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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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Important in identifying sleep disorders is a conversation with an
elderly patient and the use of special questionnaires, for example, “Are you
satisfied with your sleep?”, “Do you have sleep disorders that interfere with
your activity during the day?”, “Does your partner notice unusual
phenomena during sleep, such as frequent unconscious awakenings?
Treatment of sleep disorders includes non-drug methods and the use
of medications.
Non-drug methods are the basis for the application of the therapeutic
environment methodology and include rational sleep hygiene, autogenic
training.
Simple rules for sleep hygiene:
• get up and go to bed at the same time;
• in bed — only to sleep;
• do not sleep during the day;
• comfortable conditions for sleeping (temperature in the room is not
more than 18–20 °С);
• do not lie in bed if you do not want to sleep;
• do not drink coffee in the afternoon;
• physical activity — no later than 3 hours before bedtime;
• light dinner without frills;
• alcohol is contraindicated;
• have your own ritual of falling asleep — a walk before going to bed,
a warm bath, pajamas, warm tea, etc.;
• any account, eg “sheep account”;
• recording problems and their solutions in order to get rid of heavy
thoughts.
Sleep disturbances and insomnia in geriatric patients may occur due to
a lack of the hormone melatonin, the content of which decreases with age.
To increase the intake of melatonin with food, it is recommended to
consume oats, corn, rice, raisins, tomatoes, bananas, barley. In case of
ineffectiveness, drug therapy with melatonin preparations is prescribed.
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12.5. MALNUTRITION SYNDROME
IN THE DEVELOPMENT OF SENILE ASTHENIA
Physiological aging of the body is accompanied by a serious functional
and organic restructuring of the organs of the digestive system. Improper
nutrition most adversely affects the body of an elderly person.
Currently, the diet of many older people is dominated by food
containing fats of animal origin. The amount of protein consumed with food
is reduced, while meat is consumed in much larger quantities than fish.
There are obvious excesses in the intake of carbohydrate-containing foods,
especially starchy and sweet foods, there is an excessive intake of salt. At
the same time, vegetables, fruits, herbs, vegetable oil are supplied in limited
quantities.
Older people often do not take enough fluids. In this regard, nutritional
assessment is important in the diagnosis of a geriatric patient. In the early
period of a person's life, the greatest risk to health is being overweight. In
the future, with each passing decade, the relationship between underweight
and mortality increases. In this regard, when assessing the health status of
an elderly person, it is important to identify the risk of development and the
presence of malnutrition syndrome. To do this, use the questionnaire
“Assessment of the risk of developing malnutrition syndrome” (Mini
nutritional Assessment), consisting of two parts. This questionnaire is
considered mandatory when conducting a comprehensive geriatric
assessment. The questions of the first part of the questionnaire allow
assessing the risk of development and the degree of malnutrition (deficiency
or excess) in an elderly person. At the same time, the following parameters
are evaluated in points: the state of appetite (from 0 to 2 points), the
dynamics of body weight throughout the month (from 0 to 3 points), the
presence of stress (0–1 point), the presence of psychological problems
(dementia or depression) and patient mobility (from 0 to 2 points). When
summing the scores for these indicators, a value of less than 11 indicates the
risk of developing malnutrition syndrome, 12 or more points is a normal
value. The second part of the questionnaire makes it possible to judge the
food habits of an elderly person, the regularity of the use of basic foods —
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protein products, vegetables, fruits, as well as the water regime, selfsufficiency in eating, self-assessment of health and nutrition. The
assessment of the parameters of this part of the questionnaire ranges from 0
to 2 points, depending on the question. A score of 0 points indicates that the
patient has a severe problem; the higher the score, the smaller the problem
for this criterion. The assessment of the second part of the questionnaire is
also carried out by the sum of points, after which the total sum of the points
of both parts is calculated.
Malnutrition syndrome is determined with a total score of 17 points or
less, 18–23.5 points indicate a risk of developing malnutrition syndrome,
24 points or more indicate a normal nutritional indicator. The main
problems of old age leading to the development of malnutrition syndrome
are deterioration in health, decreased physical activity, age-related changes
in the gastrointestinal tract, a decrease in the number of teeth and taste buds.
Given the high risk of developing malnutrition syndrome in geriatric
patients, it is necessary to provide people of elderly and senile age with a
balanced diet. At the same time, the nutrition of the elderly should be subject
to requirements for compliance with measures of both sanitary and
epidemiological safety, and a balanced diet in terms of calorie content and
the content of basic nutrients, and the normalization of the drinking regimen.
Basic recommendations for nutrition in the elderly and senile age:
• use foods and dishes with easy digestibility and assimilation;
• maintain a moderate level of protein intake by introducing dairy
products into the diet, including meat or fish in the daily menu;
• limit the consumption of animal fat, use vegetable oils;
• use grain products (cereals, pasta and bakery products) as sources of
carbohydrates;
• increase the amount of foods containing fiber, consume vegetables
and fruits at least 3 times a day, reduce the consumption of sugar and sweets;
• reduce salt intake to 5–6 g per day;
• observe the diet (there should not be long breaks between meals);
• ensure adequate fluid intake (at least 30 ml per 1 kg of weight per
day in the absence of congestion in the body).
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12.6. POLYPHARMACY AS A GERIATRIC SYNDROME
An urgent problem of geriatrics is the simultaneous administration of
a large number of drugs to an elderly patient. Chronic use of 5 or more drugs
is called polypharmacy.
Of course, drug treatment is the basis for managing elderly and senile
patients, however, the risk of undesirable effects of drug therapy in people
over 60 years of age is 2–3 times higher than in middle-aged people. The
largest number of drug-related deaths occur in the 80–90 age group. The
high risk of side effects of medications in patients of older age groups is
associated both with involutive changes at this age and with a large number
of prescribed medications due to polymorbidity. This leads to the
development of interaction between them, which often blurs the line
between the benefits and harms of prescribing a particular drug. All this
requires a careful individual approach and dynamic monitoring when
prescribing drug therapy to elderly and senile patients.
Currently, to optimize the drug treatment of patients of older age
groups, it is advisable to use the screening STOPP/START criteria. STOPP
therapy (Screening Tool of Older Persons ' Prescriptions is the unjustified
prescribing of potentially inappropriate medications to elderly patients. This
is the most common error in the medical management of patients of older
age groups. START therapy (Screening Tool to Alert to Right Treatment) —
recommendations for the rational choice of tactics of drug management of
patients aged 65 years and older. In addition, when prescribing drug therapy
in the elderly, it must be taken into account that an elderly person, due to a
weakened state of health, may confuse the prescribed medications and take
them incorrectly. In this regard, it is important to control the medication
intake of an elderly patient, especially if he lives alone. Since the modern
concept of geriatric service involves not a nosological, but a syndromic
approach in the treatment of elderly patients, it is important to minimize
drug therapy, combine it with non-drug methods in order to prevent
excessive use of drugs.
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12.7. SENSORY DISTURBANCES IN OLDER PATIENTS
According to WHO, 7–8 % of the population suffer from hearing loss,
of which 65–90 % are due to sensorineural hearing loss. Every third person
over the age of 65 suffers from a hearing impairment, which makes it
difficult to communicate in everyday life and social life. The high incidence
of sensorineural hearing loss (SHL) is explained by a large number of
patients with cardiovascular diseases, inflammatory and degenerative
diseases of the musculoskeletal system, adverse environmental and
production factors, viral infections, allergization and ototoxic effects of a
number of medications, the process of natural aging of the body and injuries.
heads.
The vast majority of adults (77.6 %) who seek help in the audiology
departments are diagnosed with II1-IV degree hearing loss and deafness, i.e.
socially significant hearing impairment. Hearing loss caused by damage to
the inner ear is called sensorineural hearing loss. Hearing loss with age is
called age-related hearing loss or presbycusis.
The first cause of hearing loss with age (presbyacuse frailty) is a
violation of the blood supply to the labyrinth due to ischemia,
microcirculation disorders, changes in the rheological properties of blood,
and atherosclerosis. The second reason is degenerative processes in the
nerve cells themselves due to age-related involution.
Hearing loss may develop gradually. The most difficult thing is to hear
and understand high-frequency sounds. However, the voiceless consonants
“S”, “F”, “Sh”, “T”, “Ts” play a key role in word discrimination and clear
speech understanding. That is why people often say: “I hear, but I do not
understand what is being said”.
Hearing loss in one person affects everyone around him.
Conversations and communication are significantly hampered not only for
those who have hearing loss, but also for those with whom he
communicates. At first, with reduced hearing, you have to constantly ask
again, turn on the TV or radio at full volume, which irritates others a lot.
With further hearing loss, having ceased to understand speech, these people
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try to avoid communication — and ultimately become isolated in
themselves, lose their incentive to live. Moreover, the absence of new
information leads to the involution of brain tissue.
Most people with hearing impairment do not seek help for an average
of 5–7 years. At the same time, studies show that people who take corrective
measures in time have significantly improved their quality of life. According
to the recommendations of European and American audiologists, an elderly
person needs to purchase a hearing aid as soon as there are difficulties in
communicating with his social environment. And first of all, not only and
not so much in order to hear better.
It is necessary to delay the development of degenerative processes in
the brain as much as possible, and the auditory function plays one of the
most important roles here. Hearing loss is much more noticeable than having
a hearing aid. Modern hearing aids are small and very comfortable. They
are behind the ear and intra-ear. High technology will achieve good results.
With the ability to divide the sound into frequency bands (channels),
the device now amplifies the sound signal for each frequency individually
according to the hearing loss. The compression technology (gain
compression) does not allow the device to excessively amplify loud sounds
and thereby prevent the user from being deafened.
Evaluation of the effectiveness of hearing rehabilitation in age-related
hearing loss is subjective. Audiograms and consultations of the audiologist
help a little. The true effectiveness can only be assessed by the patient
himself — if it has become more comfortable for him to perceive
information during speech contacts. Experts can only help with choosing the
optimal model and setting up the device.
Any device that artificially replenishes the lost functions of the body
requires getting used to. The adaptation process is individual: a month is
enough for someone, and six months is not enough for someone. Of course,
the role of the family in this process is important, which must patiently go
through a period of adaptation together with the patient.
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Modern approaches to the treatment and prevention
of age-related hearing loss
Strategically, drug therapy is a weak hope in the fight against agerelated hearing loss, so it can only be part of a comprehensive approach to
the problem. If we expect the benefits of drugs in terms of slowing down the
development of age-related hearing loss, then nootropic drugs are the most
promising. These drugs improve the higher functions of the brain, while not
causing addiction or nervous excitement, they are characterized by low
toxicity and rare side effects.
The mildest nootropic drug is the amino acid glycine, which is
harmless and improves the functions of the aging brain, including in relation
to the processing of sound information. Among a large number of nootropic
drugs, piracetam-like drugs of the second generation are preferred. They are
easier to tolerate by patients because they cause a minimum of side effects.
With significant impairment of speech intelligibility in conditions of
using a hearing aid, it is recommended to use centrally acting
cholinomimetics (choline alfoscerate). Otherwise, there is no data on the
need to give preference to any particular subgroup of nootropic drugs in agerelated hearing loss.
It is possible to achieve a significant clinical effect in the treatment of
age-related hearing loss only on the basis of an integrated approach. And the
first point of this complex should be a healthy lifestyle. First of all, we are
talking about physical activity and safe nutrition. It has been proven that
physical education classes help prevent the development of degenerative
changes in brain regions responsible, among other things, for the perception
of sounds and speech production. Modern imaging methods show that in
physically active older people (those who spend about 40 minutes on
physical exercise every day) there is an increase in the volume of the
cerebral cortex in the temporal lobe responsible for the analysis of sound
information, compared with persons leading a sedentary image. life. Along
with numerous private fitness clubs, healthcare institutions pay very little
attention to the use and development of physiotherapy exercises in its
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modern versions. At the same time, the availability of exercise therapy for
the elderly would be a huge breakthrough in terms of preventing
cardiovascular diseases and increasing life expectancy.
Nutrition and age-related processes in the central nervous system play
a key role in the development of age-related hearing loss. Not only the
amount of food matters, but also the nature of the food. Food rich in
cholesterol and saturated fats should be abandoned or at least severely
limited, since these substances contribute to the inhibition of the mental
function of the brain, memory impairment, and limiting the ability to
perceive non-standard speech situations. Useful products containing —
omega-3-polyunsaturated fatty acids, folic acid, aromatic spices, as well as
flavonols — substances that have a pronounced neuroprotective effect on
the aging brain.
Features of the management of “frailty” and “pre-fralty”
patients with visual impairment
Visual impairment is one of the functional deficits that determine the
“Index of senile asthenia” during a specialized gerontological examination.
In the questionnaire for determining the index of senile asthenia, there are a
number of questions, the answers to which allow the geriatrician to assign a
certain number of points and use them in calculating the index of senile
asthenia and determine further tactics for managing the patient. There are
literature data on some features of ophthalmic diseases in the syndrome of
senile asthenia. It is known that glaucoma primarily and to a greater extent
limits the patient's mobility, the ability to perform “step tests” due to
difficulty in performing the actions necessary to maintain balance due to
loss of visual fields.
In general, all diseases of the organ of vision reduce the indicators of
living space, leading to a significant decrease in the activity of the patient
with frailty. The features of the course of diseases of the organ of vision,
including those in the presence of cataracts, glaucoma and other diseases,
depend to a greater extent not on age, but on the nature of the course of the
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underlying disease and concomitant pathology, so the choice of tactics
remains the prerogative of an ophthalmologist. Medical tactics for visual
impairment in elderly patients, including those with senile asthenia, do not
differ from those for people of other age groups.
More important for older people is the creation of conditions that
improve the quality of life of people with visual impairment. In this regard,
for primary health care physicians and employees of organizations
providing social services to the population, when providing assistance to
patients with visual impairment or the blind, social aspects and rules of
etiquette when communicating come to the fore.
It is important to remove informational and physical barriers to
movement, provide information in an accessible form (larger print, flat-dot
Braille, contrast signs), the admission of a typhlo translator, the admission
of a guide dog.
Rules of etiquette when communicating with patients who have a
visual impairment or are blind:
• When offering to help, guide the person, don't squeeze their hand,
and walk as you normally would. No need to grab a blind person and drag
him along.
• Briefly describe where you are. Warn of obstacles: steps, puddles,
pits, low ceilings, pipes, etc.
• Use, if appropriate, phrases describing sound, smell, distance. Share
what you see.
• Treat guide dogs differently than regular pets. Do not command,
touch or play with the guide dog.
• If you are going to read to a blind person, let them know first. Speak
in a normal voice. Do not skip information unless you are asked to. If this is
an important letter or document, you do not need to give it to touch for
persuasiveness. At the same time, do not replace reading with retelling.
When a blind person has to sign a document, be sure to read it. Disability
does not release a blind person from the responsibility stipulated by the
document.
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• Always speak directly to the person, even if they cannot see you, and
not to their sighted companion.
• Always identify yourself and introduce others as well as the 36 others
present. If you want to shake hands, say so.
• When you invite a blind person to sit down, do not make him sit
down, but point your hand at the back of the chair or the armrest. Do not
move his hand over the surface, but give him the opportunity to freely touch
the object. If you were asked to help take some object, you should not pull
the blind man's hand to the object and take this object with his hand.
• Do not force your interlocutor to broadcast into the void: if you are
moving, warn him.
• It's okay to use the word “look”. For a blind person, this means
“seeing with hands”, touching.
• Avoid vague definitions and instructions that are usually
accompanied by gestures, expressions like “The glass is somewhere on the
table”. Try to be precise: “The glass is in the middle of the table”.
• If you notice that a blind person has lost his way, do not control his
movement from a distance, come and help him get on the right path.
• When descending or ascending stairs, lead the blind person
perpendicular to them. When moving, do not make jerky, sudden
movements. When accompanying a blind person, do not lay your hands
back — this is inconvenient.
• In the presence of a fall syndrome, such a patient must use an optical
vision correction selected by an ophthalmologist when moving; do not use
glasses with multifocal lenses while driving; if necessary, it is recommended
to use aids when walking — tactile canes.
12.8. UROLOGICAL PATHOLOGY IN THE ELDERLY PATIENTS
The main urological problem of elderly patients is the problem of
urination. Depending on the available diagnoses, it may include the situation
of urgent urinary incontinence, and vice versa, the state of difficulty
urinating, up to acute urinary retention.
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