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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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8. TREATMENT, INCLUDING DRUG AND NON-DRUG THERAPY,
DIET THERAPY, PAIN RELIEF. BASIC PRINCIPLES OF TREATMENT
OF PATIENTS WITH FRAILTY SYNDROME
The main principles of managing patients with frailty syndrome are:
Preserving and maintaining autonomy and improving the quality
of life
Patient-oriented approach and individual approach to the choice of
management tactics
Active identification of the need for geriatric care
Overcoming barriers to communication with the patient
Interdisciplinary interaction and work in a geriatric team
Interaction with family, carers, guardians
Continuity of patient management between different medical and
social institutions with an emphasis on long-term care and ensuring
interagency cooperation (health and social care)
Maintaining and maintaining autonomy and improving the
quality of life. The most important specific goal of treating elderly and
senile patients, regardless of the presence of the frailty syndrome, is to
maintain and, if possible, improve their functional status while maintaining
autonomy for as long as possible by reliably and safely controlling existing
diseases, preventing the progression of existing ones and the emergence of
new ones. geriatric syndromes.
Goal-oriented approach. The identification of frailty in a patient
implies a lower life expectancy. It is this group of patients that can benefit
the most from a comprehensive geriatric evaluation using a holistic geriatric
approach. Diagnosis of frailty may entail the need to adjust the goals of
patient care and treatment tactics.
The presence of many diseases and geriatric syndromes in debilitated
and dependent patients with frailty syndrome does not allow simultaneous
diagnosis and correction in full. The choice of priority treatment direction
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at the moment should be based on the results of a comprehensive geriatric
assessment, taking into account the following sequence:
1. Treatment of potentially life-threatening diseases and conditions
2. Correction of diseases and geriatric syndromes that impair
functional activity and affect the quality of life at the moment
3. Correction of diseases and geriatric syndromes that impair
functional activity and affect the quality of life in the long term, taking into
account the patient's life expectancy.
When choosing a treatment method, consider:
confirmation of its effectiveness in clinical trials for this disease,
in which population its effectiveness has been demonstrated,
at what doses and for how long the prescribed drugs were used.
Patient-oriented approach and individual approach to the choice
of management tactics. The general system of medical care is aimed
primarily at the treatment of a specific disease. This "disease-based
approach" is suboptimal and sometimes even harmful, primarily because the
clinical evidence for recommendations for the management of a particular
condition/disease is based on research data from younger, low- comorbidity
patients that take significantly fewer drugs than elderly and senile patients
with a large number of chronic diseases or patients with frailty. The patientoriented approach does not take into account the amount of chronic diseases
in an elderly or senile patient, but his functional and cognitive safety,
dependence on outside help, quality of life. This approach, when deciding
on the appointment of treatment, takes into account the preferences,
priorities and life orientations of the patient.
When drawing up an individual plan for managing a patient with
frailty syndrome, it is important to assess how the provisions of existing
clinical recommendations for certain nosologies are applicable to a given
patient, taking into account the identified geriatric syndromes, the results of
functional status assessment, cognitive and emotional impairments, as well
as social problems and life expectancy. The management of patients with
frailty syndrome requires particularly careful weighing of the risks and
benefits of all medical and diagnostic procedures, as aggressive treatment
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of chronic diseases, frequent hospitalizations, overtreatment in non-lifethreatening situations, can lead to the risks exceeding the benefits of such
interventions and reduce quality of life of the patient.
Active identification of the need for geriatric care. Active
identification of the need for geriatric care among patients seeking medical
care is necessary, since the elderly themselves may not present complaints
due to the presence of frailty or other geriatric syndromes (falls, urinary
incontinence, depression, cognitive impairment).
Overcoming barriers to communication with the patient. An
important professional skill of a geriatrician and other members of the
geriatric team is the ability to overcome barriers when communicating with
elderly and senile patients. Hearing loss, slowing down of speech,
movements, deterioration of cognitive functions and the presence of many
diseases — all this requires patience and the ability to use non-verbal
techniques and special devices when communicating.
Interdisciplinary interaction and work in a geriatric team. The
presence of many other geriatric syndromes in patients with frailty
syndrome, as well as polymorbidity, requires the participation of specialists
of various profiles in their management. It is important to ensure consistency
in the work of all team members — doctors, nurses, social workers,
caregivers. Each of the members of the interdisciplinary team contributes to
the assessment of the patient's condition and needs, which allows making
the most optimal decision on the tactics of its management. Periodic team
discussion of patient management tactics can reduce the prevalence of
polypharmacy, improve patient adherence and satisfaction with the quality
of medical and social care.
Interaction with family, carers, carers. Frailty patients are more or
less dependent on outside help. Successful management of these patients is
not possible without close collaboration between geriatric team members
and family members and caregivers. Identified health problems, goals of
therapy and ways to achieve them, activities of daily activity in which the
patient needs help, options and methods of non-drug therapy, and a drug
treatment plan should be discussed. When a patient is hospitalized with
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frailty syndrome, it is important to ensure that visits by family members are
possible without time limits, which reduces the likelihood of delirium.
Issues related to discharge should also be discussed with family members at
the stage of the patient's admission to the department, if necessary, with the
involvement of a social work specialist.
Continuity of patient management between different medical and
social institutions with an emphasis on long-term care and ensuring
interagency cooperation (health and social care). The high rate of
rehospitalizations, as well as the high prevalence of loneliness and lonely
living against the background of dependence on outside help, require
continuity in patient management and ensuring close interaction between
medical and social services at all stages of care for patients with frailty
syndrome. It is especially important to coordinate the management plan of
the patient when they are discharged home from the hospital or when they
are transferred from one institution to another.
8.1. NON-PHARMACOLOGICAL METHODS
OF TREATMENT OF FRAILTY SYNDROME
Regular physical activity in volume and intensity, depending on
individual functional capabilities, is recommended for all patients with
senile asthenia syndrome or the risk of its development in order to improve/
maintain physical, functional and cognitive status.
The following types of physical activity are recommended for patients
with senile asthenia or the risk of its development:
resistance exercises;
strength exercises;
aerobic training (walking with a change in pace and direction,
walking on a treadmill, climbing stairs);
balance exercises.
Programs should be regular and long-term, tailored to the individual
patient, and intense enough to improve muscle strength and balance. The
intensity and/or duration of training should be increased gradually. To
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improve functional performance, resistance and strength training should be
combined with exercises that simulate daily activities, such as stand-sit,
tandem walking, climbing stairs, shifting body weight from one leg to
another, walking in a straight line lines, balancing on one leg. Training
programs should be compiled by qualified specialists (physicians). The
training program should be regularly reviewed and adjusted depending on
the progress of the patient and changes in his condition.
It is recommended to conduct nutritional counseling for all patients
with frailty syndrome in order to prevent malnutrition syndromes and
sarcopenia, with an emphasis on adequate protein intake with food and
water and drinking regimen. The diet must necessarily include meat and fish
dishes, dairy products (cottage cheese, cheese, yogurt are preferred). The
total water regime should be at least 1.5 liters (including dishes and dietary
products), while the pure liquid should account for at least 800 ml. In view
of the decrease in carbohydrate tolerance with age, it is recommended to
take foods containing “complex” carbohydrates and rich in dietary fiber.
The diet should contain a sufficient amount of fresh vegetables and fruits.
Salt intake should not exceed 5.0 g per day, but if the elderly person has not
previously adhered to this level of salt intake, it should not be severely
limited.
It is recommended to increase protein intake up to 1.0–1.5 g/kg of
body weight per day for patients with frailty syndrome in order to treat and
prevent sarcopenia. The consumption of this amount of protein is safe
provided that the GFR is not lower than 30 ml/min/1.73 m2. The optimal
intake is 25-30 grams of high-quality, easily digestible protein per meal.
Recommended to use nutritional support in patients with frailty
syndrome and malnutrition in order to maintain body weight, correct
sarcopenia and maintain functional status. With the development of
malnutrition syndrome, the energy value of the diet of patients should be
increased to 3000 kcal per day.
Absolute indications for prescribing active nutritional support in the
form of liquid oral nutritional supplements include: the presence of
relatively rapidly progressive and significant weight loss of more than 2 %
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per week, 5 % per month, 10 % per quarter, or 20 % per 6 months; the
patient's initial signs of hypotrophy: body mass index less than 19 kg/m2,
shoulder volume < 90 % of the standard (less than 26 cm in men and 25 cm
in women), hypoproteinemia (< 60 g/l), hypoalbuminemia (< 30 g/l),
absolute lymphopenia (< 1.2 × 109/l).
It is not recommended to reduce weight in elderly patients with
overweight and obesity of the I degree (body mass index 25–35.9 kg/m2) in
view of the increased risk of developing geriatric syndromes and adverse
outcomes. In contrast to middle-aged people, in older people, an increase in
body mass index to 25–29.9 kg/m2 compared to its normal values is
associated with a decrease, not an increase, in the risk of death.
It is recommended that all elderly and senile patients, as well as
patients with frailty, with repeated falls or with a high risk of falls, be
counseled on the organization of a safe living environment in order to reduce
the risk of falls.
It is recommended that all patients with elderly and senile age, with
frailty syndrome, with repeated falls or with a high risk of falls, be advised
on the selection of shoes in order to reduce this risk. Incorrectly selected is
considered: shoes with a heel, the height of which exceeds 4.5 cm; shoes
without a back; shoes with a heel that can be compressed more than 45°;
completely worn out shoes or shoes with completely flat soles.
Cognitive training is recommended for all elderly and senile patients
with senile asthenia syndrome in order to prevent cognitive decline and slow
the progression of senile asthenia.
Complex interventions that include short-term memory and attention
training, physical training, and nutritional interventions are most effective.
Recommended to refer elderly and senile patients for a consultation
with social care specialists in order to identify potentially correctable
problems of a social nature, as well as to recommend contacting social
service centers to increase social activity.
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8.2. MEDICAL THERAPY
It is recommended that when choosing the tactics of drug therapy in
elderly and senile patients, it is recommended to take into account not only
the presence of chronic and/or acute diseases, but also geriatric syndromes
(especially senile asthenia), the results of assessing the functional status, the
presence of cognitive and emotional disorders, as well as social problems.
in patients with senile asthenia syndrome. Drug therapy for patients with
FRAILTY syndrome should be prescribed taking into account the results of
a comprehensive geriatric assessment, the patient's life priorities and be
focused on optimal quality of life and maintaining the patient's
independence from outside help.
recommended to monitor the appearance/worsening of geriatric
syndromes when prescribing drug therapy in elderly and senile patients with
frailty syndrome or the risk of its development in order to assess the safety
of treatment. With the appearance/aggravation of geriatric syndromes, the
use of alternative drugs and treatment regimens, including nonpharmacological methods, is recommended, focusing on the
Methodological Guidelines “Pharmacotherapy of elderly and senile
patients”.
Comments: In elderly patients, the use of certain drugs may lead to
the development or aggravation of geriatric syndromes or the development
of potentially dangerous conditions, the appearance of which may require
the withdrawal/change of drug therapy and the transition to other treatment
regimens, including non-drug ones.
It is recommended to regularly review drug therapy using
STOPP/START criteria, focusing on the Methodological Guidelines
“Pharmacotherapy of elderly and senile patients” in all elderly and senile
patients in order to improve the safety and efficacy of pharmacotherapy,
reduce polypharmacy, reduce the risk of developing or slowing down the
progression of senile syndrome. asthenia.
Comment: Polypharmacy is associated with a significant increase in
the risk of adverse events, an increase in the duration of hospitalization and
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an increase in the risk of adverse outcomes. A thorough review of
indications, contraindications, potential drug interactions, and dosing of
medicinal products should be carried out regularly. In order to screen for
potentially irrational drug prescribing, it is advisable to use the
STOPP/START criteria to identify unreasonable prescriptions and
unjustifiably unprescribed drugs.
It is recommended to take vitamin D preparations or its analogues
to patients with frailty syndrome and vitamin D deficiency/insufficiency in
order to correct its level, prevent falls and fractures, and improve life
prognosis.
Vitamin D deficiency corresponds to a concentration of
25(OH)vitamin D < 20 ng/ml (50 nmol/l), deficiency — from 20 to 30 ng/ml
(from 50 to 75 nmol/l), adequate level — more than 30 ng/ml (75 nmol/l).
The recommended target level of 25(OH) vitamin D for deficiency
correction is 30–60 ng /mL (75–150 nmol/L). To prevent vitamin D
deficiency, it is recommended to prescribe at least 800–1000 IU of vitamin
D or its analogues per day, to maintain the level of 25 (OH) O more than
30 ng/ml, consumption of at least 1500–2000 IU of vitamin D per day may
be required. The drug of choice for treating vitamin D deficiency is
cholecalciferol. Treatment of vitamin D deficiency in adults is
recommended to start with a total loading dose of 400,000 IU of
cholecalciferol using one of the proposed regimens with a further transition
to maintenance doses:
Correction of vitamin D deficiency (when the level of 25(OH)D in the
blood is less than 20 ng/ml):
50,000 IU weekly for 8 weeks by mouth or
200,000 IU monthly for 2 months by mouth or
150,000 IU monthly for 3 months orally or
7,000 IU per day — 8 weeks orally
Correction of vitamin D deficiency (at the level of 25(OH)D in the
blood 20–29 ng/ml)
50,000 IU weekly for 4 weeks by mouth or
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200,000 IU once orally or
150,000 IU once orally or
7,000 IU per day — 4 weeks orally
Maintain blood vitamin D 25(OH)D levels > 30 ng/mL 1000–2000 IU
daily by mouth
A combination of vitamin D or its analogues and a calcium
preparation is recommended for all patients with frailty syndrome and
osteoporosis.
osteoporotic therapy is recommended for patients with frailty
syndrome and osteoporosis in order to prevent fractures.
8.3. FEATURES OF THE TREATMENT
OF CONCOMITANT DISEASES AND CONDITIONS
IN PATIENTS WITH SENILE ASTHENIA SYNDROME
It is recommended to take into account the results of a
comprehensive geriatric assessment, life expectancy and personalized goals
of a patient with frailty syndrome when treating chronic diseases (including
the most common age-related diseases — arterial hypertension, coronary
heart disease, heart failure, atrial fibrillation, diabetes mellitus, oncological
diseases, diseases of the musculoskeletal system, etc.) taking into account
current clinical recommendations.
Comment: Individually tailored management of diseases and clinical
conditions is effective in improving physical and functional performance in
patients with frailty syndrome, improves the quality and prognosis of life,
allows for a more rational use of health care resources, reducing the cost
of treating elderly people living at home and not increasing the cost of
inpatient and outpatient management.
A practical approach to the management of such patients includes:
identification of a priority disease, the treatment of which at a given
time will improve the quality of life of the patient and the prognosis of his
health;
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identifying treatment that may be discontinued due to limited benefit
or high risk of adverse events;
the use of non-pharmacological therapies as a possible alternative to
certain drugs.
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