Добавил:
ivanov666
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
.pdf
31
care. At a Community Care and Long Term Care Need Level of 2 or higher,
the patient's information should be forwarded to social services.
Comments: An individual case management plan, developed on the
basis of a comprehensive geriatric assessment, aims to plan long-term care
and care for a patient with frailty in close cooperation with medical and
social services. The social status of the patient is partially assessed by all
members of the geriatric team, but the most complete assessment is carried
out by a social work specialist. When conducting a comprehensive geriatric
assessment, they clarify data on the level of education, profession, family
status of the patient, with whom the patient lives, to whom he turns for help
if necessary, assess the safety of life, identify signs of neglect, self- neglect
and abuse of an elderly person.
5.7. THE ROLE OF NURSING PERSONNEL
IN COMPREHENSIVE GERIATRIC ASSESSMENT
An important role in the management of patients in the geriatric
department belongs to the nursing staff. Nursing staff are actively involved
in performing a number of tests in a comprehensive geriatric assessment
(Table 5).
Table 5
Components of a comprehensive geriatric assessment
and the participation of a nurse in its implementation
Domain
Domain
Components
Assessment tools
Comments
physical health
chronic diseases
Data of anamnesis and medical
records
Assessed by
the doctor
Drug therapy
STOPP/START criteria and other
scales according to the guidelines
“Pharmacotherapy in elderly and
senile patients”
Assessed by
the doctor
32
Domain
Domain
Components
Assessment tools
Comments
Anthropometry
Measurement of height and weight
Carried out by
a nurse
Orthostatic
hypotension
Orthostatic test
Carried out by
a nurse
Vision and
hearing
Rosenbaum table Audiometry
Carried out by
a nurse
Power status
Body mass index
Nurse counts
Brief Nutritional Rating Scale
Completed by
a nurse
Availability
of required
vaccinations
Medical records data
Can be
assessed by a
doctor or nurse
functional activity
Basic functional
activity
Barthel index
Completed by
a nurse
Instrumental
functional
activity
Lawton scale
Completed by
a nurse
Mobility
Get Up and Walk Test Short Battery
of Physical Functioning Tests
Carried out by
a nurse
muscle strength
Carpal dynamometry
Carried out by
a nurse
Psycho
-emotional
sphere
cognitive
functions
Mini Clock Drawing Test — COG
Mini-Mental Status Scale or
Montreal Cognitive Assessment
Battery of Frontal Dysfunction Tests
Conducted by a
doctor or nurse
trained to
perform these
tests. The set of
tests may vary
depending on
the specific
situation.
Emotional
condition
Geriatric Depression Scale
Health Rating Scale Cornell
Depression Scale
Carried out by
a trained nurse
33
Domain
Domain
Components
Assessment tools
Comments
social status
marital status, presence of a spouse or partner
circle of communication and social contacts
living conditions
financial opportunities
work activity, profession
education
the opportunity to engage in familiar activities —
cleaning the house, cooking, shopping for groceries, etc.
care needs and preferences of patients related to care
loss of loved ones, stresses that have happened in life,
psychological problems, the ability to cope with them
and with psychological problems
alcohol abuse, drug addiction in relatives, people
around the patient
religiosity
cruel treatment
household safety
May be
performed by a
nurse.
A detailed
assessment is
carried out by a
social work
specialist
involved in a
comprehensive
geriatric
assessment
Based on a comprehensive geriatric assessment, the geriatrician
develops an individual management plan for a patient with senile asthenia,
which recommends the inclusion of recommendations on the following
items:
physical activity,
food,
cognitive training,
additional laboratory and instrumental examinations, consultations
of specialists in accordance with the identified geriatric syndromes and
conditions that affect the course of senile asthenia,
correction of identified geriatric syndromes and goal-oriented
treatment of the patient's chronic diseases. Neurologists, cardiologists,
endocrinologists, clinical pharmacologists, nutritionists, rheumatologists,
urologists, obstetricians can be involved as consultants, if necessary, for the
purpose of dynamic monitoring of the patient in the multidisciplinary
34
team — gynecologists, otorhinolaryngologists, audiologists,
ophthalmologists, traumatologists-orthopedists, physiotherapists and
medical rehabilitation specialists, etc.,
optimization of drug therapy taking into account STOPP/START
criteria with a consultation with a clinical pharmacologist, if necessary, and
also, if necessary, assistance in taking medications (assistance in purchasing
medications, use of pillboxes, direct control of medications, etc.),
the use of means and methods that adapt the environment to the
patient's functional capabilities and/or the patient's functional capabilities to
the environment (mobility, cane, walker, joint prosthetics and orthotics,
glasses, hearing aid, etc.),
organization of a safe life,
direction for rehabilitation activities,
the level of need for social assistance and long-term care that can be
provided by social services — and, depending on the situation, the need for
medical patronage and palliative care can be assessed.
Whenever possible, a discussion of the individual management plan
should be held with the patient and/or relatives/carers to ensure that the plan
is in line with the patient's goals and priorities and to ensure that the
family/carers are involved in its implementation. It is recommended to
communicate an individualized patient management plan with frailty,
directly observing the patient (district physician, general practitioner, family
doctor), in order to ensure joint successive long-term follow-up. An
individual plan for managing a patient with senile asthenia is carried out by
a doctor directly observing the patient, together with a geriatrician. An
individual patient management plan may be revised based on the results of
monitoring the patient's functional status.
Scheduled repeated comprehensive geriatric evaluation of a patient
with senile asthenia is recommended at least once every 12 months.
Unscheduled repeated comprehensive geriatric assessment is
recommended in situations that significantly affect the functional state of
the patient (for example, fractures, acute cerebrovascular accident,
35
oncological disease, acute disease with a long period of convalescence
(pneumonia), surgical treatment).
In patients with acute functional disorders, in order to establish their
cause and determine management tactics, it is necessary to conduct a
thorough analysis of the clinical and social situation, exclude
acute/exacerbation of chronic diseases, fractures of the femur,
thoracic/lumbar spine, and depression.
It must be remembered that:
recommended to perform a comprehensive geriatric assessment
before carrying out diagnostic and other measures according to clinical
guidelines for a suspected/previously diagnosed disease (if this
disease/condition is not acute and/or life-threatening) in patients with highly
probable senile asthenia in order to determine management tactics based on
the whole patient- oriented approach. If it is not possible to conduct a
comprehensive geriatric assessment by a multidisciplinary geriatric team,
the management of a patient with senile asthenia syndrome by a general
practitioner, family doctor and specialist doctors should be based on a
holistic approach to assessing his needs and in cooperation with a
geriatrician.
recommended to perform a comprehensive geriatric assessment of
elderly patients before performing elective surgical interventions, deciding
on the tactics of treating oncological and other diseases in order to determine
the benefit/risk ratio of the intervention, predicting possible changes in the
functional status of the patient and his needs for assistance and care, as well
as planning volume of rehabilitation measures.
It is recommended to carefully collect and analyze the drug history
in all patients 60 years of age and older in order to identify polypharmacy
and irrational prescribing of drugs using STOPP/START — the criteria
presented in the Guidelines “Pharmacotherapy in the elderly and senile age”.
Careful analysis of the drug history and detection of polypharmacy is
necessary for all patients of elderly and senile age and is especially
important in patients with a high probability of frailty. In elderly and senile
patients, the risk of adverse drug reactions is significantly increased. The
36
presence of polymorbidity, observation by different specialists leads to
polypharmacy. Polypharmacy 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 actually taken
drugs (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. It is imperative to assess the patient's ability
to independently take medications, paying attention to the state of cognitive
functions, the preservation of hand functions, visual acuity and motivation.
37
6. LABORATORY RESEARCH
In view of the non-specific manifestations of frailty , the possibility of
the occurrence/aggravation of functional disorders in an elderly person
against the background of an acute or exacerbation of a chronic disease, the
possibility of an atypical picture of diseases, in the course of a
comprehensive geriatric assessment, a complex of laboratory and
instrumental studies should be performed to diagnose/differential diagnosis
of conditions, potentially affecting the course of frailty and/or having similar
clinical manifestations, including anemia, heart failure, diabetes mellitus,
chronic kidney disease, liver and thyroid dysfunction, electrolyte
disturbances, etc. Performing part of the examination before referring the
patient to a consultation with to a geriatrician will reduce the number of
visits of a patient with frailty to a medical institution, and will contribute to
a faster and better implementation of a comprehensive geriatric assessment
and the development of an individual management plan.
Necessary:
Determination of serum creatinine with the calculation of the
glomerular filtration rate in all elderly and senile patients, especially those
with a high probability of senile asthenia, to assess the functional state of
the kidneys and select a dosing regimen for drugs.
General blood analysis. To assess the presence of anemia in patients
referred for a comprehensive geriatric assessment, in view of its high
prevalence in patients with senile asthenia, close association with other
geriatric syndromes and high value for predicting the course of senile
asthenia and the patient's life.
The level of thyroid-stimulating hormone in the blood due to the
high prevalence of thyroid dysfunction in patients with senile asthenia, its
close association with other geriatric syndromes (cognitive decline,
decreased mobility) and the prognosis of the course of senile asthenia.
The level of total protein and blood albumin in order to identify
malnutrition syndrome and predict the risk of progression of senile asthenia.
38
The level of vitamin B12 in the blood in patients with cognitive
impairment identified during a comprehensive geriatric assessment to assess
potentially modifiable causes and determine treatment tactics.
The level of 25(OH) vitamin D in the blood in patients diagnosed
with senile asthenia in order to select the optimal dosing regimen for vitamin
D and its analogues.
39
7. INSTRUMENTAL DIAGNOSTIC STUDIES
In patients with a high probability of frailty, it is recommended to
assess the state of previously diagnosed chronic diseases, as well as
differential diagnosis between frailty and diseases with similar clinical
manifestations using the necessary instrumental treatment. At the same
time, the scope of the examination is determined taking into account the
results of a comprehensive geriatric assessment, the doctor's clinical
judgment about the patient's life expectancy and personalized treatment
goals. When deciding whether to conduct a diagnostic search or examination
for a chronic disease, one should take into account the contribution of this
condition/disease to the progression of the frailty syndrome, take into
account the tolerability and potential risks associated with the performance
of the examination, and the impact of the results of the examination on
further management of the patient in the context preservation of functional
activity and quality of life. The volume of diagnostic measures in patients
with senile asthenia may be incomplete in relation to clinical
recommendations for this condition.
Lateral X-ray examination of the thoracic and lumbar spine (Th4-
L5) is recommended in patients with senile asthenia with a high risk of
fractures according to FRAX, a high risk of falls, with back pain, a decrease
in height > 4 cm compared with younger age or > 2 cm with regular medical
examination, taking glucocorticoids, with type 2 diabetes mellitus, with
diagnosed fractures of another localization in order to actively detect
compression fractures of the vertebral bodies.
It is recommended to perform studies aimed at identifying the causes
of falls associated with transient hypoperfusion of the brain
(hemodynamically significant stenosis of the carotid arteries, aortic valve
stenosis, hemodynamically significant disturbances in heart rhythm and
conduction), osteoporosis and pathology of the musculoskeletal system,
pathology of the central and peripheral nervous system, if necessary,
resorting to consultations of specialized specialists, in patients with falls for
40
the purpose of differential diagnosis and development of an individual
management plan.
It is recommended to perform studies aimed at identifying chronic
cerebrovascular insufficiency and/or previous cerebrovascular accidents,
atrophic processes in the brain (including determining the volume of the
hippocampus ), brain tumors/metastases, normotensive hydrocephalus, as
well as consulting a neurologist for advanced neuropsychological testing in
patients with cognitive impairments identified during a comprehensive
geriatric assessment, in order to clarify the nature and severity of cognitive
disorders and the selection of specific therapy.
Consultation with a psychologist/psychotherapist/psychiatrist is
recommended for patients diagnosed with depression during a
comprehensive geriatric assessment in order to clarify the diagnosis and
include appropriate treatment measures in an individual management plan.
recommended to consult a urologist (for women — a urologist and
an obstetrician-gynecologist) in patients with identified urinary
incontinence syndrome to include appropriate diagnostic and treatment
measures in an individual management plan.
It is recommended to perform the following studies in patients with
senile asthenia and malnutrition syndrome in order to identify the causes
and determine management tactics:
a thorough assessment of the condition of the oral cavity, if
necessary, with a referral for consultation and treatment to a dentist (dental
treatment, selection of prostheses, etc.);
conducting an examination to exclude diseases of the esophagus,
stomach, duodenum, if necessary, using less invasive research methods (for
example, fluoroscopy of the esophagus and stomach with a barium mixture);
if necessary — consultation of a dietitian, organization of social
assistance (purchase of products, cooking, feeding).
It is recommended to conduct a thorough analysis of the clinical
situation and its causes (pain, constipation, acute urinary retention, bleeding,
acute infectious disease, acute kidney injury, acute cerebrovascular
accident, etc.) in patients with the development of geriatric delirium.
Соседние файлы в предмете [НЕСОРТИРОВАННОЕ]