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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
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Separate recommendations can be given to patients who have a
cystostomy installed after surgery and their relatives. Such patients require
self-lavage, monthly revision and replacement of the cystostomy catheter.
Urinary incontinence is one of the most common disorders and occurs
twice as often in older women as compared to men. Urinary incontinence is
the cause of a significant deterioration in the quality of life and often
becomes a prerequisite for the avoidance of society, the development of an
inferiority complex in a person and the manifestation of guilt, and also
provokes depressive states.
There is no cure for urinary incontinence in older men and women.
Therapy should be only complex and aimed at normalizing the functioning
of not only the organs of the urinary system, but also other organs, the
pathologies of which could serve as a “trigger” for urinary incontinence.
Usually, doctors prescribe the following groups of drugs for urinary
incontinence in older men and women:
combined anticholinergics;
smooth muscle relaxants;
calcium channel blockers.
Folk remedies for urinary incontinence in the elderly are also used:
psyllium powder; freshly squeezed carrot juice; dry herb medicinal sage.
Folk remedies for therapy can be used only after agreement with the
attending physician. Otherwise, uncontrolled intake can cause the
progression of various complications.
Medicines for urinary incontinence in the elderly are used only in
combination with regular physical activity and exercises that will help
strengthen the muscles of the pelvic floor and abdominal wall, as well as in
combination with diet therapy.
It is important to normalize the diet and regulate the amount of fluid
consumed.
Pelvic floor exercises for urge and/or stress urinary incontinence
Kegel exercises — 3 sets of 8–12 pelvic floor muscle contractions for
8–10 seconds each 3 times a day daily for at least 15–20 weeks.
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Bladder training aims to restore voluntary control over bladder
function. With the help of a urination diary, the minimum time interval
between urination is determined. Regular urination is recommended at
regular intervals, starting from the minimum. After 2 days without episodes
of urinary incontinence — an increase in the interval between urination
(distraction by relaxation, deep breathing or rapid contraction of the pelvic
floor muscles). The interval gradually increases until it reaches 3–4 hours.
Duration of training — up to 6 weeks.
In addition to training the bladder through exercise, prevention of
constipation is necessary. It is recommended to increase the amount of fluid
consumed up to 1.5–2 liters per day; an increase in the diet of foods rich in
vegetable fiber (up to 100 grams of raw vegetable salad per day); the use of
products with lacto- and bifidoflora; exclude products that delay bowel
movements (strong black tea, blueberries, semolina and rice porridge). It is
important to develop the habit of morning bowel movements (behavioral
therapy).
Compliance with the rules of personal hygiene
During treatment, it is important to maintain the hygiene of the patient,
especially if he cannot do it himself. Pads for the elderly with urinary
incontinence will help keep the skin of the perineum dry and prevent the
formation of ulcers and wounds on it. It is important to carry out timely
replacement of these products (on average, replacement is done every two
hours). They are selected for each patient strictly individually. Also often
used diaper pants for adults with urinary incontinence. A person should be
washed four to six times a day, after which it is recommended to treat the
skin of the perineum with glycerin. It is also necessary to convince the
elderly person to empty the bladder every three hours.
Acute and chronic urinary retention
Difficulty in the outflow of urine in older men is a very common
phenomenon. It leads to pain and discomfort, worsens the general well-
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being of a person. It is rare in women. The disease is fraught with
complications, if left untreated, it passes from an acute form to a chronic
one: obstruction of the urethra becomes a permanent phenomenon.
If acute urinary retention occurs, as an emergency, urine should be
urgently removed with a soft or metal catheter, call an ambulance, in case
of sharp pain, put a warm heating pad on the groin area or take a bath.
An acute condition associated with a delay in emptying the bladder is
possible in the case of a person being intoxicated with alcohol, stress,
hysteria, after surgery on the rectum, perineum, as a result of a long stay of
a man in bed, as well as drug intoxication. But most often urinary retention
is observed in prostate adenoma in men aged 60–65 years. Also with a
sedentary lifestyle, frequent diarrhea or constipation, when the gland
experiences a strong rush of blood. Pelvic fractures and a history of trauma
to the urethra also provoke urinary retention.
If urinary retention becomes a constant phenomenon, the muscular
walls of the bladder and sphincter gradually stretch, possibly involuntary
discharge of urine in droplets, in small portions. In case of acute urinary
retention, it is necessary to catheterize the bladder and treat the disease based
on the diagnosis, identifying the initial causes that led to such a disease.
Catheterization is a one-time manipulation, then you need to eliminate the
underlying disease through drug treatment.
Additionally, treatment can be carried out with folk remedies, which
are only an addition to drug therapy and can relieve unpleasant painful
symptoms. It is useful to take tea rose fruits infused with alcohol, decoctions
of juniper bark, rosehip infusion for alcohol, walnut shells ground into
powder or infused with alcohol.
Urinary retention in men requires a diagnosis of the entire
genitourinary system.
Caring for patients with a cystostomy catheter
Cystostomy is installed in patients in urological practice for various
diseases and conditions. The most common reason is the impossibility of
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independent urination with: prostate adenoma, urethral injury, bladder
injuries, in the recovery period after genital surgery, spinal cord injury in a
patient (lying patients).
The cystostomy consists of a cystostomy drain (most often a Foley
catheter) and a urinal (a bag into which urine enters through the drainage
catheter).
There are twelve rules for caring for a cystostomy:
1. Avoid kinking and bending of the catheter and urinal tube.
2. It is highly desirable (on the recommendation of a doctor) to pinch
the catheter for several hours during the day (from five to eight times a day)
and disconnect the urinal from the catheter to simulate the act of urination,
train the muscles of the bladder and prevent bladder shrinkage.
3. It is necessary to monitor the cleanliness of the skin around the
cystostomy drainage (catheter). A good remedy is baby or laundry soap,
sometimes antiseptics in the form of an ointment.
4. Exclude the patient from taking a bath, visiting saunas and baths
5. In the absence of inflammation around the Foley catheter, dressings
and patches can be omitted.
6. It is necessary to ensure that the urinal is (was fixed) below the
bladder. This rule applies both day and night. The urinal should not be
placed on the floor, the bag should be fixed to the bed below the bladder.
7. Do not flush the catheter with any solutions.
8. If the catheter is obstructed or does not work well, the catheter
should be replaced with a new one.
9. It is necessary to regularly empty the urinal, not allowing the bag to
be filled to the maximum value.
10. The catheter should be changed regularly (at least once a month).
11. Urine from the urinal must be drained through a special valve.
12. Regular replacement of the urinal, every 24-48 hours, but at least
once a week.
13. Cystostomy drain replacement should only occur after training
with a urologist.
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Seven reasons when you need to urgently consult a urologist:
1. If the catheter falls out and it is impossible to replace it yourself.
2. If there is a large amount of blood in the urine.
3. An increase in body temperature over 38 degrees Celsius.
4. Infection of the skin around the catheter.
5. Severe pain in the lower back or side, especially in combination with
chills, fever, nausea and/or vomiting.
6. Decreased volume or complete cessation of urine output through the
catheter.
7. Constant leakage of urine past the cystostomy drain (catheter).
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13. MATHEMATICAL MODELING OF THE RISK
OF DEVELOPING SENILE ASTHENIA AND SARCOPENIA
In order to study the possibility of predicting the risk of developing
frailty and sarcopenia in elderly and old patients with polymorbid pathology,
we developed mathematical models.
First, the selection of statistically significant predictors for univariate
regression analysis was carried out, then the final model was built with
stepwise inclusion of predictors with the highest prognostic significance.
Mathematical models were built with stepwise inclusion of predictors. The
method of multiple binomial logistic regression was used. As a result of the
model, the separation point was taken as 0.5. The value of 0.0 and
1.0 corresponded to 0 % and 100 % probability of the event.
ROC-analysis was used to calculate the informativity indicators of the
developed models. Sensitivity is the ability of a predictive model to predict
a positive outcome, the proportion of true positives among the total number
of confirmed cases. Specificity is the ability of a predictive model to predict
a negative outcome, the proportion of true negatives among the total number
of unconfirmed cases. An ideal mathematical model is characterized by a
graph of the ROC curve passing through the upper left corner, while the
proportion of true positive and negative cases is 100 %, and the proportion
of false positive and false negative results is 0 %. The approach of the ROC
curve to the diagonal line indicates low model parameters. The area under
the ROC-curve (AUC) is used to measure the diagnostic informativeness of
models; the larger the AUC area, the higher the diagnostic information
content. For high information content AUC 0.9–1.0; for good — 0.8–0.9;
for the average — 0.7–0.8; for satisfactory — 0.6–0.7; for unsatisfactory —
less than 0.6 (Picture 1).
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Mathematical model of the risk of development of pre-frail
Picture 1 — ROC-curve for a mathematical model
of the risk of developing pre-frail
Formula: -8.97 + 0.14*(Age) + 0.03*(Waist circumference) –
0.41* (glycated hemoglobin).
Sensitivity 98.7 %, specificity 10.6 %. Area under the curve (AUC)
0.71. The overall reliability of the model is 78.0 %.
The resulting model is characterized by high sensitivity, medium
information content and medium reliability. The low specificity of the
resulting model may be due to the relatively low number of strong patients
used for comparison with the pre-frail in this model (47 people, 12.0 % of
the total number of patients). In addition, many anthropometric, functional
and laboratory parameters of the examined patients did not reveal any
dynamics among strong and pre-frail patients. This indicates the similarity
of many parameters in the group of strong and fragile patients and the
preservation of the state of health of pre-frail patients in comparison with
frailty ones (Picture 2).
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Mathematical model of the risk of frailty development
Picture 2 — ROC-curve for a mathematical model
of the risk of developing fragility
Formula: 12.69 + 0.15*(fall risk) – 0.1*(Barthel index) + 0.13*(carpal
dynamometry index) – 0.9*(phase angle)
Sensitivity 75.8 %, specificity 75.0 %. Area under the curve (AUC)
0.81. The overall reliability of the model is 75.4 %.
The resulting model for the risk of developing frailty is characterized
by moderate sensitivity and specificity, good information content, and
moderate reliability.
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Mathematical model of the risk of developing probable sarcopenia
Picture 3 — ROC-curve for a mathematical model
of the risk of developing probable sarcopenia
Formula: 3.56 – 0.3*(Carpal Dynamometry) + 0.25*(Five Chair Stand
Up Test) – 0.15*(Appendicular SMM)
Sensitivity 88.2 %, specificity 84.8 %. Area under the curve (AUC)
0.94. The overall reliability of the model is 86.7 %.
The resulting model for the risk of developing probable sarcopenia is
characterized by good sensitivity and specificity, high information content
and good reliability (Picture 3).
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Mathematical model of the risk
of development of confirmed sarcopenia
Picture 4 — ROC curve for a mathematical risk model
for the development of confirmed sarcopenia
Formula: 27.26 – 3.39 * (gender) – 0.15 * (carpal dynamometry) –
4.28 * (Appendicular SMM index) + 0.13 * (walking time at a distance of
4 meters) + 0.41 * (total cholesterol)
Sensitivity 95.7 %, specificity 84.2 %. Area under the curve (AUC)
0.97. The overall reliability of the model is 92.3 %.
The resulting model for the risk of developing confirmed sarcopenia
is characterized by high sensitivity, good specificity, high information
content, and high reliability (Picture 4).
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