Молодежный инновационный вестник

2415-7805

Федеральное государственное бюджетное образовательное учреждение высшего образования "Воронежский государственный медицинский университет имени Н.Н. Бурденко" Министерства здравоохранения Российской Федерации

9335

Conference Proceedings

Irrational pharmacotherapy of patients 60 years of age and older with comorbid diseases as a cause of cognitive and psychoemotional disorders

Muradova

Aminat Sultanovna

<pre id="tw-target-text" class="tw-data-text tw-text-large tw-ta" dir="ltr" data-placeholder="Перевод" data-ved="2ahUKEwiLqN7O3JyEAxWKDxAIHSpPBZkQ3ewLegQIBRAU">sixth year student of the Faculty of Medicine at VSMU</pre>muradova_aminat@bk.ruhttps://orcid.org/0000-0003-4889-4472Muravitskaya

Marina Nicolaevna

<pre id="tw-target-text" class="tw-data-text tw-text-large tw-ta" dir="ltr" data-placeholder="Перевод" data-ved="2ahUKEwiLqN7O3JyEAxWKDxAIHSpPBZkQ3ewLegQIBRAU">Candidate of Medical Sciences, Associate Professor of the Department of Polyclinic Therapy</pre>mnmuravitskaya@mail.ruhttps://orcid.org/0009-0007-1174-8275Pashkova

Anna Alexandrovna

<pre id="tw-target-text" class="tw-data-text tw-text-large tw-ta" dir="ltr" data-placeholder="Перевод" data-ved="2ahUKEwiLqN7O3JyEAxWKDxAIHSpPBZkQ3ewLegQIBRAU">Doctor of Medical Sciences, Head of the Department of Polyclinic Therapy, Vice-Rector for Academic Affairs</pre>zuikova-terapia23@mail.ruhttps://orcid.org/0000-0002-4849-0200Plehanova

Anna Igorevna

sixth year student of the Faculty of Medicine at VSMUplehanovanya13@mail.ruhttps://orcid.org/0000-0003-1120-6701

Voronezh State Medical University named after N.N.BurdenkoVoronezh State Medical University named after N.N. Burdenko

19042024

13S1380385

09022024

10042024

2024

Abstract.Introduction.Every year there is an increase in the number of elderly and senile people, and along with this there is an increase in the prevalence of cognitive impairment (CI). Target. To assess the prevalence and nature of CI, taking into account pharmacotherapy and adherence to treatment in elderly and senile people with comorbid pathology. Materials and methods. The clinical study was conducted on the basis of the VGKP №4. A group of patients was formed - 116 people 60 years of age and older with chronic non-communicable diseases. To diagnose senile asthenia, the Age is not a hindrance questionnaire was used; cognitive and psycho-emotional disorders, - clock drawing tests, Mini-Cog, MMSE, Geriatric Depression Scale. Pharmacotherapy in patients 60 years of age and older was assessed using the STOPP/START criteria. Results. 101 (87.1%)patients with hypertension, 87(75%) patients with dyslipidemia, and 99 (85.3%) patients with senile asthenia had irrational pharmacotherapy. Non-dementia cognitive disorders were found in 83 (71.6%) patients with chronic NCDs according to the Mini-Cog data and 36 (31%) according to the MMSE data. Probable dementia was verified in every fifth (Mini-Cog) and every second (MMSE) patient. Probable depression was detected in 77(66.4%)geriatric patients. Conclusion. This study showed an underestimation of the high prevalence of cognitive disorders in people over 60 years of age.

pharmacotherapycognitive disorderspsychoemotional disorders

фармакотерапиякогнитивные расстройствапсихоэмоциональные нарушения

Introduction. Given the growing number of elderly and senile people around the world every year, the prevalence of cognitive disorders (CD) is also growing. Globally, 47 million people (5% of the global elderly population) were diagnosed with dementia in 2015, and this figure could rise to 75 million by 2030 and 132 million by 2050 [1, 2]. Currently, there are no reliable data on the prevalence of non-dementia cognitive impairment and dementia in Russia. According to rough estimates, there are about 2 million patients with dementia in the Russian Federation [1, 2]. Persons with dementia are incapacitated, require guardianship, constant care, treatment, and do not take part in the lives of loved ones and society as a whole. Due to the lack of effective treatment for cognitive impairment (CI) at the stage of dementia, significant attention should be paid to non-dementia cognitive disorders that can be treated without resulting in dementia, subject to timely diagnosis and treatment. Goal of the work. To assess the prevalence and nature of cognitive disorders, taking into account pharmacotherapy and treatment adherence in elderly and senile people with comorbid pathology. Materials and methods of research. The clinical study was conducted on the basis of the BUZ VO VGKP No. 4. Using a random sampling method, a group of patients (n=116) with chronic non-infectious diseases who sought medical help from a local physician was formed. Criteria for inclusion in the group: elderly men and women (60-74 years), senile age (75-89 years) and centenarians (90+), the presence of any chronic non-infectious disease. For each patient with comorbid pathology (n=116), risk factors for cognitive impairment were analyzed: non-modifiable (gender, age, heredity) and modifiable (smoking, alcohol abuse, cardiovascular diseases (hypertension, ischemic heart disease, heart failure), diabetes mellitus, obesity, dyslipidemia, depression)). Each of the patients with chronic NCDs at an outpatient appointment for the purpose of screening for senile asthenia syndrome was used a validated questionnaire Age is not a hindrance, consisting of 7 questions. For each positive answer, 1 point was awarded. For each geriatric patient, the structure of comorbidity is determined by the coexistence in one patient of two or more diseases, syndromes or mental disorders, interconnected by a single pathogenetic mechanism. Pharmacotherapy in patients 60 years of age and older was assessed using STOPP/START criteria to prevent potentially inappropriate drug prescribing in elderly and geriatric patients. For the purpose of preliminary assessment of compliance and screening identification of insufficiently compliant patients in routine outpatient practice, the Morisky-Green scale was used, consisting of 4 points regarding the patients attitude towards taking medications [3]. For each answer Yes - 0 points, No - 1 point. To assess cognitive impairment (memory, attention, etc.) in people 60 years of age and older, the following were used: clock drawing test, Mini-Cog, Montreal Cognitive Assessment Scale - MoCA test, Mini-Mental State Examination - MMSE [4]. Clock drawing test. The patient was asked to independently draw a round clock on paper, put the numbers in the required positions on the dial, and draw arrows showing the given time. The assessment of task completion was carried out on a 10-point formal scale. Mini Cog. The patient with CND was given the task to remember three words that were not interconnected (apple, table, coin); draw a round clock so that all the numbers on the dial are placed correctly, the arrows mark the time 11 hours 10 minutes. After this, the patient with CND was asked to reproduce three words that he was asked to remember. For each word reproduced, 1 point was given; for correctly drawn numbers on the dial in the correct sequence without duplication with the correct indication of the time 11.10, the patient received 2 points. The total score for the test is 5 points. The Mini Mental State Examination (MMSE) was offered to patients with chronic NCDs to identify the nature of cognitive impairment: non-demented cognitive impairment and dementia. Cognitive functions were assessed in points (1 correct answer - 1 point): orientation in time, place, perception, concentration, memory, speech. Determination of orientation: the patient was asked to name the year, season, day, month, day of the week. They asked what country, city, district of the city, what institution, what floor the patient was in, and a point was added for each correct answer. Determination of perception: the patient was asked to listen and repeat three unrelated words (bus-door-rose). Determination of attention and ability to count: the patient was asked orally to subtract 7 from 100 5 times in a row. Determination of memory functions: the patient was asked to remember three words. Determination of the functions of speech, reading, writing: the patient was shown two objects (a watch, a pencil, a neurological hammer, etc.). They were asked to repeat the phrase: no ifs, buts, ands; read the instructions (write on the piece of paper - close your eyes). If the patient read and closed his eyes, one point was added. Next, they were given a task to read: take a sheet of paper with your right hand, fold it in half with both hands and place it on your knees. Then they gave me a piece of paper. If all actions were performed correctly, 3 points were awarded (1 point for each step). Then they were asked to write a complete sentence on a piece of paper. Drawing: asked to draw two intersecting pentagons. A completed task was considered correct if the intersection of two figures formed a quadrilateral and all angles of the pentagons were preserved. The Geriatric Depression Scale was used in each patient for the purpose of early diagnosis of probable depression as a risk factor for cognitive impairment in persons 60 years of age and older. It was proposed to answer 15 questions on patients life satisfaction. With a total score of 5 or more, probable depression is identified, 0-4 points - no depression. A retrospective analysis of 116 outpatient records of patients 60 years of age and older with comorbid diseases was carried out. Statistical processing of the obtained data was carried out using the Statistica 6.0 software package. Research results. For each patient with comorbid pathology (n=116), risk factors for cognitive impairment were analyzed for the purpose of early detection and prevention. The study involved 116 people: 88 (75.9%) women and 28 (24.1%) men aged 6094 years. There were 13 (11.2%) elderly patients, the majority were senile patients - 91 (78.4%), centenarians - 12 (10.3%). 78 (67.2%) people had a family history of cardiovascular and endocrine diseases (acute cerebrovascular accident (ACVA), myocardial infarction, type 2 diabetes mellitus). There were 2 (1.7%) patients who smoked, the majority were non-smokers - 114 (98.3%). Analysis of body mass index showed that the majority of comorbid patients were overweight - 61 (52.6%), obese - 18 (15.5%). Patients with normal body weight were observed - 37 (31.9%). Dyslipidemia IIa or IIb as a risk factor for cognitive impairment was found in the majority - 87 (75%) people. Impaired glucose tolerance was detected in 8 (6.9%), type 2 diabetes mellitus - in every fifth - 23 (19.8%). We analyzed the structure of comorbid pathology. Hypertension was present in 116 patients (100%). No patients with stage I headache were identified, stage II was observed in 24 (20.7%) patients, stage III - 92 (79.3%). There were 101 (87.1%) patients with uncontrolled hypertension, 15 (12.9%) patients with controlled hypertension. In every fifth patient 60 years of age and older, 24 (20.7%) had hypertension with damage to target organs: heart (left ventricular myocardial hypertrophy (LVH)), eyes (angioretinopathy), brain (CVB: DEP), blood vessels (hemodynamically insignificant atherosclerosis), kidneys (CKD C3a, C3b). In the structure of comorbid pathology, 1st place belonged to IHD + HD - 82 people (70.7%). IHD is presented in different forms: patients with stable angina - 74 (63.8%), PICS - 2 (1.7%), atrial fibrillation - 8 (6.9%). Type 2 diabetes mellitus with damage to target organs (kidneys, heart, nerves, retina, blood vessels) in combination with hypertension was detected in 28 (24.1%) patients, ranked II. The third place in the structure of comorbidity belonged to CHF, detected in 27 (23.3%) patients with CHNCD. In elderly, senile, and long-livers, senile asthenia was verified if 5 or more points were scored on the Age is not a hindrance questionnaire - 99 (85.3%); signs of preasthenia (3-4 points 17 (14.7%)). Patients with senile asthenia presented nonspecific complaints of constant fatigue, fatigue, slow gait, falls, memory loss, inattention, and often associated them with aging of the body or existing chronic diseases. In order to prevent potentially incorrect prescription of medications to elderly and elderly patients, all patients with comorbid pathology were analyzed pharmacotherapy taking into account the STOPP/START criteria (see Table 1). Depending on the combination of comorbid diseases, taking into account age-related characteristics, rational combinations of drugs were recommended, which patients did not receive for any reason; Potentially dangerous combinations have been replaced with safe ones. Table 1. STOPP/START criteria for preventing potentially inappropriate drug prescribing in elderly and geriatric patients <table width="815"> <tbody> <tr> <td width="638"> START </td> <td width="177"> Число больных </td> </tr> <tr> <td width="638"> Initiation of antihypertensive therapy when SBP 160 mmHg. or DBP 90 mmHg; patients with type 2 diabetes with SBP 140 mmHg. or DBP 90 mmHg </td> <td width="177"> 71 (61,2%) </td> </tr> <tr> <td width="638"> ACE inhibitors for patients with systolic CHF and/or ischemic heart disease </td> <td width="177"> 82 (70,7%) </td> </tr> <tr> <td width="638"> -адреноблокаторы пациентам с ИБС, стабильной ХСН </td> <td width="177"> 82 (70,7%) </td> </tr> <tr> <td width="638"> -blockers for patients with coronary artery disease, stable CHF </td> <td width="177"> 101 (87,1%) </td> </tr> <tr> <td width="638"> Do not receive a rational combination of planned antihypertensive drugs: </td> <td width="177"> </td> </tr> <tr> <td width="638"> Hypertension + LVH (not received, ACEI/ARB+AC or Diuretic are recommended) </td> <td width="177"> 28 (24,1%) </td> </tr> <tr> <td width="638"> HD + CKD (not received, ACEI/ARB + CCB or Diuretic are recommended) </td> <td width="177"> 21 (18,1%) </td> </tr> <tr> <td width="638"> HD+IHD (not received, ACE inhibitors or ARBs+BB or CCB are recommended) </td> <td width="177"> 39 (33,6%) </td> </tr> <tr> <td width="638"> Hypertension + IHD + type 2 diabetes + CHF pEF (not received, ACEI/ARNI + beta blocker AMKR + NGLT2 + diuretic are recommended) </td> <td width="177"> 24 (20,7%) </td> </tr> <tr> <td width="638"> Hypertension + IHD + type 2 diabetes + CHF nEF (not received, ARNI + beta blocker AMKR + NGLT2 + Diuretic are recommended) </td> <td width="177"> 3 (2,6%) </td> </tr> <tr> <td width="638"> Statin therapy (not received, recommended) with a documented history of ischemic heart disease, CVD, peripheral atherosclerosis </td> <td width="177"> 76 (65,5%) </td> </tr> <tr> <td width="638"> Antiplatelet therapy (not received, recommended) in patients with a documented history of ischemic heart disease, CVD, peripheral atherosclerosis </td> <td width="177"> 52 (44,8%) </td> </tr> <tr> <td width="638"> Vitamin K antagonist drugs or direct factor Xa inhibitor for chronic AF </td> <td width="177"> 8 (6,9%) </td> </tr> <tr> <td width="638"> Vitamin D in a prophylactic dose of 2000 IU for persons with senile asthenia, a history of falls (recommended, do not receive) </td> <td width="177"> 94 (81,0%) </td> </tr> <tr> <td width="638"> STOPP </td> <td width="177"> </td> </tr> <tr> <td width="638"> Verapamil for patients with CHF III, IV FC </td> <td width="177"> 3 (2,6%) </td> </tr> <tr> <td width="638"> Centrally acting antihypertensive drug (AHD) moxonidine in the absence of intolerance or ineffectiveness of other antihypertensive drugs </td> <td width="177"> 4 (3,4%) </td> </tr> <tr> <td width="638"> Combination of acetylsalicylic acid and clopidogrel as secondary prevention of stroke </td> <td width="177"> 2 (1,7%) </td> </tr> <tr> <td width="638"> NSAIDs + vitamin K agonists or direct thrombin or factor Xa inhibitors (risk of gastrointestinal bleeding) </td> <td width="177"> 16 (13,8%) </td> </tr> <tr> <td width="638"> NSAIDs + antiplatelet agents without H+,K+-ATPase inhibitors </td> <td width="177"> 3 (2,6%) </td> </tr> </tbody> </table> Using the Morisky-Green compliance scale, 75 (66.4%) patients with chronic NCDs were found not to be adherent to treatment (scored 2-4 points). Not sufficiently adherent to treatment (1 point), - 23 (20.3%). Only 15 (13.3%) patients were adherent to treatment (0 points), regardless of the number and nature of comorbidities. A comparative analysis of the degree of compliance with medical recommendations by patients with chronic NCDs showed the absence of significant differences (p0.05) in compliance, regardless of the number and combination of different diseases in one patient. The most adherent to treatment were patients with comorbid pathology: hypertension + ischemic heart disease (stable angina) + type 2 diabetes + CHF and hypertension + ischemic heart disease (stable angina) + stroke + type 2 diabetes (p0.05). Cognitive functions were analyzed in each patient with comorbid pathology (n=116). According to the clock drawing test, only 8 (6.9%) patients with comorbid pathology coped with the task, drew a circle, indicated the numbers in the correct places, the hands showed the specified time 11.10 (10 points) or made slight inaccuracies in the location of the hands (9 points) . Cognitive impairment was found in the majority of patients - 108 (93.1%). Noticeable errors in the location of the arrows (8 points) were identified in 24 (20.7%) patients with CND; the arrows showed the wrong time (7 points), in 59 (50.9%); incorrect arrangement of numbers on the dial: they follow in the reverse order (counterclockwise) or the distance between the numbers is unequal - in 25 (21.6%) patients. The Mini-Cog test (Reproducing words + Drawing a clock) in patients with CND, only 8 (6.9%) remembered 3 words and correctly drew a clock, receiving 5 points. The majority of patients, 83 (71.6%), were found to have cognitive impairment, with a total score of 3-4. A validated screening criterion for highly probable dementia (total score less than 3) was identified in 25 (21.6%) patients. 3 (2.6%) patients did not remember a single word, 5 (4.3%) patients were unable to draw a clock correctly. Unfortunately, the Mini-Cog questionnaire did not make it possible to verify mild and moderate impairment of cognitive functions. In order to clarify the severity of cognitive impairment, we used the brief mental status assessment scale MMSE. The majority of the subjects were oriented in time and place - 98 (84.5%) people; disoriented (did not name the date, month, year, day of the week, season, country, region, city, clinic, floor) 8 (6.9%) patients with CND. 10 (8.6%) patients were partially disoriented. Perception and memory (could not remember and repeat three words) 8 (6.9%) patients with CND. Concentration of attention was impaired in the majority - 74 (63.8%), only every third (42 (36.2%) people) was able to cope with serial counting or pronounce the word earth backwards. Analysis of the ability to correctly name which object is shown (pen) or repeat the sentence: No ifs, ands or buts showed that 64 (55.2%) people coped with the task, every third - 36 (31%) did not cope with the task. Assessment of optical-spatial activity demonstrated the inability to correctly copy the drawing in the majority - 110 (94.8%) patients. Taking into account the final score on the MMSE scale, it was found that only 16 (13.8%) patients did not have cognitive impairment (28-30 points). Cognitive deficit was detected in the majority - 100 (86.2%) patients. Presented with pre-dementia cognitive impairment in 36 (31%) patients with CND; probable dementia of any severity - 64 (55.2%): mild severity - 45 (38.8%), moderate - 17 (14.7%), severe - 2 (1.7%). A geriatric depression scale was used for each patient with CND. Depression with a high degree of probability as a factor of cognitive deficit was diagnosed in more than half of the subjects - 77 (66.4%) people. Patients with diagnosed cognitive, psycho-emotional disorders, senile asthenia in combination with CND were referred to a neurologist, geriatrician for the purpose of conducting a comprehensive geriatric assessment (CGA), clinical observation, treatment, prevention, and rehabilitation. Recommendations for cognitive training are given to each patient. Conclusion. 1. Cognitive impairments are more often detected in elderly women with chronic non-diseases (p0.05): hypertension, coronary artery disease and probable depression. 2. The structure of comorbid pathology is dominated by hypertension + coronary artery disease (in every third), hypertension + target organ damage (in every fifth), hypertension + coronary artery disease (stable angina) + type 2 diabetes + CHF + osteoarthritis (in every tenth). The majority of people aged 60 years and older showed signs of senile asthenia - 100 (86.2%). 3. Irrational combination of antihypertensive drugs with failure to achieve target blood pressure - in 98 (84.5%); target values of LDL in patients with ischemic heart disease, CVD, and peripheral atherosclerosis were not achieved in 76 (65.5%); almost every second person does not receive rational antiplatelet therapy; Prophylactic vitamin D intake in patients with senile asthenia is not carried out in the majority. Only every eighth patient with comorbid pathology is adherent to treatment. 4. Non-dementia cognitive disorders were found in 83 (71.6%) patients (Mini-Cog) and 36 (31%) patients with CND (MMSE); probable dementia was verified according to Mini-Cog and MMSE data in every fifth and every second patient, respectively. 5. Possible depression in elderly and senile people with CND was diagnosed in 77 (66.4%).

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