Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
.pdf
186
C. Kuttner
dysfunction. Chronic conditions or diseases such as Parkinson’s disease, anemia,
osteoarthritis, diabetes, cerebrovascular disease, cardiovascular disease, bladder
incontinence, dementia, and chronic pain are frequent comorbidities that increase the
risk of falls. Patient care plans should reect the interventions put in place to help
prevent falls such as frequent toileting, non-skid footwear, keeping personal items
within reach on the bedside table, and having assistive devices close at hand.
According to the AMDA The Society for Post-Acute and Long-Term Medicine
clinical practice guideline on falls [7], it is important to document a fall risk assess-
ment for each patient, and to discuss those risks at the care plan conference. After a
fall, a huddle should occur in which the possible factors contributing to the fall are
reviewed. The guidelines state that a “multicomponent intervention by a multidisciplinary team may reduce the number of falls and the number of fallers in the long
term care setting.”
When performing the Physical Examination, it is important to assess gait, balance, mobility, lower extremity joint stability, muscle strength, and overall function. The neurologic exam should include an evaluation of cognition, peripheral
proprioception, reexes, cortical and extrapyramidal and cerebellar function, and
muscle strength of the lower extremities. Cardiovascular assessment should include
heart rate and rhythm, blood pressure, orthostatic blood pressure, and peripheral
pulses. Test visual acuity and check feet and footwear. The Functional Assessment
should include an assessment of ADLs and adaptive equipment including mobility
aids. Query on the fear of falling and any self-imposed limitations due to that fear.
An Environmental Assessment should be done to check for lighting, obstacles,
uneven surfaces, and other hazards, especially in community dwelling older adults.
Specic tests that may be useful include the “get up and go” test [8], the “functional reach test” [9], the “Berg balance test” [10], and the “POMA-performance
oriented mobility assessment” [11]. Carotid sinus massage-induced bradycardia
may also be diagnostic in patients with repeated falls of unknown etiology.
Recommendations to decrease fall risk include:
• Exercise programs to maintain strength and mobility and decrease risk of falls.
Yoga, Tai Chi, and weight-bearing exercises are most helpful.
• Supplement residents with at least 800IU of vitamin D daily for those with vita-
min D deciency and/or impaired balance. Patients who have vitamin D levels
less than 20 ng/mL may have a decreased fall risk with vitamin D
supplementation.
• Consider dose reduction of medications that can cause orthostasis or increase
risk of falls (psychotropic medications particularly benzodiazepines, sedatives,
and anxiolytics) or use of multiple antihypertensives (see Chapter “Medication
Management in Long-Term Care” for further discussion), and opioids.
• Consider treatment of osteoporosis in residents who can tolerate pharmacologic
therapy and have a life expectancy of 5–10years, particularly for those who have
had a prior wrist, vertebral or hip fracture(s).
• Residents with cognitive impairment may be impulsive and unable to remember
information taught on fall prevention. Frequent monitoring and regular toileting
may decrease but not eliminate their risk of falls.
Goals ofCare andPrevention
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
187
Bed and chair alarms do not prevent falls; they only alert staff to a resident who
is trying to stand or get out of bed. Most nursing facilities are now alarm free.
Restraints should be avoided at all times (both chemical and physical) because they
neither prevent falls nor injury and instead increase falls and injuries! The use of
side rails is controversial, with double rails considered a restraint. Many side rail
injuries are linked to older beds, which allowed entrapment of the patient between
the rails and mattress or the side rail and the wall. There is also a great risk that a
patient climbing over the side rail and falling from this higher height to the oor can
suffer a more severe impact injury than a fall from bed without a rail in place. The
efcacy of hip protectors is controversial [12]. There is limited evidence that they
are effective and many patients are reluctant to wear them. Putting them on requires
extra effort by the nursing staff. Given the high risk of falls and injuries, if a patient
is willing to wear hip protectors, consider a trial.
Nursing facilities may have a “fall teams” or a falls protocol to evaluate each fall
and to determine what preventive interventions to initiate such as the use of low bed.
Input by the practitioner can be vital due to his/her expertise to take into account
intrinsic and extrinsic risk factors, patient multimorbidities, and to guide the interdisciplinary term to create an appropriate plan of care to lessen fall risk. Medication
review performed by the practitioner and the facility contract pharmacist can provide critical input to lessen fall risk.
AHRQ has excellent resources to help identify medication that may increase risk
of falls as does the Beers criteria. Deprescribing can be helpful in reducing risk
[13]. An optimal falls team would include an occupational therapist, physical therapist, pharmacist, nurse/nursing assistant, recreation therapist, and either physician
or nurse practitioner. Decreasing falls and avoiding major injury is an excellent
quality improvement project (PIP) for the IDT team to undertake under Quality
Assurance and Performance Improvement (QA-PI).
Immunizations
Vaccines currently recommended for the elderly include the inuenza vaccine,
pneumococcal vaccine, herpes zoster vaccine (Shingrix), tetanus (Tdap) booster,
and the COVID-19 vaccine.
Inuenza
Efcacy of the inuenza vaccine varies from year to year, depending upon the strains
selected for the vaccine and those strains that infect the population. It is paramount to
vaccinate residents, staff, and visiting family members while discouraging sick visitors from coming into the facility during inuenza season. If unvaccinated staff
become ill with inuenza, it can result in the widespread dissemination of the u virus
to residents, patients, and other staff, causing absenteeism and increased workload on
188
C. Kuttner
remaining staff. Inuenza can be a life-threatening illness, so practitioners and staff
should be vigilant as to the possibility that an inuenza outbreak has occurred. Some
facilities are now mandating u vaccine as a condition of employment unless there is
a medical or religious contraindication. Staff vaccination rates of 60–70% may
decrease the likelihood of an outbreak in the facility among patients and staff.
The facility medical director should be notied when an outbreak of inuenza
occurs and to decide if and when to provide prophylaxis to all residents in the facility. CDC.gov provides an excellent “Toolkit for Post-Acute and Long-term Care
Facilities” that describes all aspects of inuenza prophylaxis and treatment [14].
Vaccination of residents and staff with the trivalent inuenza vaccine should start as
soon as the vaccine is available (usually in September or early October). Having
standing orders to vaccinate residents and vaccinating all staff unless there is a
medical contraindication or personal choice not to receive the vaccine can increase
compliance. For residents, consent can be obtained from the health care power of
attorney or guardian if the resident is unable to give informed consent due to incapacity or lack of decision-making capacity.
An outbreak in a nursing facility is dened when two residents are sick with ulike symptoms within a 72-h period and one has conrmed Inuenza by viral testing.
When this occurs, all residents should be treated or prophylaxed with either oseltamivir or zanamivir for 5days. Transit between facility units by staff and residents
should be limited. Standard and droplet precautions should be followed for all residents with suspected or conrmed inuenza. To help prevent further spread, dining
and activities may need to occur in patient rooms rather than in common areas. Note
that amantadine and rimantadine are no longer considered to be effective due to the
development of resistance and thus should not be used for treatment or prophylaxis.
It is essential to have a policy and procedure at the facility on how to manage an
inuenza outbreak including its isolation protocol. The medical director should collaborate with the infection preventionist in the building to create durable policies
and procedures to keep patients, staff, and visitors safe.
Pneumococcus
Currently there are several recommended vaccines to help prevent pneumococcal disease
in older adults: the Prevnar 20, Pneumovax 23, Prevnar 15 and the Prevnar 13. Common
presentations of pneumococcal disease in older adults are pneumonia, sepsis, and meningitis [15]. PCV 13, 15 and 20 are conjugate vaccines and the PPS 23 is a pneumococcal polysaccharide vaccine. Current recommendations are on the CDC website and
continue to evolve for different age groups. For adults 19–64 years of age, there is a
long list of diagnoses such as alcoholism, diabetes, chronic renal failure, that put
patients at higher risk for severe pneumococcal disease. These patients should receive
the PCV 20 or PCV 15, followed by the PPS 23 in 1 year. All patients over 65 years of
Goals ofCare andPrevention
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
age are recommended to receive pneumococcal vaccination. They can either receive a
dose of PCV 15 followed by PPS 23 in a year, or a one time dose of PCV20.
189
Shingles (Herpes Zoster)
The Herpes Zoster vaccine (Shingrix) has been shown to decrease the risk of shingles and post-herpetic neuralgia [17]. This recombinant vaccine is much more effec-
tive than the prior vaccine (Zostavax) and can prevent 90% of herpes zoster and
89% of post-herpetic neuralgia. Shingrix was approved in 2017, and it is effective
in preventing shingles for at least 4years. This vaccination is a two part series, with
the second dose being given 2months after the rst dose [16].
Tdap is preventive for tetanus, which can occur in long-term care patients with
wounds. It is given as an IM vaccination every 10 years. In addition to preventing
tetanus in wounds, it may also prevent pertussis infection which can be serious in
older patients.
COVID-19 Vaccination
In 2020 several vaccines to prevent COVID-19 infection were approved. The science and technology of these vaccines is rapidly evolving; however, they have been
very effective in preventing COVID infection in many nursing home and assisted
living residents and reducing the severity of illness in the few patients who do
become infected after having had a previous COVID-19 vaccination. It has been
determined that ongoing boosters will be needed to maintain immunity. Monoclonal
antibody treatments are also being utilized to decrease severity and duration of illness and prevent hospitalizations.
Nutrition andVitamin andMineral Supplementation
“We are what we eat,” continues to be true in the LTC setting. There are consequences to being underweight and overweight. Being underweight increases risk for
infections, pressure ulcers, physical decline, cognitive decline, and death.
Malnutrition and dehydration are common in the NF setting, with a recent article
identifying the prevalence of malnutrition at about 20% depending on the patient
population [17]. Being overweight increases risks of developing metabolic syndrome, hypertension, diabetes, and the personal need for more physical assistance
from staff for daily tasks of living (ADLs).
190
C. Kuttner
A nutritional and dietary plan is required for all residents in order to ensure that
nutrient and calorie needs are being met. Goals of care are paramount. Resident
rights allow patients to decline a prescribed diet and to eat what they choose, even
if it compromises their medical condition. This can complicate the treatment of
diabetes, CHF, and renal disease, and raise conict between health care providers
and the resident/patient. However, the nursing or assisted living facility is their
“home” and just like community dwelling persons, residents are entitled to make
informed decisions on food preferences. Despite this, care planning requires the
facility to set goals for residents in order to achieve adequate nutrition. At times this
can be challenging. If the dietician has a goal that the resident needs to lose 10lbs
and achieve a hemoglobin A1C of 7% but the patient eats double portions and
snacks throughout the day, the listed goals in the care plan may not be realistic.
Conversely, if a patient with dysphagia is on a pureed diet with thickened liquids
and the patient refuses to eat the prescribed diet, the goal to gain weight may be
futile and paradoxically result in weight loss!
Poor dentition can be a barrier to adequate nutrition. Encouraging the nursing staff
to provide routine and thorough mouth care is essential. Engaging a dentist with an
interest in geriatrics to come to the facility can be invaluable, but also challenging.
Some dentists may offer on-site bedside dental care such as cleaning and tooth extractions. Starting a tooth brushing or mouth swabbing program (for patients who are
edentulous) will improve oral hygiene and may decrease rates of aspiration pneumonia.
Another common problem is swallowing dysfunction (dysphagia) due presbyesophagus or neurologic conditions such as Parkinson’s or cerebrovascular disease.
Dysphagia can affect the texture of food and liquids that can be tolerated. A visit to the
dining room at mealtime to observe how the patient is eating can be very informative.
Is staff assistance needed ? How is the food texture and liquid consistency being tolerated? Such a visit can provide insight into why a resident is losing weight and suggest
possible therapeutic interventions. If a resident has advanced dementia and the family
chooses comfort care, hand feeding to the best of the staff’s ability is the best option
to offer meal with dignity. Choosing Wisely guidelines from AGS and AMDA strongly
advise against insertion of feeding tubes in those with dementia (see Chapter “Weight
and Nutrition in Post-Acute and Long-Term Care” for further discussion) [18].
The dietician, the speech language therapist, and the pharmacist can be allies in
the management of unintended weight loss. The dietician can offer preferred foods
after the speech therapist determines which foods and consistency are safe for the
patient to eat. The pharmacist can advise which medications may be affecting taste
and appetite and suggest a trial of deprescribing.
A diet balanced with protein, carbohydrates, and fats can help residents maintain
good health, muscle strength, and mental vigor. Fresh fruit and vegetables, often
absent in dietary plans, should be encouraged in order to provide natural nutrients,
hydration, and ber. The medical director can encourage the facility administration
and dietary to supply more fresh fruit and vegetables on the meal plan as well as
healthy snacks between meals. Fruit and vegetable smoothies or pureed fruits may
be a good choice for those with dysphagia. Frozen fruits and vegetables can also
provide excellent nutritional options if fresh products are not available. If patients
Goals ofCare andPrevention
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
191
eat a healthy diet, a supplemental multivitamin may not be needed. However, if not
eating a balanced diet, a vitamin/mineral supplement may be reasonable.
The most common electrolyte abnormalities in nursing home residents are hypokalemia related to diuretics and abnormalities in sodium (either hypo or hypernatremia) related to uid balance abnormalities. Avoiding uid restrictions whenever
possible and providing uids in between meals can help to avert dehydration.
Consider a hydration cart with avored water and other healthy drinks that can be
given to residents several times a day. Providing extra uid at the times of medication administration is another option.
Many residents are decient in vitamin D deciency, which has been associated
with falls, fractures, musculoskeletal pain, and muscle weakness [19]. Routine testing of 25-hydroxyvitamin D levels is usually not needed when a vitamin D supplement is being given. However, if checked, a level of at least 40–50 is optimal.
Different organizations recommend differing doses of vitamin D supplements,
ranging from 800IU to 4000IU a day. Residents at highest risk of vitamin D deciency include those with dark pigmented skin, obesity, malabsorption, and who
take medications that accelerate the breakdown of vitamin D (such as phenytoin and
phenobarbital) or bind oral vitamin D (such as cholestyramine). Consider a calcium
supplement of 1000–1200mg daily with vitamin D if dietary intake is poor and
supplementation is consistent with goals of care. Calcium supplements enhance the
benet of vitamin D on bone mineral density; however, calcium supplements can be
constipating. If the calcium supplements result in a need for additional laxatives,
this may cause a prescribing cascade where the risks outweigh its benets.
Magnesium is often decient, particularly in residents on diuretics or proton
pump inhibitors that have been taken for an extended period of time and in those
with diabetes mellitus [20]. Oral zinc replacement has been found to be benecial
in patients who have zinc deciency and a wound; the optimal amount of supplementation and duration of therapy is currently being studied. There seems to be a
correlation between adequate zinc levels and cognition and depression [21].
Screening Tests
Screening forOsteoporosis
The US Preventive Services Task Force has not made a specic recommendation
about resident screening for osteoporosis in nursing homes. However, it does rec-
ommend consideration of screening in women over age 65. Currently there is inadequate evidence to recommend screening in men. On the other hand, the National
Osteoporosis Foundation recommends screening in women over 65 and men over
70 [22]. Screening options may include DEXA scanning of the lumbar spine and
hip, quantitative ultrasound of the calcaneum or FRAX risk calculation [23]. Some
residents may have already sustained an osteoporotic fracture or have an elevated
Dexa T-score greater than −2.5. Life expectancy, prognosis, and clinical judgment
192
may determine which residents would be most appropriate for screening. For many,
treatment with bisphosphonates or other agents may be appropriate and tolerated;
for others, it is burdensome and inconvenient and has potential adverse side effects
such as GERD, osteonecrosis, and atypical fractures. The lag effect for benets
needs to be considered; if a patient is at end of life, treatment of osteoporosis should
not be prioritized. Residents in assisted living may be more appropriate for screen-
ing than those in a nursing facility.
C. Kuttner
Tuberculosis Screening
Recommendations for tuberculosis screening in nursing homes has changed over
the past 10 years due to declines in both active and latent tuberculosis in the
USA.Tuberculosis screening of residents is recommended on admission to nursing
facilities and for a facility tuberculosis risk assessment. The initial testing should be
done with a two-step tuberculin skin test (TST) or an IGRA (interferon gamma
release assay) blood test. Many older people are anergic due to immunosenescence
and may not respond to skin testing (manifest as a false negative). Symptoms suggestive of active or reactivated TB should be aggressively pursued. Fortunately, this
situation is infrequent in most US NFs. Many NFs (especially those at low risk) use
an annual “symptom screen” rather than repeating the TST every year. It is no longer recommended to do a TB skin test or an IGRA test yearly if the incidence of
tuberculosis is low in the facility.
Cancer Screening
Cancer screening of residents in NFs and assisted living may be reasonable if consistent with residents’ goals of care. Depending on the age, prognosis, and physical/
cognitive function of the patient, decisions about whether or not to screen should be
made in concert with the patient/family.
Cervical Cancer screening should rarely if ever be needed and Breast Cancer
screening can be considered if the patient is able to participate in mammography;
however, many nursing home residents are unable to stand and be properly positioned for a mammogram. Some may be unwilling to undergo surgery and potential
radiation and chemotherapy if a cancer is found. Physical exam can detect most
signicant breast cancers in elderly residents. Workup and treatment of any breast
mass should be discussed with the patient/family. Periodic clinical breast exams by
the practitioner are prudent and reasonable if the resident provides consent. Consider
mammograms for residents in assisted living.
Colon cancer screening is not recommended over the age of 75 by the USPSTF,
and should only be undertaken if the patient is willing and able to undergo major
surgery.
Goals ofCare andPrevention
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
193
Screening for lung cancer with low dose CT scan is limited to select patient
populations who are under the age of 75 and have smoked at least 40 pack years and
would be willing/able to undergo treatment if cancer is found. This CT screening
recommendation was intended for otherwise healthy patients in the community; not
for frail elderly in a nursing facility.
Prostate Cancer screening with PSA testing is NOT recommended for most male
residents, as it has no mortality benet and it may be associated with increased
morbidity and mortality resulting from diagnostic workup and unnecessary
treatment.
AMDA discussed cancer screening in its “Choosing Wisely” campaign. It did
not recommend screening for breast, colorectal, or prostate cancer unless life expectancy is estimated to be over 10years and stated that for most long-term residents
over age 75 the burdens of screening likely outweigh any benets
Exercise
Exercise is a low risk activity with high benet to improve function and prevent
physical decline in residents. Exercise has shown to have positive effects on
mood and to help maintain physical function in patients with Alzheimer’s disease [24, 25]. The best benets involve an exercise program that includes walking, strength training, balance, and exibility exercise. Unfortunately, not all
residents are able to walk, but restorative programs can keep many residents
ambulatory for longer than expected. Restorative programs are generally provided by nursing, based on recommendations from rehabilitation therapy and
the restorative care coordinator. Exercise programs for people who are wheelchair-dependent or bedbound are also helpful. Yoga, Tai Chi, and stretching programs have been adapted for those chairbound [26]. Exercise for bedbound
patients is more challenging, but less intense programs can be given based on
individual needs and capabilities. Exercise combined with music has been
shown to be effective in patients with Parkinson’s disease [27]. Further research
on best practices is ongoing to avert increased frailty and sarcopenia. Exercise
training, particularly resistance/muscle training and weight-bearing are the most
effective [28].
Mental exercise is important as well. Depending on the cognitive reserve of the
resident, there are opportunities for mental stimulation. Reminiscence, music, sensory activities, arts, current events, and visits from family and friends are all important in maintaining cognitive vitality.
Peals for the Practitioner
• Discuss, revisit, and then document residents’ revised goals of care when a
change in condition occurs.
• Preventive health interventions and treatments are guided by residents’ multi-
morbidities, prognosis, advance directives, and goals of care.
194
C. Kuttner
• Fall prevention should always include a medication review and attempts to dis-
continue medications that potentially increase fall risk.
• Vaccination of residents and staff is vital to maintaining personal health and
preventing outbreaks of infectious disease in the facility.
• Good nutrition is key to the maintenance of physical and cognitive health.
Observation of residents at mealtime may help determine interventions in those
with weight loss.
• Liberal diets are appropriate for most frail older patients. Restrictive diets should
be avoided unless medically necessary. And may cause loss of appetite, refusal
to eat, and weight loss.
• Screening for cancer in asymptomatic residents should be individualized and
generally minimized. But may be more appropriate for residents in assisted liv-
ing who tend to be younger and independent than those in a nursing facility.
• Mental and physical exercise programs improve quality of life of residents;
meeting the exercise needs of individual residents requires thought, teamwork,
and creativity.
References
1. Age-friendly health systems. Guide to using the 4Ms in the care of older adults-institute for
health care improvement; July 2020.
2. POLST, physician orders for life-sustaining treatment paradigm®. http://www.polst.org.
Accessed 1 July 2021.
3. Medical orders for life sustaining treatment; MOLST. https://www.molst.org. Accessed 1
July 2021
4. Trends in non-fatal falls and fall-related injuries among adults greater than 65 years-United
States, 2012-2018. https://www.cdc.gov/mmwr/volumes/69/wr/mm6927a5htm. Accessed 1
July 2021.
5. Leland NE, et al. Falls in newly admitted nursing home residents: a national study.
JAGS. 2012;60(5):939–45.
6. American Geriatrics Society. AGS/BGS clinical practice guideline: prevention of falls
in older persons, summary of recommendations. http://www.americangeriatrics.org/
health_care_professionals/clinical_practice/clinical_guidelines_recommendations/
prevention_of_falls_summary_of_recommendations.
7. AMDA Clinical Practice Guideline on Falls. Accessed 1 July 2021.
8. Balance in elderly patients: the “get up and go” test. Arch Phys Med Rehabil Jun 1986
67(6):387–9.
9. de Waroquier-Leroy L, etal. The functional reach test: strategies, performance and the inuence of age. Ann Phys Rehabil Med. 2014;57(6–7):452–64.
10. Neuls P, etal. Usefulness of the berg balance scale to predict falls in the elderly. J Geriatr Phys
Ther. 2011;34(1):3–10.
11. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients.
JAGS. 1986;34:119–26.
12. Santesso N, Carrasco-Labra A, Brignardello-Petersen R.Hip protectors for preventing hip
fractures in older people. Cochrane Database Syst Rev. 2014;3:CD001255. https://doi.
org/10.1002/14651858.CD001255.pub5.
Goals ofCare andPrevention
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
195
13. AHRQ “Preventing Falls in Hospitals”. Tool 31:Medical Fall Risk Score and Evaluation Tools.
Accessed 1 July 2021.
14. Centers for Disease Control and Prevention. Post-acute and long-term-care facility toolkit:
Inuenza. https://www.cdc.gov/u/toolkit/long-term-care. Accessed 28 April 2023.
15. ACIP Vaccine Recommendations and Schedules. https://www.cdc.gov/vaccines/acip/recom-
mendations.html. Accessed 28 April 2023.
16. James S.Shingrix: the new adjuvanted recombinant herpes zoster vaccine. Ann Pharmacother.
2018;52(7):673–80.
17. Bell C, et al. Malnutrition in the Nursing Home. Curr Opin Clin Nutr Metab Care.
2015;18(1):17–23.
18. https://www.choosingwisely.org. Accessed 28 April 2023.
19. Yanamadala M, etal. Ensuring Vitamin D supplementation in nursing home patients: a quality
improvement project. J Nutr Gerontol Geriatr. 2012;31(2):158–71.
20. Arinzon Z, Peisakh A, Schrire S, Berner YN.Prevalence of hypomagnesemia (HM) in a geriatric long-term care (LTC) setting. Arch Gerontol Geriatr. 2010;51(1):36–40.
21. Markiewicz-Żukowska R, Gutowska A, Borawska MH.Serum zinc concentrations correlate
with mental and physical status of nursing home residents. PLoS One. 2015;10(1):e0117257.
22. https://www.nof.org. Accessed 28 April 2023.
23. Welcome to FRAX®. FRAX® WHO fracture risk assessment tool. http://www.shef.ac.uk/
FRAX. Accessed 28 April 2023.
24. Rolland Y, Pillard F, Klapouszczak A, et al. Exercise program for nursing home residents with Alzheimer’s disease: a 1-year randomized, controlled trial. J Am Geriatr Soc.
2007;55(2):158–65.
25. Williams CL, Tappen RM. Effect of exercise on mood in nursing home residents with
Alzheimer’s disease. Am J Alzheimers Dis Other Demen. 2007;22(5):389–97.
26. Cordes T, et al. Chair-based exercise interventions for nursing home residents: a systematic
review. JAMDA. 22(4):733–40.
27. de Dreu MJ, van der Wilk AS, Poppe E.Rehabilitation, exercise therapy and music in patients
with Parkinson’s disease: a meta-analysis of the effects of music-based movement therapy
on walking ability, balance and quality of life. Parkinsonism Relat Disord. 2012;18(Suppl
1):S114–9.
28. Levinger I, Duque G.Sarcopenia: innovation and challenges. JAMDA. 22(4):728–30.
Соседние файлы в папке Библиотека им академика М.И. Перельмана