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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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Table 2
Signs and symptoms indicating the possible presence
of frailty syndrome or an increased risk of its formation
Clinical signs
and symptoms
unintentional weight loss (especially > 4.5 kg in the past year)*
urinary incontinence*
loss of appetite
loss of muscle mass/strength (sarcopeni)
osteoporosis
decreased vision/hearing
chronic pain
repeated calls for ambulance/hospitalization
Psycho-emotional
signs
and symptoms
delirium*
cognitive impairment/dementia*
depression
behavioral disorders
disturbed sleep/wake patterns
Functional signs
and symptoms
dependence on outside help*
significant limitation of mobility*
recent fall (s)*, fear of falling
imbalance
fatigue
decreased physical activity/endurance
Medications
and alcohol
presence in the patient of factors**
predisposing to the development of adverse drug reactions*
polypharmacy
increased alcohol consumption
Social factors
social isolation
change in life circumstances
change in family/carer support
caregiver being stressedfrailty
*Signs indicating a higher likelihood of a patient having senile asthenia
syndrome
**Factors predisposing to the development of adverse drug reactions include:
the presence of > 4 chronic diseases, chronic heart failure, liver disease, polypharmacy,
history of adverse reactions
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5. DIAGNOSIS OF THE FRAILTY SYNDROME
5.1. STAGES OF DIAGNOSTICS.
COMPREHENSIVE GERIATRIC ASSESSMENT
Diagnosis of frailty syndrome consists of two stages: screening for
frailty (performed by any medical worker in contact with a patient 60 years
of age and older, primarily a general practitioner, general practitioner,
family doctor) using the “Age is not a hindrance” questionnaire (Table 3).
Table 3
Screening on the scale “Age is not a hindrance”
Questions
Answer
Have you lost 5kg or more in the last 6 months? (the weight)
Not really
Do you experience any limitations in daily life due to vision or
hearing loss?
Not really
Have you had a fall-related injury in the past year?
Not really
Have you been feeling depressed, sad or anxious during the last
weeks? (mood)
Not really
Do you have problems with memory, understanding, orientation, or
the ability to plan?
Not really
Do you suffer from urinary incontinence?
Not really
Do you have difficulty moving around the house or outside? (walking
up to 100m/climbing 1 flight of stairs)
Not really
Interpretation:
For each positive answer, 1 point is awarded. The result is 2 points or
less — no senile asthenia, 3–4 points — probable pre-asthenia, 5–7 points —
probable senile asthenia.
It is recommended to refer to a geriatric office for a comprehensive
geriatric assessment of patients (Appendix 1, Table 4) with a score of 5 or
more according to the screening questionnaire “Age is not a hindrance” in
order to diagnose senile asthenia and develop an individual management
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plan, with a score of 3–4 points for age is no barrier screening questionnaire
to perform a short battery of physical functioning tests, and/or dynamometry
and the Minicog test to clarify geriatric status and determine indications for
a comprehensive geriatric assessment.
A comprehensive geriatric assessment is an interdisciplinary
diagnostic process that includes an assessment of not only medical, but also
psychological, social problems and functional abilities of an elderly person.
With the help of a comprehensive geriatric assessment, a specialist can
determine the geriatric status of patients syndromically, linking it to quality
of life and psychosocial adaptation. All this data makes it possible to
develop treatment and rehabilitation regimens that can stop certain
manifestations of diseases and improve the quality of life and the level of
social integration.
Comprehensive geriatric assessment, in no way being an alternative or
substitute for syndromic nosological diagnosis, complements it. At the same
time, it significantly expands the understanding of the state of health and
functional capabilities of an aging person, and allows targeted treatment and
rehabilitation measures.
Based on the results of a comprehensive geriatric assessment, an
individual plan of treatment and rehabilitation measures is developed. The
ultimate goal of a comprehensive geriatric assessment and subsequent
treatment and rehabilitation measures is the timely elimination of reversible
involutive-pathological changes, the stabilization and slowdown of the
aging process and pathological processes caused by chronic diseases, the
prevention of disability, the return of social activity.
Table 4
Key Points for Conducting a Comprehensive Geriatric Assessment
Who gets a
comprehensive
geriatric
assessment?
Only patients in stable condition, selected on the basis of
screening. Comprehensive geriatric assessment is not
carried out against the background of acute
diseases/decompensation of chronic conditions.
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Where is a
comprehensive
geriatric assessment
performed?
In the geriatric office, in the geriatric department, at home.
During hospitalization, a comprehensive geriatric
assessment is performed once. Some scales can be used to
assess the dynamics of the state
Who performs a
comprehensive
geriatric
assessment?
Multidisciplinary team: a geriatrician, a nurse trained in
geriatrics, a social work specialist, if necessary, an
instructor-methodist in physical therapy, other specialists
(for example, a dietitian, a neurologist, a psychologist).
Prior to being seen by a geriatrician, a series of tests,
measurements, and scales are performed by a trained nurse.
Which domains are
assessed in a
comprehensive
geriatric assessment
Domains of Comprehensive Geriatric Assessment
Physical health (complaints and anamnesis, including
medication, physical examination and examination of
organs and systems)
functional status (physical functioning, risk of falls,
instrumental and basic functional activity)
cognitive functions and emotional state (performed first, as
patient fatigue may affect their results)
social status and need for social assistance The results of
laboratory and instrumental studies are taken into account
Presence of Family
Members/Caregivers
for Comprehensive
Geriatric
Assessment
The presence of a family member/guardian or person caring
for the patient is recommended in order to obtain the
necessary history data, a more reliable assessment of the
patient's problems and functionality, and discuss a further
management plan.
5.2. PHYSICAL HEALTH DOMAIN
• It is recommended that when performing a comprehensive geriatric
assessment, pay attention to the patient's appearance, behavior, posture,
facial expressions, and gait.
Comments: The way the patient enters the room, whether he uses
walking aids and whether they are correctly selected, whether the patient
himself can undress, the features of his appearance (grooming, cleanliness
of clothes, neatness, smell, etc.) can provide important information about
functional and cognitive status, as well as social problems.
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• When conducting a comprehensive geriatric assessment, it is
recommended to conduct a thorough collection of complaints and
anamnesis in order to actively identify symptoms and signs of senile
asthenia, assess their duration and development in dynamics, direct and
indirect signs of reduced autonomy, paying particular attention to:
- weight loss;
- repeated falls
- violations of walking;
- a decrease in physical activity (an elderly person began to move
less, leave the house less often, stopped taking walks, etc.);
- refusal to eat;
- the appearance of untidiness in clothes;
- Decreased ability to self-care.
• When conducting a comprehensive geriatric assessment, a thorough
collection and analysis of drug history is recommended in order to identify
polypharmacy and irrational prescribing of drugs using the STOPP/START
criteria presented in the Guidelines “Pharmacotherapy in the elderly and
senile”.
Comments: A thorough review of the drug history and identification
of polypharmacy is necessary for all elderly and senile patients and is
especially important in patients with a high likelihood of frailty. In elderly
and senile patients, the risk of adverse drug reactions is significantly
increased. The presence of polymorbidity, observation by different
specialists leads to polypharmacy, which is associated with an increased risk
of adverse outcomes (progression of frailty, cognitive impairment, falls,
dependence on outside help, death.
• It is necessary to find out the list of drugs actually taken (name, dose,
multiplicity, route of administration, duration of administration), including
over-the-counter drugs, herbal remedies and dietary supplements. If
possible, ask the patient (relatives/guardians/caregivers) to show the
medications taken, ask the patient to bring to the visit all the drugs that he
takes.
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• Be sure to assess the patient's ability to independently take
medications, paying attention to the state of cognitive functions, the
preservation of hand function, visual acuity and motivation.
• It is strongly recommended that the patient's weight and height be
measured during a comprehensive geriatric assessment and that BMI be
calculated. Due to the importance of body weight dynamics for the diagnosis
and evaluation of frailty syndrome, its measurement should be performed
during each patient visit.
Comments: Unintentional weight loss is an important feature and one
of the most important clinical manifestations of frailty and malnutrition
(malnutrition syndrome) in old age. Height loss may be considered as a sign
of osteoporosis and/or compression fractures of the vertebral bodies.
Clinical signs of osteoporosis: a decrease in height by 2 cm or more in
1–3 years or by 4 cm or more compared to the age of 25 years, pronounced
thoracic kyphosis, a decrease in the distance between the lower ribs and the
iliac wing to a width of 2 fingers or less. With a decrease in height of 2 cm
or more in 1–3 years or 4 cm or more in a lifetime, compression fracture(s)
of the vertebral body should be suspected.
• A thorough examination of the skin of elderly and senile patients is
recommended.
Comments: you should pay attention to signs of xerosis, mycosis,
diaper rash, bedsores, malignant skin lesions. The presence of hematomas
may indicate falls or abuse of an older person.
• It is highly recommended to perform an oral examination and assess
the presence/condition of the teeth.
Comments: Oral problems may be potentially avoidable causes of
malnutrition and weight loss syndromes. It is necessary to assess the
presence of teeth, signs of xerostomia, periodontal disease, malignant
formations of the oral cavity. If the patient wears prostheses, it is
recommended to examine the oral cavity without prostheses and clarify
whether there are any discomfort during their use, soreness, incomplete fit,
difficulty in chewing food. If necessary, refer the patient to a dentist.
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• When examining the cardiovascular system during a comprehensive
geriatric assessment, it is recommended to:
- auscultate the carotid arteries and the heart and pay attention to the
presence of systolic murmur over the carotid arteries (a sign of carotid
stenosis) and over the aortic valve (a sign of aortic valve stenosis);
- during the first comprehensive geriatric assessment, measure blood
pressure in both arms to detect differences and use the arm with the higher
systolic blood pressure for further measurements;
- measure blood pressure at least three times in the supine position and
calculate the average of the last two measurements;
- conduct an orthostatic test to detect orthostatic hypotension (after at
least 7 minutes of rest in a horizontal position, measure blood pressure
3 times with an interval of 1 minute) and heart rate, ask the patient to move
to a vertical (if impossible, sitting) position and measure blood pressure and
heart rate at 1, 2 and 3 minutes, note the presence of symptoms. Orthostatic
hypotension — a decrease in systolic blood pressure by 20 mm Hg. Art. and
more and/or diastolic blood pressure by 10 mm Hg. Art. and more when
moving to a vertical position);
- measure heart rate;
- pay attention to the presence of bradycardia and cardiac arrhythmias;
- evaluate the pulsation of the arteries of the lower extremities (a sign
of atherosclerosis of the arteries of the lower extremities).
Comments: Cardiovascular assessment should be performed in all
elderly and senile patients and is especially important when FRAILTY is
suspected. The pathology of the cardiovascular system can be both the cause
of other geriatric syndromes (falls, cognitive impairment), and a
manifestation of chronic diseases that affect the functional status of the
patient and the progression of senile asthenia. Orthostatic hypotension has
been shown to be associated with poor prognosis.
• A thorough physical examination of the joints is recommended,
assessing range of motion, pain and crepitus on movement, and the presence
of deformity. It is recommended to pay special attention to the condition and
functioning of the brush.
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Comments: Joint assessment should be performed in all elderly and
senile patients and is especially important when frailty is suspected. Joint
pathology can cause chronic pain, reduce mobility and increase the risk of
falls. The functionality of the hand significantly affects the patient's ability
to self-care. In addition to examining and assessing the range of motion of
the hand, it should be clarified whether the patient can wash and dry hair,
insert the key into the keyhole and turn it, put on a sweater, cut food with a
knife.
• When conducting a comprehensive geriatric assessment, it is
recommended to assess the 10-year risk of osteoporotic fractures using the
FRAX instrument
Comments: The FRAX® tool was developed by the World Health
Organization to assess the 10-year risk of osteoporotic fractures and is based
on a person-specific model that includes clinical risk factors and bone
mineral density at the femoral neck. FRAX® models are based on
population-based studies conducted in Europe, North America, Asia and
Australia. The FRAX® tool is computerized and available at
www.sheffield.ac.uk for worldwide use in country-specific versions. Link
to Russian version: URL: https://www.sheffield.ac.uk/FRAX/tool.aspx?
lang=rs.
• When conducting a comprehensive geriatric assessment, it is
recommended to evaluate the state of vision and hearing (audiometry) in
order to identify sensory deficits.
Comments: Sensory impairments (vision and hearing loss) make it
difficult to perform daily tasks, increase the risk of cognitive impairment,
depression, falls, social isolation, worsen the prognosis for the life of older
people. If a hearing loss is detected, the patient is recommended to be
referred for audiometry.
• It is recommended to pay attention to the presence of ataxia, postural
instability, tremor, muscle rigidity, which may indicate the presence of
diseases of the nervous system.
Comments: An assessment of the state of the nervous system should
be carried out in all patients of elderly and senile age and is especially
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important if frailty is suspected, since the changes detected can be the cause
of geriatric syndromes (falls, cognitive impairment) that contribute to the
formation of the progression of senile asthenia. When conducting a
comprehensive geriatric assessment, it is recommended to evaluate
nutritional status using a brief nutritional assessment scale in order to
identify malnutrition syndrome.
5.3. DOMAIN OF THE FUNCTIONAL STATUS
• When conducting a comprehensive geriatric assessment, it is
recommended to assess the patient's functional status based on the
assessment of baseline (Bartel scale) and instrumental (Lawton scale)
functional activity, patient mobility and muscle strength using a short
battery of physical functioning tests, the “Get up and go” test and carpal
dynamometry.
Comments: The formation of dependence on outside help is a
stronger predictor of mortality and is more important for assessing the
prognosis for a patient's life and health than even the presence of specific
diseases. Dependence on outside help in daily life requires the organization
of patient care. Decreased mobility is a predictor of addiction, disability,
cognitive decline, falls, hospitalizations, and overall mortality.
Muscle weakness is one of the key components of the frailty syndrome
and is more strongly associated with it than with chronological age.
• It is recommended that the risk of falls be assessed on the Morse scale
or on the results of a short battery of physical functioning tests and the Get
Up and Walk Test.
• When conducting a comprehensive geriatric assessment, it is
recommended to assess the impact of existing diseases on the general
condition and functional activity of the patient in order to identify priority
treatment goals to preserve the patient's autonomy.
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5.4. DOMAIN OF COGNITIVE STATUS
• It is recommended that a comprehensive geriatric assessment assess
the patient's cognitive function using the Mini Mental Status Scale, the clock
drawing test, the Montreal Cognitive Assessment Scale (includes the clock
drawing test, frontal battery tests.
Comments: Assessment of cognitive function can vary greatly from
simple screening tests, which can be performed by a pre-instructed nurse, to
detailed neuropsychological testing performed by medical specialists or
neuropsychologists in memory impairment rooms.
5.5. DOMAIN OF ЕMOTIONAL STATUS
• When performing a comprehensive geriatric assessment, screening
for depression using the Geriatric Depression Scale and the Health Rating
Scale is recommended.
Comments: depression reduces the quality of life and functional
activity of elderly patients, increases the risk of death. For screening for
depression in elderly and senile patients, the use of the Geriatric Depression
Scale and the Health Rating Scale is recommended.
The Cornell Depression Inventory is recommended for the detection
of depression in patients with moderate or severe dementia. When
identifying signs of depression in elderly and senile patients, the presence
of suicidal thoughts and plans should be ascertained. The management of
patients with overt depression, especially in the presence of suicidal
thoughts, is carried out in conjunction with a psychiatrist.
5.6. DOMAIN OF SOCIAL STATUS
• When conducting a comprehensive geriatric assessment, it is
recommended to assess the social status of a patient with senile asthenia, his
living conditions, determine the need for social assistance and long-term
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