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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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9. MEDICAL REHABILITATION
Patients with frailty syndrome who have undergone an acute illness or
surgery need longer rehabilitation due to a decrease in the level of functional
activity and the appearance/increase in the level of dependence on outside
help.
Rehabilitation can be carried out in a rehabilitation center/department
(if there is a specialist in geriatric rehabilitation) or geriatric departments
after receiving specialized or high-tech medical care and should include
measures for physical activity, maintaining nutritional status, social
adaptation, selection of means and methods that adapt the environment to
the functionality of the patient and (or) the functionality of the patient to the
environment.
The goal of rehabilitation programs is to restore as much as possible
the basic functional activity of elderly and senile patients to ensure their
maximum independence from outside help. Comprehensive rehabilitation
programs are developed on the basis of a comprehensive geriatric
assessment.
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10. PREVENTION AND DISPENSARY OBSERVATION
It is recommended to conduct group and individual educational
programs for elderly and senile patients living at home in order to prevent
the development and progression of the senile asthenia syndrome.
Comment: Conducting group educational programs for patients
without frailty syndrome, as well as individual educational programs for
patients at risk of developing frailty, is an effective intervention to prevent
the development of frailty.
In the course of preventive counseling for elderly and senile persons,
age-related features of the correction of risk factors for chronic noncommunicable diseases, a high probability of polypharmacy, should be
taken into account. It is necessary to orient the patient not only to the
elimination of the symptoms of diseases (if any), but also, in general, to
healthy aging and longevity, an active lifestyle. All counselees should be
given age-appropriate advice on regular physical activity, nutrition,
cognitive training, safe living arrangements, and medication rules. If
sensory deficits (hearing loss, visual impairment), chronic pain, signs of
depression are detected, consultation with specialized medical specialists
should be recommended. When conducting medical examinations of
citizens 65 years of age and older, in accordance with the current procedure,
it is recommended to conduct a survey of patients on the “Age is not a
hindrance” scale in order to identify common geriatric syndromes.
A patient with pre-frail older adults is observed by a local general
practitioner in accordance with the current procedure for preventive
examinations and medical examinations. When observing a patient, the
local general practitioner evaluates the dynamics of the identified geriatric
syndromes, the effectiveness of measures to correct them.
Dispensary observation of a patient with senile asthenia syndrome is
carried out by a geriatrician in accordance with an individual management
plan. A comprehensive geriatric assessment is recommended at least once a
year. Comprehensive geriatric evaluation may be performed earlier if acute
functional decline develops.
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11. ORGANIZATION OF MEDICAL CARE
The attending physician of a patient with frailty syndrome is a general
practitioner (general practitioner, family doctor), who, together with a
geriatrician, implements an individual patient management plan. If
necessary, but at least once a year, a patient with frailty syndrome is referred
for a consultation with a geriatrician to monitor geriatric status.
11.1. INDICATIONS FOR HOSPITALIZATION
IN A MEDICAL ORGANIZATION
For most patients with frailty syndrome, when they experience an
exacerbation of chronic diseases, it is preferable to provide medical care at
home, if it is possible to provide the necessary amount of diagnostic and
therapeutic care. If there are difficulties associated with conducting the
necessary examinations and selecting therapy at home, it is recommended
to consider the issue of hospitalizing a patient with frailty syndrome in a
geriatric department.
If it is necessary to provide specialized or high-tech medical care, a
patient with frailty syndrome is hospitalized in a department of the
appropriate profile. The presence of the frailty syndrome can not be a reason
for refusing to provide specialized, including high-tech, medical care.
11.2. INDICATIONS FOR HOSPITALIZATION
OF PATIENTS IN THE GERIATRIC DEPARTMENT
The referral of a patient with senile asthenia for hospitalization in a
geriatric department is carried out by a local general practitioner, a general
practitioner, a family doctor, a geriatrician, and other medical specialists.
Indications for hospitalization in the geriatric department are:
Diseases of a therapeutic profile and some diseases of a neurological
profile in a patient with frailty syndrome requiring hospitalization. Patients
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with post-stroke disorders (not earlier than 6 months after a stroke),
dyscirculatory encephalopathy (cerebrovascular disease), dizziness, sleep
disorders, neuromuscular diseases, chronic pain syndromes, mild and
moderate depression, patients with Alzheimer's disease and cognitive
disorders of other origin at the stage of pre- dementia disorders and dementia
of mild and moderate severity in the absence of affective-behavioral
disorders.
The need to extend the period of inpatient treatment in order to
restore the lost ability to self-service after orthopedic, surgical interventions,
as well as after hospitalization in the departments of the therapeutic profile
of patients with frailty syndrome.
The need to conduct a survey of patients with frailty syndrome and
dependence on outside help in the absence of the possibility of examination
on an outpatient basis.
Tasks of managing patients with frailty syndrome
in the geriatric department
1. Examination, treatment and rehabilitation for the underlying disease
that caused hospitalization.
2. Maintaining and restoring the level of functional activity of a patient
with frailty syndrome
3. Prevention of the development of complications associated with
hospitalization (falls, delirium, bedsores, etc.).
One should strive for a minimum duration of hospitalization of a
patient with frailty. The duration of hospitalization is determined
individually depending on the purpose and can be up to 2 weeks if it is
necessary to restore the lost ability to self-care.
During hospitalization, it is recommended to keep nursing care cards
that reflect the dynamics of the main geriatric syndromes (risk of falls,
delirium, chronic pain (if detected), chronic wounds/bedsores, etc.). To
ensure the optimal operation of the geriatric department and the proper
provision of medical care to patients with senile asthenia, protocols should
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be developed and implemented for the prevention and management of the
main geriatric syndromes and complications (falls, delirium, bedsores,
malnutrition, etc.), including the actions of both a doctor and a paramedic.
medical personnel.
11.3. INDICATIONS FOR DISCHARGE
OF THE PATIENT FROM THE GERIATRIC DEPARTMENT
Completion of examination, treatment and rehabilitation for the
underlying disease that caused hospitalization.
Improving the level of functional activity of a patient with frailty
syndrome or justifying the impossibility of improvement.
Discharge planning should start from the moment a patient enters the
geriatric unit to make the process more coordinated. In some cases, the
discharge of the patient should be discussed with members of his family.
During hospitalization, the patient's need for social services is determined
and, depending on this, discharge planning is carried out with the mandatory
participation of a social work specialist.
The need for a consultation with a geriatrician after the patient is
discharged from the geriatric department is decided on an individual basis
and, if necessary, indicated in the individual patient management plan in the
discharge.
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12. SOME GERIATRIC SYNDROMES.
12.1. FALL SYNDROME
AS ONE OF THE MAIN ONES IN GERIATRICS
A fall is an unconscious change in body position that may be
accompanied by injury. Old age is a risk factor for falls. Thus, at the age of
65–69 years, falls occur in 20–30 % of cases, while at the age of over
85 years — in 50 % of cases. Falls are more common among women.
Significantly more falls do not occur at home, but in health and social care
settings.
The most common complication of falls, fear of subsequent falls,
occurs in at least 70 % of all cases.
Risk factors for falls associated with the health of the elderly patient:
• age over 65;
• information that the patient has previously had a fall;
• impaired vision and balance;
• instability and gait disturbance;
• pathology of the musculoskeletal system;
• taking certain medications, such as sedatives, sleeping pills,
analgesics;
• orthostatic reaction, accompanied by dizziness, when the patient
moves from a lying position to a sitting or standing position;
• increase in reaction time (inability of the patient to quickly make a
decision in case of danger of falling);
• cognitive impairment, confusion or disorientation.
Risk factors for falls associated with exposure to external
environmental factors:
• Poor quality flooring: slippery flooring, small sliding carpets, wires
on the floor, protruding thresholds;
• poor illumination;
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• unsuitable for use by the elderly bath and toilet: lack of handrails,
high sides, slippery surface;
• uncomfortable to move chairs and bed;
• uncomfortable shoes — tight or large soles sliding on the surface of
the support;
• faulty technical means of rehabilitation: wheelchair, cane, walker;
• inability to use some devices for the elderly in a stationary institution.
Taking into account risk factors for falls will reduce the frequency of
occurrence of the syndrome of falls and its consequences.
Fall prevention measures:
1. Assessment of the risk of falls using diagnostic scales (Morse scale).
2. Organization of a safe barrier-free therapeutic environment in health
care and social care institutions, including sufficient lighting in all rooms,
avoiding slippery surfaces, equipping handrails and railings.
3. A detailed study of the cause of each fall in order to develop
measures to prevent the recurrence of this geriatric syndrome.
4. If the patient has a high risk of falling, you should:
• place the patient in a ward located near the nursing station, provide
him with a means of communication with the nurse's station and quickly
respond to the call;
• bring the bed to the lowest possible position (there must be night
lighting next to the bed);
• store essential items in a place accessible to the patient;
• provide the patient with the opportunity to carry out all hygiene
procedures, visit the toilet in a timely manner (there should be handrails in
the toilet and bathroom);
• remove carpets and other obstructions in the area of the patient's
movement, especially if he uses assistive devices during the movement; you
should move while holding onto the wall, avoid moving on a wet floor;
• teach the patient how to safely use assistive devices, how to properly
select a cane and be sure that it is in good working order.
When using a wheelchair, you must be sure of its serviceability, as
well as the serviceability of its blocking device; when moving the patient to
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a wheelchair in the absence of a brake, this manipulation should be
performed together with an assistant;
• use only safe shoes: flat, with a heel, non-slip;
• educate women, especially from menopause, on prevention of
osteoporosis and its consequences;
• Nurse — when providing geriatric care, to convince the patient of
the need for adequate physical activity;
• patients — walk with someone's help at least 3 times a day for
20 minutes, move from bed to chair and back with someone's help, move to
the edge of the bed on their own only with handrails, perform feasible
physical exercises;
• eliminate drugs that increase the risk of falls.
One of the common causes of falls in elderly and senile people is
sarcopenia, which must be taken into account when organizing the
environment. Sarcopenia is an age-related decrease in muscle mass and
strength. It is known that the peak of muscle mass normally occurs at the
age of 25 years, by the age of 50, muscle mass decreases by 10 %, by
80 years — by 30 %.
The main causes of sarcopenia include nutritional factors (poor
nutrition, impaired motility of the gastrointestinal tract, the age-related
phenomenon of rapid satiety), age-related changes in hormonal levels, and
decreased motor activity. The clinical picture is characterized by a feeling
of muscle weakness, a decrease in walking speed, an imbalance — stability
and balance.
Sarcopenia increases the likelihood of falls and impairs a person's
ability to perform even normal daily activities such as climbing stairs, going
to the store, cleaning, doing laundry, thereby leading to dependence on
outside help. In the prevention of sarcopenia, physical activity plays a
central role. Performing aerobic, anaerobic (strength) physical training and
balance exercises helps to increase and maintain muscle strength and, in
fact, is a non-drug method of treating sarcopenia.
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12.2. OSTEOPOROSIS.
LOW-TRAUMATIC SKELETAL FRACTURES
Fractures represent one of the most important causes of morbidity,
mortality, and health and social care costs in the elderly. The incidence of
fractures of the pelvis, hip, vertebrae, radius, and ankle increases with age.
Fractures in the elderly often have a multifactorial nature. Osteoporosis and
falls are the most common causes of fractures in the elderly and account for
56 % of hospitalizations for this reason. Current evidence suggests that
people who exercise regularly, lead an active lifestyle, eliminate bad habits
(smoking, alcohol), and live in a safe environment have a lower risk of falls
and fractures. In addition, a number of researchers have shown the
preventive role of osteoporosis education for patients in terms of preventing
falls and fractures. This article presents an analysis of the current literature
on fracture prevention in the elderly in the context of pharmacological and
non-pharmacological agents.
Osteoporosis causes more than 9 million fractures per year, of which
1.6 million are hip fractures, 1.7 million are forearm fractures, and
1.4 million are clinical vertebral fractures. In the Russian Federation, there
are 4 million fractures per year due to osteoporosis, 34 million people have
a high risk of fractures. Estimates show that 50 % of women and 20 % of
men over age 50 are at risk of osteoporotic fracture. The incidence varies
greatly from one population to another. In the United States, the number of
fractures associated with osteoporosis exceeded 2 million in 2005. It is
estimated that vertebral fractures account for 73 % of the total. Women aged
65 years and older accounted for 74 % of all fractures. About 3.5 million
new osteoporotic fractures occur annually in the European Union, including
620,000 hip fractures, 520,000 vertebral body fractures, 560,000 forearm
fractures and 1,800,000 other fractures (pelvis, ribs, humerus, tibia, fibula,
collarbones, shoulder blades, sternum, etc.). However, given the rapid
growth of an aging population and increased life expectancy, it has been
estimated that more than 50 % of hip fractures will be concentrated in Asia.
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Assessment of risk factors for fractures in the elderly
Bone mineral density is the “gold standard” for diagnosing
osteoporosis and assessing the risk of fracture. Several additional clinical
factors have been identified that significantly increase the risk of fractures
regardless of bone density. These include age, gender, race, height, weight,
body mass index, prior fracture, smoking, excessive alcohol consumption,
family history, rheumatoid arthritis, and oral glucocorticoid use. These risk
factors, combined with bone mineral density, can be integrated to produce
estimates of the likelihood of fractures using the FRAX scale (10-year
probability of fracture). But bone mineral density takes into account only
bone density and does not allow assessment of bone microarchitecture. A
new tool for assessing osteoporosis and fracture risk called Trabecular has
now been developed. Bone Score (TBS). TBS is a parameter that assesses
the microarchitecture of bone tissue and has a prognostic value for assessing
the risk of fractures. Measurement of bone density and TBS together provide
more complete information about bone tissue. However, a number of other
factors, including causes of secondary osteoporosis, cognitive impairment,
adverse environmental conditions, and poor vision, can cause falls and
increase the risk of fractures. Vitamin D deficiency is associated with an
increased risk of falls and fractures.
The list of examinations of a patient with osteoporosis for differential
diagnosis of osteopenic syndrome, the development of a plan for therapeutic
and preventive measures should include: complete blood count, biochemical
blood test: calcium, creatinine , calculation of glomerular filtration rate,
phosphorus, magnesium, alkaline phosphatase, liver enzymes, glucose ;
determination of the hormonal profile: thyroid hormones (thyroid
stimulating hormone, free T4), parathyroid hormone, vitamin D level, if
hypogonadism is suspected — sex hormones.
It is known that many drugs that are commonly prescribed for older
people are associated with an increased risk of falls and, as a result,
fractures. These include antihypertensives, diuretics, β-blockers, sedatives
and hypnotics, antipsychotics, antidepressants, narcotic and non-steroidal
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