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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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anti-inflammatory drugs. In this regard, it is necessary to weigh the “benefit-
risk” when prescribing such therapy. Thus, it has been proven that the
rejection of psychotropic drugs and the correction of cognitive status by
66 % reduce the frequency of falls.
Pharmacological prevention of fractures in the elderly
Calcium and vitamin D have long been recognized as important and
essential components for bone metabolism. A number of studies have
proven the effectiveness of vitamin D and calcium supplementation in
treating low bone density and reducing the risk of fractures in the elderly.
So, taking calcium in combination with vitamin D leads to a significant
reduction in the risk of hip fracture (16 %), fracture of the vertebral bodies
(14 %), any fracture (11 %). At the same time, the effect of vitamin D alone
is not significant in preventing hip fracture or any new fracture. However,
the risks associated with calcium supplementation are not uncommon in
elderly patients. Some evidence suggests that increased calcium intake may
increase the risk of cardiovascular disease and the deposition of calcium in
the walls of blood vessels. However, the perceived risk of cardiovascular
disease associated with calcium intake may depend on the source of calcium
intake. There is no evidence that calcium from dietary sources increases the
risk of cardiovascular disease, while there is an increased risk of myocardial
infarction when taking calcium supplements. Food remains the best source
of calcium. However, calcium supplements should be considered in cases
where dietary calcium intake is insufficient.
Bisphosphonates, teriparatide, denosumab have been proven effective
in increasing bone mineral density and reducing the risk of fractures.
Estrogen replacement therapy has a beneficial effect on reducing the risk of
fractures in patients with osteoporosis. Selective estrogen receptor
modulators (SERMs) inhibit bone resorption and prevent bone loss caused
by estrogen deficiency.
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Non-pharmacological methods for the prevention
of osteoporotic fractures in the elderly
Hip protectors
Hip protectors are one of the non-pharmacological options for
preventing falls and fractures in high-risk patients. However, not all older
people with a high risk of hip fracture agree to use protective devices, but
compliance decreases over time in those who agree. Therefore, adherence is
a major issue when evaluating the effectiveness of hip protectors in
preventing fractures. To improve compliance, it is necessary to educate
older people at high risk of hip fracture about osteoporosis and the role of
hip protectors in preventing fractures. In addition, the most common
complications when wearing them is skin irritation (occurrence up to 5 %).
Physical exercises
Physical exercise has been shown to be beneficial in reducing the risk
of falls. In addition, exercise programs prevented or reversed nearly 1% of
bone loss per year in both the lumbar spine and femoral neck in pre- and
postmenopausal women. Training appears to significantly reduce the fear of
falling, as well as the risk and number of falls.
Certain exercises, such as weight training, seem to have the greatest
impact on bone density. It has been proven that people who exercised with
weights had higher bone density compared to those who did not. What's
more, this type of exercise can improve neuromuscular activity, muscle
mass, strength, power, and functionality. Tai Chi exercises have also been
shown to improve balance and therefore reduce the risk of falls, increase
gait speed, muscle strength and quality of life in older adults. Improvement
in balance after Tai Chi exercises ranges from 5 % to 80 %. Thus, multicomponent exercise programs are important in preventing bone loss,
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reducing the incidence of falls, and therefore reducing the number of
fractures.
Lifestyle
Certain lifestyle factors, including diet, smoking, and alcohol
consumption, are known to play an important role in bone health. From a
nutritional perspective, accumulating evidence suggests that eating
vegetables and fruits is potentially effective in preventing bone and structure
loss in postmenopausal women. It has also been found that increased
consumption of vegetables, but not fruits, is associated with a lower risk of
hip fracture.
Alcohol consumption is considered a modifiable factor influencing
bone health. It is known that a lower risk of hip fracture is observed in people
who consume up to 0.5–1 drink per day (one drink = 14 grams of pure
alcohol), and in people who consume more than 2 drinks per day, the risk of
hip fracture is higher.
Smoking is recognized as a risk factor for low bone density and an
increased risk of fractures. In addition, smoking can contribute to physical
imbalance and increase the risk of falling.
Thus, a healthy lifestyle helps to reduce the risk of fractures.
12.3. COGNITIVE IMPAIRMENT
In neurogeriatrics, there is an idea of the so-called normal aging of the
brain. These are regular involutive changes in the brain that are acceptable
in old age and do not serve as the basis for any diagnosis.
This age is characterized by difficulties when trying to remember the
names of objects and dates of events, despite the preservation of memory
for the actual events. Also, older people sometimes cannot remember
recently learned information or new names. At the same time, it is
characteristic that these changes are short-lived, can occur with fatigue, after
an illness, and do not significantly affect the quality of life.
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This type of memory impairment is called benign senile forgetfulness
or age-related memory impairment. In this type, unlike dementia, the
increase in impairment does not occur over many years or it is minimal, so
this type of memory impairment does not significantly affect the
professional and daily activities of a person. To answer the question of
whether senile forgetfulness is the beginning of the development of
dementia, it is necessary to assess cognitive status using diagnostic tests:
Mini-Mental State Study (Mini-Mental State Examination — MMSE),
Brown — Peterson, Minicog, Clock Drawing, etc.
The repetition of heard words, such as sequences of numbers,
orientation in time and space, the ability to learn and remember certain
terms, mathematical ability and counting, and memory (especially longterm memory) remain at a higher level during normal aging than during the
development of dementia.
Dementia is a process characterized by the degradation of all mental
activity of a person. With dementia, memory, creative thinking are affected,
it is impossible to perform simple tasks. A person ceases to navigate in time,
space, in severe cases — in his own personality, changes in the emotionalvolitional sphere occur — emotional lability, irritability appear, motivation
suffers significantly (consciousness does not suffer). Learning and
understanding become impossible, the language becomes poorer, speech
and the ability to count are destroyed. The main causes of dementia are
cerebral atherosclerosis, Parkinson's disease, epilepsy, severe diabetes
mellitus, and vascular disorders.
The most common cause of dementia is Alzheimer's disease.
There are several stages in the course of dementia:
1) mild — memory impairment, most noticeable in the field of
assimilation of new information, often repeated forgetfulness can be
observed. At this stage, it is possible for an older person to maintain
independent living;
2) moderate — memory impairment is a serious obstacle to everyday
life. Only very well learned or very familiar material is retained. New
information is retained only occasionally or for a very short time. The
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patient is unable to remember basic information about where he lives, what
he recently did, or the names of his acquaintances. He loses orientation in
time and space, can get lost in his own apartment, where he lived for many
years.
3) severe — characterized by a complete inability to assimilate
information. The patient is not able to recognize even close relatives, there
is a weakening of criticism and thinking, a decrease in intellectual abilities.
The progression of the disease leads to a violation of the social
adaptation of a geriatric patient, makes him unable to continue his
professional activities, often limits the possibility of self-care, and leads to
dependence on outside help. If the diagnosis of dementia is made, specialist
doctors prescribe treatment for the underlying disease, according to
indications — drugs that improve cerebral circulation, and programs are
developed to ensure adequate care.
An important principle of care is to try to keep the patient's self-care
skills as long as possible.
Dementia care tips:
1. It is necessary to strive for a caring, but at the same time confident
and clear tone in dealing with patients. Be patient, understanding, even if it's
hard.
2. Give precise instructions to the elderly person in simple, short
sentences. If necessary, repeat important information, in extreme cases —
many times.
3. To name specific data regarding time, date, place and names, it is
necessary to help the patient remember them.
4. It is necessary to support the patient's ability and desire to
communicate with the outside world: use correctly selected glasses, a
hearing aid, a receiver with simple controls.
5. When communicating, it is necessary to avoid meaningless
discussions. Instead of insisting on your opinion, you need to distract the
patient or make concessions yourself. It is better not to react to reproaches
and reproaches. Praise can achieve more than criticism.
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With the right behavior of the patient, praise can be expressed in
words, touch, smile.
5. Take care of the invariability of the patient's daily routine.
6. For the elderly, good nutrition and sufficient fluid intake, as well as
regular movement, are very important.
7. The patient needs an incentive to mental activity that does not
require excessive effort from him, and he especially needs an interlocutor.
Cognitive rehabilitation classes are useful for such patients. These can
be different types of art therapy programs, jigsaw puzzles, appliqués, kinetic
sand exercises, solving riddles, crossword puzzles, memorizing poems and
songs, playing musical instruments, drawing, activities with your favorite
animals and much more. Only properly organized assistance to patients with
cognitive impairment will allow them to spend the last years of their lives
fully and with dignity.
Delusional and hallucinatory disorders
Protracted and chronic delusional disorders in old age with a
systematized delirium of ordinary content are called involutional paranoid.
Patients express unreasonable ideas of damage, oppression, wrecking,
stealing. There are pathological ideas of poisoning, persecution in relation
to the people of the immediate environment. Patients verbally and in writing
apply to law enforcement and administrative authorities with a demand to
hold the persecutors accountable in the person of neighbors or relatives. In
delusional ideas and experiences, such patients do not find any oddities in
their statements and behavior, retain their ability to work and social
connections.
Hallucinosis occurs in old age with a decrease in the function of
analyzers — auditory, visual, tactile, olfactory, gustatory.
Visual hallucinosis is characterized by scenic, colorful hallucinations
or episodic visual illusions that arouse interest, surprise, and sometimes
frighten the patient.
Auditory hallucinosis intensifies in the evening, is polyvocal in nature.
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Tactile hallucinosis manifests itself in the form of unpleasant,
sometimes painful sensations under the skin and within the skin, often
associated with delusions of obsession with skin parasites. Typically, such
patients turn to dermatologists or infectious disease specialists, demanding
treatment for imaginary skin parasites.
Depression in geriatric practice
Depression is a mental disorder characterized by the depressive triad:
decreased mood; loss of the ability to experience joy and negative judgments
with a pessimistic view of what is happening; motor retardation and
increased fatigue.
With depression, self-esteem is reduced, there is a loss of interest in
life and habitual activities. In some cases, a person suffering from it may
begin to abuse alcohol or psychotropic substances. Depression often occurs
against the background of stress, long-term severe traumatic situations
(family conflicts, loss of significant people, beloved work, change of
residence).
Depression can develop against the background of chronic somatic
diseases, as a result of the side effects of many drugs (for example,
antipsychotics, corticosteroids, benzodiazepines). Sometimes depression
occurs for no apparent reason. Women suffer from depression much more
often than men. There is a form of depression that begins in menopause.
Depression is a fairly common phenomenon with an incidence of up
to 35 % in geriatric patients, up to 45 % in patients with myocardial
infarction, and up to 47 % in post-stroke patients. In older patients, the risk
factors for depression are the presence of serious diseases, frequent seeking
medical help, chronic pain syndrome, hearing and visual impairment.
In the clinical picture of depression, the main and additional symptoms
are distinguished.
Main symptoms:
• depression of mood, obvious in comparison with the patient's
characteristic norm, prevailing most of the day almost daily and observed
for at least 2 weeks, regardless of the situation;
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• loss of former interests and the ability to enjoy the usual range of
activities;
• decrease in the level of activity, vigor, increased fatigue.
Additional symptoms:
• reduced ability to concentrate and concentrate;
• decrease in self-esteem, the appearance of a feeling of self-doubt,
consciousness of one's own worthlessness;
• inadequate sense of guilt, gloomy and pessimistic vision of the
future;
• thoughts of death, suicide, or self-harm.
For a diagnosis of a depressive disorder, 2 main symptoms and
2 additional symptoms must be observed.
Depression can manifest itself in various “masks”, or proceed under
the guise of other diseases, for example, pains of a different nature,
respiratory failure (reminiscent of asthma), gastrointestinal disorders,
autonomic manifestations. These patients often have disturbed sleep with
early awakenings, usually at 3–4 am, shortened nighttime sleep, and
unexplained weight fluctuations.
Often depression leads to serious changes in the state of internal
organs. A mandatory diagnostic criterion for depression is the duration of
symptoms for at least 2 weeks.
To diagnose this disease, diagnostic questionnaires and scales are
used, including the morale questionnaire, the Geriatric Depression Scale,
etc.
When identifying signs of anxiety and depression, a consultation with
a specialist doctor or psychotherapist is mandatory.
Modern treatment is carried out in the following areas:
• basic therapy — exclusion of social isolation and feelings of
loneliness, methods of psychotherapy;
• drug therapy — antidepressants, treatment of pain syndrome and
concomitant somatic pathology.
Medications are prescribed by a specialist doctor. A revision of the
drug therapy taken is mandatory, since when taking many drugs, there may
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be a potentially negative effect on the course of geriatric syndromes (betablockers, benzodiazepines, levodopa, opiates, steroids). The effect of drug
therapy after the appointment of antidepressants is most often manifested
after 2–3 weeks of admission. After relief of depressive symptoms,
antidepressants are continued for several weeks. An important condition is
the slow withdrawal of drugs with a duration of administration of more than
2 months. Abrupt discontinuation of an antidepressant may result in a
withdrawal syndrome.
It has been proven that psychotherapeutic techniques are quite
effective for mild and moderate depression.
Physical exercises, various methods of physiotherapy (aromatherapy,
acupuncture, hypnotherapy, light therapy) have a positive effect.
Useful walks on the street in any weather, especially in sunny.
In the aspect of positive impact, creative self-expression therapy,
various methods of art therapy, music therapy, occupational therapy are
used.
Tips for the management of patients with depression:
• patients should be under the constant supervision of specialists;
• it is necessary to teach patients self-help techniques:
methods of self-hypnosis and psychological help to oneself;
regularly listen to uplifting music;
do what you love — dancing, needlework, etc.;
• a pronounced antidepressant effect is exerted by physical exercises
and walks;
• nutrition of patients should be balanced, using enough fiber and
vitamins;
• drug therapy should be carried out up to 4-6 months, strictly under
the supervision of a physician;
• withdrawal of drugs should be gradual.
An example of a memo for patients “How to deal with depression
yourself” is presented in Appendix 2.
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12.4. SLEEP DISORDERS IN THE ELDERLY
Sleep is a physiological state of a person, alternating with the state of
wakefulness. Good sleep is of great importance for health. It is vital for a
person to restore his strength and maintain the body in good functional
condition.
The physiology of human sleep consists of two phases: slow and fast.
The first phase after falling asleep is slow, followed by fast-wave. Sleep
phases change each other cyclically, several times throughout the night,
allowing a person to restore his life potential. At the same time, the duration
of the fast phase increases from cycle to cycle. Under conditions of
physiological aging, certain changes in the physiology of sleep are observed.
Sleep disorders in the elderly can be represented as:
• disorders of physiological functions during sleep (dyssomnia):
snoring, obstructive sleep apnea syndrome, alveolar hypoventilation (on the
background of obesity, chronic obstructive pulmonary disease), restless legs
syndrome, nocturnal heart rhythm disturbances, angina pectoris during
sleep;
• proper sleep disorders: insomnia (difficulty falling asleep),
hypersomnia (unaccustomed sleepiness), parasomnia (night terrors and
nightmares).
Older people experience frequent brief awakenings, often due to
somatic problems accompanied by pain. There is a feeling of dissatisfaction
with night sleep, which is compensated by sleep during the daytime.
Polycyclic sleep syndrome develops during the daytime.
Often polycyclic sleep develops in patients with cognitive disorders.
In the development of this type of disorders, sleep hygiene is of no small
importance: when an elderly patient is in bed unnecessarily, his sleep-wake
cycle is modified.
Hypersomnia (abnormal drowsiness and daytime sleepiness) can also
be a symptom of dementia or a consequence of an overdose of sedatives.
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