Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 249

Weight loss in older patients is associated with increased mortality, morbidity, and other unfavourable outcomes (e.g. loss of muscle mass, decreased muscle strength, altered immune function, decreased wound healing). The data on benefits and outcomes with nutritional management are controversial and mixed. More recent studies that have shown oral nutritional suppliement (ONS) can result in weight gain of 1–3 kg over one to three months have not shown decreased mortality or improved functional benefits in the general elderly population. In certain subgroups of older adults who were frail, malnourished, or had had recent illnesses, the use of ONS showed improved cognition, weight gain, and functional status, reduced rehab stays, and prevention of wounds.⁷

Table 9.1 The Health Maintenance Clinical Glidepath.

Item	Robust elderly Life expectancy >5 years and functionally independent	Frail Life expectancy <5 years or significant functional impairment	Moderately Demented Life expectancy 2–10 years	End of life Life expectancy <2 years and functionally non‐independent
Office visits	Do 2 times/year	Do 1–4 times/year	Do 1–4 times/year	Do as needed
Blood pressure including orthostatics	Do each visit	Do each visit	Do each visit	Do each visit
Weight	Do each visit. If loss of >5 lb/year, perform SNAQ/MNA	Do each visit. If loss of >5 lb/year, perform SNAQ/MNA	Do each visit. If loss of >5 lb/year, perform SNAQ/MNA	* * * *
Height	Do each visit	Do yearly	* * * *	* * * *
Pain assessment	Do each visit	Do each visit	Do each visit	Do each visit
Medication review including OTCs and herbal medicines	Do each visit	Do each visit	Do each visit	Do each visit
Lifestyle education (exercise, smoking cessation, alcohol, and injury prevention)	Do each visit	Do each visit	Discuss periodically with caregiver	* * * *
Maintain awareness of elder abuse	Do each visit	Do each visit	Do each visit	Do each visit
Assess ADLs and IADLs	Do yearly	Do yearly	Do each visit	Do each visit
Visual acuity testing	Consider yearly	Consider yearly	Consider yearly	* * * *
Auditory testing	Consider yearly	Consider yearly	Consider yearly	* * * *
Ask about urinary incontinence	Do yearly	Do yearly	Do yearly	Do yearly
Males: ask about erectile dysfunction and ADAM screen for hypogonadism Rapid Geriatric Assessment	Do yearly Do at each visit	Do yearly Do at each visit	Consider yearly Do at each visit	* * * * Consider
Cognitive screening	Do initially; do if symptomatica	Do initially; do if symptomatic	Do initially	Consider if symptomatic
Depression screening	Do initially; do if symptomatic	Do initially; do if symptomatic	Do initially; do if symptomatic	Do initially; do if symptomatic
Screening for gait and balance	Do initially; do if symptomatic	Do initially; do if symptomatic	Do initially; do if symptomatic	Do if symptomatic
Advance directives	Do yearly and as needed	Do yearly and as needed	Do yearly and as needed	Do yearly and as needed
Influenza vaccine	Do yearly	Do yearly	Do yearly	Do yearly
Pneumococcal vaccine	Do once; consider repeat every 6 years for patients with chronic diseases	Do once	Do once	Consider vaccination once
Tetanus	Do primary series if not vaccinated before and booster every 10 years	Do primary series if not vaccinated before	Do primary series if not vaccinated before	* * * *
Zostavax Hepatitis C	Do once Do once	Do once Do once	Do once * * * *	Consider * * * *
Breast examination	Do yearly	Do yearly	Do yearly	* * * *
Mammography	Do every 1–2 years up to age 80	Consider every 1–2 years up to age 75	Consider every 1–2 years up to age 70	* * * *
Pap smear	Consider 1–3 Pap smears if patient has never had one	* * * *	* * * *	* * * *
Faecal occult blood test	Do yearly	Consider yearly	Consider yearly	* * * *
Colonoscopy	Consider every 10 years	* * * *	* * * *	* * * *
PSA	Discuss pros and cons with patient	Discuss pros and cons with patient	Discuss pros and cons with caregiver	* * * *
Osteoporosis	Do at least once; consider every 2 years	Do at least once every 2 years	Do at least once	* * * *
Cholesterol screening	Consider screening for patients aged 65–75 if they have additional risk factors (e.g. smoking, diabetes, hypertension)	Consider screening for patients aged 65–75 if they have additional risk factors (e.g. smoking, diabetes, hypertension)	* * * *	* * * *
TSH	Do every 5 years or if symptomatic	Do every 5 years or if symptomatic	Do every 5 years or if symptomatic	Consider
Fasting blood glucose	Do if symptomatic or every 3 years if the patient has risk factors	Do if symptomatic or every 3 years if the patient has risk factors	Do if symptomatic or every 3 years if the patient has risk factors	Consider if symptomatic
Sleep apnoea Abdominal aortic aneurism	Do yearly Do once	Do yearly Do once	* * * * * * * *	* * * * * * * *

MNA, Mini‐Nutritional Assessment; OTC, over‐the‐counter; ADLs, activities of daily living; IADLs, instrumental activities of daily living; ADAM, androgen deficiency in adult males; PSA, prostate‐specific antigen; SNAQ, Simplified Nutritional Assessment Questionnaire; TSH, thyroid‐stimulating hormone.

^a The term symptomatic refers to any complaint given by the patient or caregiver or any problem observed/elicited by the clinician.

Since screening for weight loss is very low‐cost and low‐risk and the benefits of intervention are somewhat positive, it should be done for patients in all categories except End of Life. Outpatient screening of unintentional weight loss of 10% or greater in one year is indicative of significant malnutrition.

Using validated screening tools such as the Simplified Nutritional Appetite Questionnaire (SNAQ) or Mini‐Nutritional Assessment (MNA) can identify patients who are malnourished or at risk for malnutrition.⁸