of the elderly population, Switzerland — 50 %, USA — 55 %,
Finland — 60 %, Germany — 66.4 %. One of the most unfavorable
countries in terms of the incidence of frailty is Russia, where this
syndrome occurs in 84 % of elderly and senile people [11].
Urbanization. Residents of rural areas are more susceptible to the
development of frailty.
Pathogenesis
Target organs of frailty. The following target organs of frailty are
distinguished:
- musculoskeletal system: muscle mass decreases, violations of
muscle thermoregulation occur, oxygen consumption by muscles
decreases, innervation of muscle tissue and its endurance are disturbed;
- immune system: the production and content of immunoglobulin A,
G, interleukin 2 decreases, the production of pro-inflammatory cytokines
(interleukin 6) is activated;
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- neuroendocrine system: the production and content of growth
hormone, estrogen and testosterone, insulin-like growth factor-1, vitamin
D decreases. Insulin resistance increases, sympathetic tone increases, and
steroid dysregulation increases.
Pathogenetic circles of frailty. The development of frailty is based
on three age-dependent conditions: malnutrition syndrome (malnutrition),
sarcopenia, and a decrease in the metabolic index and physical activity.
Malnutrition Syndrome. The aging process, as a rule, is associated
with a decrease in oral health, a decrease in taste sensitivity to the food
consumed, frequent repeated hospitalizations, anxiety-depressive
syndrome, dementia, physiological aging is associated with the “rapid
satiety” syndrome, in which the amount of food consumed is significantly
reduced due to increased sensitivity of the centers of saturation of the
medulla oblongata. All this taken together leads to a decrease in appetite, a
decrease in the volume and quality of food intake and malnutrition
syndrome. Its main clinical manifestations are a decrease in muscle
strength and endurance, a decrease in the volume of physical activity, the
activity of daily life, and a decrease in body weight.
Sarcopenia. The aging process is associated with pro-inflammatory
cytokinemia, oxidative stress, which, together with malnutrition, cause the
formation of age-related muscle weakness or sarcopenia. This disease is a
triggering pathogenetic factor in the formation of balance disorders with a
syndrome of falls; osteopenia; decreased sensitivity of peripheral tissues to
insulin, the intensity of metabolic processes.
Decreased intensity of metabolic processes and physical activity.
This condition is a natural consequence of the syndrome of malnutrition,
sarcopenia, as well as many acute and chronic diseases, polypharmacy,
characteristic of the elderly and senile age. These processes lead to
disruption of the functioning of all organs and systems, including reducing
cognitive abilities.
Thus, the syndrome of malnutrition, sarcopenia, and a decrease in the
metabolic index and the level of physical activity represent a vicious
pathogenetic circle of the formation of frailty. With minimal external or
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internal influences, other pathogenic factors join this circle, which can lead
to deterioration, disability and death in the shortest possible time.
Classification of frailty
Classification by stages of development or stages. The most
complete is the classification of stages of development or stages of frailty,
formulated by the working group that conducted the Canadian Study on
Health and Aging (CSHA, 2009).
Frailty, according to this classification, can go through the following
stages of development:
- health preservation: patients are active, energetic, have a high level
of motivation, are not limited in physical activity;
- good health: there are diseases in the inactive phase, which
somewhat reduce the functional state;
- good health in the presence of successfully treated chronic diseases:
there are individual symptoms of chronic diseases that are well controlled
by ongoing therapy, but further reduce the functional state;
- a state with an undulating course of diseases (pre-frail older adults):
frequent periods of exacerbation, decompensation of pathology, which
significantly reduces functionality;
- mild frailty: slight limitation of activity;
- moderate frailty: the formation of the need for long-term care;
- severe frailty: constant, thorough care is needed;
- the terminal stage of the disease.
Classification according to the degree of severity. When using
special questionnaires and scales, the Frailty Index (ISA) is revealed, and
this syndrome is regarded as mild, moderate or severe in terms of severity.
Clinic and diagnosis of frailty clinical picture. Clinically, frailty is
characterized by such symptoms as weight loss, when there is a decrease
in body weight at a rate of at least 4.5 kg/year; gait disturbance; decreased
muscle strength and development of severe sarcopenia; the development of
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cognitive disorders and a decrease in motivation, the loss of former vital
interests; low level of physical activity.
Traditional diagnostics. When collecting anamnestic data, it must
be remembered that about 65 geriatric syndromes can lead to frailty, the
main of which include the following: anorexia, apathy, chronic pain
syndrome, age-related androgen deficiency, dehydration, bedsores,
dementia, depression, violence against the elderly, hypothermia,
incontinence urine, insomnia, instability and falls, cognitive deficits,
obstipation syndrome, hearing and visual impairments.
When conducting inspection of organs and systems it is important to
pay attention to the following circumstances: the presence of cognitive
dysfunction, episodes of decreased mood, depression; detection of visual
and hearing loss; definition of muscle strength.
Laboratory research include: a general blood and urine test, a
biochemical blood test (detection of renal and liver markers, albumin
levels, cholesterol and its fractions), determination of inflammation
markers, levels of vitamin D, B12, thyroid-stimulating hormone.
Instrumental Research are necessary for the timely detection of the
consequences of frailty, which are the result of a significant decrease in
body reserves, for example, myocardial infarction, tumors, etc.
Specialized (geriatric) diagnostics. Diagnosis of frailty is carried
out on the basis of CGA (comprehensive geriatric assessment).
When conducting CGA, it is important to obtain information about
an elderly and senile patient on the following items:
- information about the patient's personality: family history, living
conditions, need for further assistance (for dementia, depression,
loneliness), including the need for hospitalization in inpatient social
institutions; assessment of the quality of life, existential aspects of old age
in a particular individual case, life priorities of a particular person;
- physical status: detection of geriatric syndromes, such as falling
syndrome, hypothermia, urinary incontinence, malnutrition, hypomobility,
age-related androgen deficiency and others;
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