Frailty: Clinical Guidelines

List of Abbreviations

AH - arterial hypertension

BP — blood pressure

ASA - acetylsalicylic acid**

ASCVD - atherosclerotic cardiovascular disease

ADL - activities of daily living

GS - geriatric syndrome

GP - glycoprotein

DAPT - dual antiplatelet therapy

CAD - coronary artery disease

IADL - instrumental activities of daily living

CGA - comprehensive geriatric assessment

CrCl - creatinine clearance

INR – international normalized ratio

ACS — acute coronary syndrome

FS - frailty syndrome

DM - diabetes mellitus

GFR – glomerular filtration rate

CVD — cardiovascular diseases

TLT - thrombolytic therapy

TSH — thyroid-stimulating hormone

AF – atrial fibrillation

CKD - chronic kidney disease

CHF – chronic heart failure

PCI - percutaneous coronary intervention

EUCALYPTUS - Epidemiological Study of the Prevalence of Geriatric Syndromes and Age-Associated Diseases in Elderly People in Regions of the Russian Federation with Different Climatic, Economic, and Demographic Characteristics (EUCALYPTUS)

25(OH)D - 25-hydroxyvitamin D (calcidiol)

CKD-EPI - Chronic Kidney Disease Epidemiology Collaboration equation

FRAX - Fracture Risk Assessment Tool

START - Screening Tool to Alert to Right Treatment (screening criteria for correct prescription of medications in patients aged 65 years and older)

STOPP - Screening Tool of Older Persons’ Prescriptions (screening for potentially inappropriate prescriptions in older people aged 65 years and older)

Terms and Definitions

Autonomy – independence from outside assistance and the ability to make decisions independently.

Basic functional activity – a person's ability to independently perform basic activities of daily living (personal hygiene, eating, dressing, bathing, using the toilet, short-distance transfers, climbing stairs, controlling urination and defecation).

Geriatric syndrome – a multifactorial age-associated clinical condition that impairs quality of life, increases the risk of adverse outcomes (death, dependency on outside assistance, readmissions, need for long-term care), and functional impairment. Unlike a traditional clinical syndrome, a geriatric syndrome is not a manifestation of pathology in a single organ or body system, but rather reflects a complex of changes across multiple systems. The occurrence of one geriatric syndrome increases the risk of developing others. Geriatric syndromes include: frailty, dementia, delirium, depression, behavioral and psychological symptoms of dementia, osteoporosis, sarcopenia, functional impairment, mobility decline, balance disorders, dizziness, orthostatic syndrome (orthostatic hypotension, orthostatic tachycardia with or without symptoms), sensory deficits (vision loss, hearing loss), urinary/fecal incontinence, constipation, malnutrition, dehydration, chronic pain syndrome.

Delirium – a state of acute confusion.

Very old adults – individuals aged 90 years and older according to the 2012 World Health Organization age group classification.

Instrumental functional activity – a person's ability to independently perform activities of daily living that are more complex than basic functional activities (using the telephone, shopping, cooking, housework, using transport, doing laundry, cleaning, taking medications, managing finances).

Comprehensive geriatric assessment – a multidimensional interdisciplinary diagnostic process that includes assessing physical and psychoemotional status, functional capabilities, and identifying social problems in an older person in order to develop a treatment and monitoring plan aimed at restoring or maintaining the patient's level of functional activity.

Acute-onset functional impairment – a decline in the level of functional activity that develops in less than 30 days.

Pre-frailty - a state preceding the development of frailty syndrome, characterized by the presence of individual signs of frailty that are quantitatively insufficient to diagnose frailty.

Elderly age - 60–74 years according to the 2012 World Health Organization age group classification.

Polypharmacy – simultaneous prescription of 5 or more drug items to a patient, or over 10 items during a course of treatment.

Polymorbidity (multimorbidity) - the presence of two or more chronic diseases in a single patient, regardless of the activity of each.

Sarcopenia – a progressive, generalized skeletal muscle disease associated with an increased risk of adverse outcomes, including falls, fractures, physical disability, and mortality. In geriatrics, the term "sarcopenia" refers to primary sarcopenia – a condition characterized by progressive, generalized loss of skeletal muscle strength, mass, and function due to aging in the absence of other causes.

Frailty – a geriatric syndrome characterized by an age-associated decline in the physiological reserve and function of multiple body systems, leading to increased vulnerability of the older person to endo- and exogenous factors and a high risk of adverse health outcomes, loss of autonomy, and death. Frailty is closely associated with other geriatric syndromes and multimorbidity, is potentially reversible, and influences patient management tactics. There are two models describing frailty, namely the phenotypic model, which includes five criteria (unintentional weight loss, low grip strength, self-reported exhaustion, slow walking speed, and low physical activity), and the deficit accumulation model, which involves assessing 40 to 70 deficits and calculating the frailty index.

Old age – 75–89 years according to the 2012 World Health Organization age group classification.

Physical activity - any bodily movement produced by skeletal muscles that requires energy expenditure.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Frailty is a key geriatric syndrome characterized by an age-associated decline in physiological reserve and function across multiple body systems, leading to increased vulnerability of the older person to endo- and exogenous factors, with a high risk of adverse health outcomes, loss of autonomy, and death. Frailty is closely linked to other geriatric syndromes and multimorbidity, is potentially reversible, and influences patient management tactics.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The concept of frailty was proposed in the early 2000s to characterize the depletion of the body's internal reserves, allowing clinicians to predict a high risk of death and other adverse outcomes in older and very old adults [1, 2]. The foundation of this concept is the understanding of heterogeneity among older and very old populations, and that prognosis and optimal management tactics are determined by more than just chronological age and/or the presence of chronic diseases. The development of frailty is accompanied by a decline in physical and functional activity, as well as the body's adaptive and recovery reserves; it increases the risk of adverse outcomes — hospitalizations by 1.2–1.8 times, functional deficits by 1.6–2.0 times, death by 1.8–2.3 times, physical limitations by 1.5–2.6 times, and falls and fractures by 1.2–2.8 times [3].

In addition to age, risk factors for frailty include low physical activity, poor nutrition, depression, polypharmacy, and social factors (low income, living alone, low education level).

Not all, but the majority of patients with frailty have multiple chronic conditions. Frailty has been associated with cardiovascular diseases (hypertension, coronary artery disease, heart failure), as well as diabetes mellitus, chronic kidney disease, joint and lower respiratory tract diseases, and malignancies [4].

While frailty develops gradually, a decline in functional activity in a patient with frailty can occur quite rapidly. In a stressful situation (infection, hospitalization, changes in pharmacotherapy, etc.), such patients have a high probability of developing or increasing dependency on outside assistance; recovery and rehabilitation are slower than in patients without frailty, and functional activity frequently fails to return to baseline levels.

The development of frailty is preceded by prefrailty, characterized by the presence of isolated signs that are insufficient in number to establish a diagnosis of frailty.

Frailty is considered a potentially reversible condition, though it progresses more often than it regresses. Frailty is not an inherent part of the aging process, but rather is viewed as an unfavorable variant of it. The development of frailty significantly increases the vulnerability of older people to adverse factors, such as an acute illness or trauma, a change in treatment, or surgery [5].

1.3 Epidemiology of the Disease or Condition

According to international studies, the prevalence of frailty among community-dwelling individuals aged 65 years and older averages about 10.7%, and prefrailty is 41.6% [6]. The prevalence of frailty increases with age, reaching 26.1% among individuals aged 85 years and older. Frailty is significantly more often diagnosed in women than in men. In nursing homes, the prevalence of frailty reaches 52.3% [7].

According to Russian studies among the population of St. Petersburg (Kolpino) aged 65 years and older, the prevalence of frailty ranges from 21.1% to 43.9% depending on the diagnostic approach, and prefrailty ranges from 24.7% to 65.5% [8]. Among outpatients in Moscow in the same age category, the prevalence of frailty ranges from 4.2% to 8.9%, and prefrailty from 45.8% to 61.3% [9].

1.4 Features of Coding the Disease or Condition

R54 – Senility without mention of psychosis, old age without mention of psychosis, senile: asthenia, debility.

When formulating a clinical diagnosis, frailty is listed as the first comorbid condition, and all identified geriatric syndromes must be reflected in the diagnosis. Frailty cannot be the sole identified geriatric syndrome.

1.5 Classification of the disease or condition

Depending on the severity of the decline in functional activity, mild, moderate, and severe frailty are distinguished (Table 1) [225].

Table 1. Clinical classification of frailty and its severity

1.6 Clinical presentation of the disease or condition

Elderly and senile patients may present with a number of non-specific signs and symptoms indicating the possible presence of frailty syndrome or an increased risk of its development (Table 2). The most significant signs of frailty are unintentional weight loss of > 5% over a period of less than 6 months and/or > 10% over 6 months or more, falls, urinary incontinence, development of delirium, dementia, dependence on outside help, and significant limitation of mobility [10].

Table 2. Signs and symptoms indicating the possible presence of frailty syndrome or an increased risk of its development

* Signs indicating a higher probability of frailty syndrome in the patient

** Factors predisposing to adverse drug reactions include: presence of ≥4 chronic conditions, chronic heart failure, liver diseases, polypharmacy, history of adverse drug reactions [11]

Symptoms characteristic of frailty may be manifestations not only of geriatric syndromes, but also of chronic diseases. Unintentional weight loss, decreased muscle strength and mobility, decreased physical activity, and fatigue can occur in many chronic conditions—oncological, rheumatological, endocrine diseases, heart and renal failure, and certain neurological diseases (e.g., Parkinson's disease). Identification of frailty in a patient should not preclude a potential diagnostic workup for other, potentially treatable diseases and syndromes that may contribute to the current clinical picture and the patient's functional status.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnosis of frailty syndrome consists of two stages:

1. screening for frailty (performed by any medical worker in contact with patients aged 60 years and older, primarily by a general practitioner (family doctor) or district general practitioner);

2. comprehensive geriatric assessment (performed by a geriatrician, nurse, and other members of the multidisciplinary team).

The algorithm for the physician's actions in diagnosing frailty syndrome is presented in Appendix B.

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process that includes the assessment of the physical, psycho-emotional status, functional capabilities, and social problems of an elderly person in order to develop a treatment and follow-up plan aimed at restoring or maintaining their level of functional activity [20, 21].

The main objectives of CGA are:

1) identifying the main problems that impair the patient's functional status and quality of life;

2) determining the severity of frailty (Table 1);

3) developing an action plan aimed at resolving/eliminating these problems.

The duration of CGA is 1.5 - 2 hours. Given the considerable length of CGA and the potential for patient fatigue, visits to the nurse and the geriatrician can be scheduled on different days with a reasonable interval (e.g., 2-3 days). During CGA, it is important to clarify the expectations and preferences of the patient and their family members. For key points of conducting CGA, see Table 3.

Table 3. Key points of conducting CGA

An important role in the management of patients in the geriatric department belongs to nursing staff. Nursing staff actively participate in performing a number of tests during CGA (Table 4).

Table 4. Components of CGA and the nurse's participation in its implementation.

Based on the CGA, the geriatrician develops an individual management plan for a patient with frailty, which is recommended to include recommendations on the following items:

- physical activity,

- nutrition,

- clinical and psychological training,

- additional laboratory and instrumental examinations, specialist consultations in accordance with the identified geriatric syndromes and conditions affecting the course of frailty,

- correction of identified geriatric syndromes and goal-oriented treatment of the patient's existing chronic diseases. If necessary, for the purpose of patient follow-up, neurologists, cardiologists, endocrinologists, clinical pharmacologists, dietitians, rheumatologists, urologists, obstetrician-gynecologists, otorhinolaryngologists, hearing aid specialists (otorhinolaryngologists), ophthalmologists, trauma and orthopedic surgeons, physical therapy and medical rehabilitation specialists, etc., may be involved as consultants in the multidisciplinary team,

- optimization of drug therapy taking into account STOPP/START criteria with a consultation of a clinical pharmacologist if necessary, as well as assistance with medication intake if necessary (assistance in purchasing medications, use of pill organizers, direct supervision of medication intake, etc.),

- use of means and methods adapting the environment to the patient's functional capabilities and/or the patient's functional capabilities to the environment (mobility aids, cane, walkers, joint prosthetics and orthotics, glasses, hearing aid, etc.),

- organization of a safe home environment,

- referral for rehabilitation measures,

- the level of need for social and domestic assistance and long-term care that can be provided by social services,

- and, depending on the situation, the need for medical patronage and palliative care can be assessed.

If possible, the individual management plan should be discussed with the patient and/or relatives/guardians to ensure that the plan aligns with the patient's goals and priorities and to ensure family/guardian participation in its implementation [20, 21]. It is recommended to hand over the individual management plan for a patient with frailty to the physician directly observing the patient (district general practitioner, general practitioner (family physician)) in order to ensure joint, continuous long-term follow-up. The individual management plan for a patient with frailty is carried out by the physician directly observing the patient, jointly with the geriatrician. The individual management plan for the patient may be revised based on the results of monitoring the patient's functional status.

Planned re-administration of a comprehensive geriatric assessment of a patient with frailty is recommended at least once every 12 months.

Unplanned re-administration of a comprehensive geriatric assessment is recommended when situations arise that significantly affect the patient's functional state (e.g., fractures, acute cerebrovascular accident, oncological disease, acute disease with a long convalescence period (pneumonia), surgical treatment).

In patients with acute functional impairments, in order to establish their cause and determine management tactics, it is necessary to conduct a thorough analysis of the clinical and social situation, rule out acute diseases / exacerbation of chronic diseases, fractures of the femur, thoracic/lumbar spine, and depression.

GCR C (LEL 5)

Comment: If it is not possible to conduct a CGA by a multidisciplinary geriatric team, the management of a patient with frailty syndrome by a district general practitioner, family physician, and medical specialists should be based on a holistic approach to assessing their needs and in cooperation with a geriatrician.

GRL B (LEL 2)

2.1 Complaints and Anamnesis

Patients with frailty syndrome may present with complaints of increased fatigue, decreased activity, increasing difficulties with walking, gait changes, as well as complaints caused by the presence of chronic diseases and geriatric syndromes. Older people themselves often do not present with complaints, considering weakness and slowness to be natural manifestations of aging. Patients with cognitive impairment or depression may not present with complaints or may present them in minimal quantities. Relatives of patients may seek medical help due to changes occurring in the elderly person.

Frailty syndrome is characterized by a gradual progression of symptoms. Rapid (days, weeks) decline in functional activity requires ruling out other causes – decompensation of chronic diseases or onset of acute diseases/conditions, as well as the development of complications from drug therapy.

It is necessary to actively identify symptoms and signs of frailty, assess their duration and development over time, identify direct and indirect signs of decreased autonomy, paying special attention to: weight loss; recurrent falls; gait disturbances; decreased physical activity (the elderly person has started moving less, going out less often, stopped taking walks, etc.); refusal to eat; appearance of untidiness in clothing; decreased ability to perform self-care.

GRL B (LEL 2)

Comments: Identification of frailty syndrome determines the prognosis for the health and life of an elderly patient, their management tactics, and the need for outside assistance and care. Frailty screening at the primary health care level has proven its effectiveness in preventing the decline in the functional status of elderly and senile patients [12, 13]. When patients aged 60 years and older seek medical care, signs indicating the possible presence of frailty syndrome or an increased risk of its development should be actively identified (Table 2). The use of short validated (in a specific country) questionnaires aimed at identifying the main signs of frailty and key geriatric syndromes is an international practice for identifying frailty syndrome that has proven its effectiveness [5, 12, 13]. Frailty screening is carried out as part of the annual clinical examination/preventive check-up (questions from the "Age Is No Obstacle" scale are included in the questionnaire for citizens aged 65 years and older). Based on the screening results, the patient is referred to a geriatrician.

GRL B (LEL 2)

GCR C (LEL 5)

Comment: Depending on the identified problems, the patient is referred, if necessary, for consultations with specialist physicians (ophthalmologist, otorhinolaryngologist-audiologist, neurologist, traumatologist-orthopedist, urologist, etc.).

GCR C (LEL 5)

Comment: a thorough analysis of the medication history and identification of polypharmacy are necessary for all elderly and senile patients, and are especially important in patients with a high probability of frailty syndrome. In elderly and senile patients, the risk of adverse drug reactions increases significantly. The presence of multimorbidity and follow-up by different specialists leads to polypharmacy. Polypharmacy is associated with an increased risk of adverse outcomes (progression of frailty syndrome, cognitive impairment, falls, dependency on assistance, death) [11, 22, 23].

It is necessary to ascertain the list of actually taken medications (name, dose, frequency, route of administration, duration of intake), including over-the-counter drugs, herbal remedies, and dietary supplements. If possible, ask the patient (relatives/guardians/caregivers) to show the medications being taken, and ask the patient to bring all the agents they take to the visit. It is essential to assess the patient's ability to take medications independently, paying attention to cognitive status, manual dexterity, visual acuity, and motivation.

2.2 Physical Examination

Level of Evidence C (Reliability of Evidence Level 4)

Comments: Unintentional weight loss is an important sign and one of the most critical clinical manifestations of frailty syndrome and adverse outcomes [1-6, 301-304]. When weight loss is detected, the oral cavity should be thoroughly assessed, with referral for consultation and treatment to a dentist if necessary; an examination should be performed to rule out diseases of the esophagus, stomach, and duodenum (less invasive diagnostic methods may be used - double-contrast X-ray examination of the stomach and duodenum instead of esophagogastroduodenoscopy). If necessary, the patient can be referred for a consultation with a dietitian, and measures can be taken to organize social assistance (grocery shopping, cooking, feeding) [280, 281]. If malnutrition or the risk of its development is detected, the examination and management of the patient are carried out taking into account the clinical guidelines "Malnutrition in elderly and senile patients".

A decrease in height can be considered as a sign of osteoporosis and/or vertebral body compression fractures. Clinical signs of osteoporosis: a decrease in height by 2 cm or more over 1-3 years or by 4 cm or more compared to age at 25 years, pronounced thoracic kyphosis, a decrease in the distance between the lower ribs and the iliac crest to a width of 2 fingers or less. If height decreases by 2 cm or more over 1-3 years or by 4 cm or more over a lifetime, vertebral compression fracture(s) should be suspected. When osteoporosis is suspected, the examination and management of the patient are carried out taking into account the clinical guidelines "Osteoporosis".

GRL B (LEL 2)

Comment: perform an orthostatic test to detect orthostatic hypotension (after at least 7 minutes of rest in a horizontal position, measure blood pressure on peripheral arteries (3 times with a 1-minute interval) and measure heart rate; ask the patient to assume a vertical (or sitting, if impossible) position and measure blood pressure on peripheral arteries and heart rate after 1, 2, and 3 minutes; note the presence of symptoms. Orthostatic hypotension is defined as a decrease in SBP of 20 mm Hg or more and/or DBP of 10 mm Hg or more upon transition to a vertical position; and by 15 and 7 mm Hg, respectively, upon transition to a sitting position);

Level of Evidence C (Reliability of Evidence Level 5)

Comment: when assessing fall risk factors, one should be guided by the clinical guidelines "Falls in elderly and senile patients", posted in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

Level of Evidence B (Reliability of Evidence Level 1).

Comment: For patients with a FRAX fracture risk in the yellow (orange) zone, dual-energy X-ray absorptiometry of the lumbar spine and proximal femur is recommended. If osteoporosis is detected, anti-osteoporotic therapy is indicated without re-evaluating FRAX. Patients with a FRAX fracture risk in the red zone are not indicated for dual-energy X-ray absorptiometry of the lumbar spine and proximal femur; the patient unequivocally needs to be prescribed anti-osteoporotic therapy. Patients with a result in the green zone are not indicated for dual-energy X-ray absorptiometry of the lumbar spine and proximal femur, and the patient does not need to be prescribed anti-osteoporotic therapy.

For the diagnosis of osteoporosis and follow-up in elderly and senile patients, including those with frailty syndrome, radiofrequency echographic multispectrometry can be used, the accuracy of which in assessing bone mineral density of the hip and spine, and predicting fracture risk is comparable to dual-energy X-ray absorptiometry, while the portability of the device allows it to be used at the patient's bedside [333-336].

The management of patients with frailty syndrome and osteoporosis is carried out taking into account the clinical guidelines "Osteoporosis", posted in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

Level of Evidence C (Reliability of Evidence Level 4)

Comments: Sensory impairments (vision and hearing loss) make it difficult to perform daily tasks, increase the risk of cognitive impairment, depression, falls, social isolation, and worsen the prognosis for the life of older people. If sensory deficits are detected, it is advisable to refer the patient for consultation with appropriate medical specialists - an ophthalmologist, an otorhinolaryngologist-audiologist.

Level of Evidence C (Reliability of Evidence Level 5)

Level of Evidence A (Reliability of Evidence Level 2)

Comment: in patients with detected chronic pain syndrome, it is necessary to assess pain intensity using scales (Appendix G12, Appendix G13) [63-67]; assess the neuropathic component of pain, the presence of which is judged by pain patterns (electricity, burning, paresthesia, numbness) and/or the touch test (Ipswich touch test; if sensitivity is absent in more than 2 locations when touching the 1st, 3rd, and 5th toes bilaterally, there is a high probability of neuropathy). To detect pain and assess its intensity in patients with dementia, the pain assessment scale for severe dementia is used (Appendix G14) [68].

When chronic pain syndrome is detected, the examination and management of the patient are carried out taking into account the clinical practice guidelines «Chronic pain in elderly and senile patients», published in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

CGR C (LeV 3)

Comment: When malnutrition or the risk of its development is detected, the examination and management of the patient are carried out taking into account the clinical practice guidelines «Malnutrition in elderly and senile patients», published in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

Level of Evidence A (Reliability of Evidence Level 2)

CGR B (LeV 1)

CGR C (LeV 4).

CGR B (LeV 3).

Comments: The development of dependence on outside help is a stronger predictor of mortality and is of greater importance for assessing the prognosis for the patient's life and health than even the presence of specific diseases. Dependence on outside assistance in daily life necessitates the organization of patient care. Reduced mobility is a predictor of dependence, disability, cognitive decline, falls, hospitalizations, and all-cause mortality [27-30]. Muscle weakness is one of the key components of the frailty syndrome and is associated with it more strongly than with chronological age [15].

CGR A (LeV 2).

Comment: to assess cognitive status during CGA, the Mini-Mental State Examination (Appendix G6) [38], or the Montreal Cognitive Assessment scale (Appendix G7) [40], or the Frontal Assessment Battery (Appendix G8) [41] may be used.

When cognitive impairment is detected, the examination and management of the patient are carried out taking into account the clinical practice guidelines «Cognitive disorders in elderly and senile individuals», published in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

GRL B (LEL 2)

Comment: For depression screening in elderly and senile patients, it is recommended to use the Geriatric Depression Scale (Appendix G9) [49] and the 36-Item Short Form Survey / Health Assessment Questionnaire (Appendix G10) [57]. To detect depression in patients with moderate or severe dementia, it is recommended to use the Cornell Scale for Depression in Dementia (Appendix G11) [48]. If signs of depression are detected in elderly and senile patients, the presence of suicidal thoughts and plans should be ascertained. Management of patients with overt depression, especially in the presence of suicidal ideation, is carried out in conjunction with a psychiatrist.

Level of Evidence B (Grade of Recommendation 2)

Comment: The patient's social status is partially assessed by all members of the geriatric team, but the most complete assessment is carried out by a social work specialist. During CGA, data on the level of education, profession, marital status of the patient, who the patient lives with, who is contacted for help if necessary, are clarified, domestic safety is assessed, and signs of neglect, self-neglect, and abuse of elderly individuals are identified [49, 50].

Level of Evidence B (Grade of Recommendation 2)

2.3 Laboratory Diagnostics

Due to the nonspecific manifestations of frailty, the possibility of the occurrence/worsening of functional impairments in an elderly person against the background of an acute illness or exacerbation of a chronic disease, and the possibility of an atypical clinical presentation of diseases, a complex of laboratory and instrumental examinations must be performed during CGA for the diagnosis/differential diagnosis of conditions that potentially affect the course of frailty and/or have similar clinical manifestations, including anemia, heart failure, diabetes mellitus, chronic kidney disease, liver and thyroid dysfunction, electrolyte disturbances, etc. Performing part of the examination prior to referring the patient for a consultation with a geriatrician will reduce the number of visits by a frail patient to a medical institution and will contribute to faster and higher-quality CGA and the development of an individualized management plan.

The list of laboratory diagnostic tests may be expanded in accordance with the identified geriatric syndromes and conditions affecting the course of frailty.

GRL B (LEL 2)

Comments: in addition to calculating GFR using the CKD-EPI formula, it is advisable to calculate creatinine clearance using the Cockcroft-Gault formula, since this parameter is used for dose adjustment in the instructions for use of many medications.

LeV B (LoE 3)

Comments: anemia is a frequently occurring condition in elderly and senile patients, associated with an increased risk of development and progression of frailty syndrome (FS) [52, 53, 54]. Even mild anemia increases the risk of mortality, raises morbidity, reduces quality of life, and is associated with the development of depression, delirium in hospitalized patients, deterioration of functional status, and cognitive impairment. When anemia is detected, it is necessary to clarify its nature by examining the serum iron level, blood ferritin level, vitamin B12 (cyanocobalamin) blood level, and serum folic acid level.

GCR C (LEL 5)

LeV B (LoE 3)

Level of Reliability of Evidence C (Level of Credibility of Data 4)

Comments: a decrease in the concentration of total protein and serum albumin in patients with FS syndrome is a sign of protein-energy malnutrition and undernutrition. Low levels of total protein and serum albumin are closely associated with the life prognosis of a patient with FS.

Level of Reliability of Evidence C (Level of Credibility of Data 4)

Level of Evidence A (Grade of Recommendation 2)

Comments: the blood level of vitamin 25(OH)D₃ is a strong independent prognostic marker of the course and outcomes of FS syndrome.

2.4 Instrumental Diagnostics

In patients with highly probable FS, it is recommended to evaluate the status of previously diagnosed chronic diseases, as well as to perform differential diagnosis between frailty syndrome and diseases with similar clinical manifestations using necessary instrumental examinations. The scope of examination is determined taking into account the CGA results, the physician's clinical judgment on the patient's expected life expectancy, and the personalized goals of their treatment. When making a decision on conducting a diagnostic search or examination related to a chronic disease, one should take into account the contribution of this condition/disease to the progression of FS syndrome, consider the tolerability and potential risks associated with the examination, and the impact of the examination results on the patient's further management in the context of preserving functional activity and quality of life. The scope of diagnostic procedures in patients with FS may be incomplete relative to the clinical guidelines for this condition.

The list of instrumental diagnostic examinations may be expanded in accordance with the identified geriatric syndrome and the condition affecting the course of FS.

Level of Evidence C (Reliability of Evidence Level 4)

GCR A (LEL 1)

GRC C (LeE 5)

GRC C (LeE 5)

Comment: among urination disorders and lower urinary tract symptoms, urinary incontinence is one of the most frequent geriatric syndromes and, according to the EUCALYPTUS study, is detected in 45.3% of patients over 65 years old, reaching 60.8% at the age of 85 and older [340]. The patient's treatment tactics depend on the type of urinary incontinence. To determine further tactics when urinary incontinence is detected by a general practitioner, geriatrician, or family physician, it is advisable to detail the patient's complaints using the following questions:

1. Do you have a feeling of incomplete bladder emptying after urination?

2. Do you have intermittent urination?

3. Do you have a weak urine stream?

4. Do you have to strain to start urinating?

5. Do you experience urine loss during physical exertion?

6. Do you have the urge to urinate earlier than 2 hours after your last urination?

7. Do you find it difficult to temporarily refrain from urinating?

8. Do you get out of bed more than once to urinate after going to sleep until you have to get up in the morning?

9. Is there continuous incontinence (leakage, dribbling) of urine between urinations?

When answering "yes" to questions 1-5, 9, the patient must be referred for a urologist consultation (when answering "yes" to question 5, a consultation with an obstetrician-gynecologist is possible for women). When answering "yes" to questions 6-8, refer the patient for an ultrasound examination with residual urine volume determination. If residual urine is present in an amount of more than 50 ml, a urologist consultation is indicated. In the absence of residual urine, the general practitioner, geriatrician, or family physician may prescribe drug treatment with agents for frequent urination and urinary incontinence, followed by a routine referral to a urologist. Treatment and follow-up of a patient with urinary incontinence are carried out in accordance with the clinical guidelines "Urinary Incontinence" posted in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

GRL B (LEL 2)

2.5 Other Procedures

Upon detection/suspicion of other GS in elderly and senile patients with FS syndrome, diagnostic examinations are performed in accordance with current clinical guidelines ("Chronic Pain in Elderly and Senile Patients", "Cognitive Disorders in Elderly and Senile Individuals", "Urinary Incontinence", "Malnutrition in Elderly and Senile Patients", "Falls in Elderly and Senile Patients", "Osteoporosis").

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Basic principles of treatment for patients with frailty syndrome

The main principles of managing patients with FS syndrome are:

1. Preservation and maintenance of autonomy and improvement of quality of life

2. Goal-oriented approach

3. Patient-oriented approach and an individual approach to choosing management tactics

4. Active identification of the need for geriatric care

5. Overcoming barriers in communication with the patient

6. Interdisciplinary collaboration and teamwork within the geriatric care team

7. Communication with family members, caregivers, and legal guardians

8. Continuity of patient care across various medical and social care facilities, with a focus on long-term care and ensuring interagency coordination (healthcare and social services)

Preservation and maintenance of autonomy and improvement in quality of life. The most important specific goal of treatment for elderly and senile patients, regardless of the presence of the frailty syndrome (FS), is to maintain and, whenever possible, improve their functional status while preserving autonomy for as long as possible through reliable and safe control of existing diseases, prevention of the progression of current geriatric syndromes (GS), and the onset of new ones.

Goal-oriented approach. Identifying FS in a patient implies a lower life expectancy. This specific patient group stands to benefit the most from a comprehensive geriatric assessment (CGA) and the application of a holistic geriatric approach. Diagnosing FS may necessitate adjusting the goals of patient care and treatment tactics.

The presence of multiple diseases and GS in frail and dependent patients with FS makes it impossible to simultaneously diagnose and manage them in full. The choice of the priority treatment direction at any given time should be based on CGA results, adhering to the following sequence:

1. Treatment of potentially life-threatening diseases and conditions

2. Management of diseases and GS that impair functional activity and impact the quality of life at the present moment

3. Management of diseases and GS that impair functional activity and impact long-term quality of life, taking into account the patient's life expectancy.

When choosing a treatment method, the following should be considered:

- confirmation of its efficacy in clinical trials for the given disease,

- the population in which its efficacy was demonstrated,

- the dosages used and the duration of administration of the prescribed drugs.

Patient-oriented approach and individualized selection of management tactics. The general healthcare delivery system is primarily focused on treating specific diseases. Such a "disease-oriented approach" is suboptimal and sometimes even harmful [70, 71], primarily because clinical evidence for management recommendations regarding a specific condition/disease is based on trial data obtained from younger patients with low levels of comorbidity who take significantly fewer medications than elderly and senile patients with numerous chronic conditions or patients with FS. A patient-oriented approach considers not the sheer sum of chronic diseases in an elderly or senile patient, but rather their functional and cognitive preservation, dependence on outside assistance, and quality of life. When deciding on treatment, this approach takes into account the patient's preferences, priorities, and life goals.

When formulating an individualized management plan for a patient with FS, it is important to assess the applicability of existing clinical guidelines for various nosologies to the specific patient, taking into account identified GS, functional status assessments, cognitive and emotional impairments, social issues, and life expectancy. Managing patients with FS requires particularly careful weighing of the risks and benefits of all therapeutic and diagnostic procedures, as aggressive treatment of chronic conditions, frequent hospitalizations, and overtreatment in non-life-threatening situations may lead to risks outweighing benefits and a decline in the patient's quality of life.

Active identification of the need for geriatric care. It is necessary to actively identify the need for geriatric care among patients seeking medical attention, as elderly individuals themselves may not voice complaints caused by FS or other GS (falls, urinary incontinence, depression, cognitive impairment).

Overcoming communication barriers with the patient. An important professional skill for a geriatrician and other members of the geriatric team is the ability to overcome barriers when communicating with elderly and senile patients. Hearing loss, slowed speech and movement, cognitive decline, and multiple comorbidities all require patience and the ability to use non-verbal techniques and special devices during communication.

Interdisciplinary collaboration and teamwork within the geriatric care team. The presence of multiple other GS and polymorbidity in patients with FS necessitates the involvement of multidisciplinary specialists in their care. It is essential to ensure coordination among all team members—physicians, nurses, social workers, and caregivers. Each member of the interdisciplinary team contributes to assessing the patient's condition and needs, enabling the most optimal decision regarding their management tactics. Periodic team discussions of management tactics help reduce the prevalence of polypharmacy and improve patient adherence and satisfaction with the quality of medical and social care.

Interaction with family, caregivers, and guardians. Patients with FS are dependent on outside assistance to a greater or lesser extent. Successful management of such patients is impossible without close cooperation between the members of the geriatric team, family members, and caregivers. Identified health problems, established therapy goals and methods to achieve them, activities of daily living requiring assistance, possibilities and methods of non-pharmacological therapy, and the drug treatment plan must be discussed. When hospitalizing a patient with FS, it is important to ensure unrestricted visiting hours for family members, which helps reduce the likelihood of delirium. Discharge-related issues should also be discussed with family members as early as the patient's admission to the department, involving a social worker if necessary.

Continuity of patient care across various medical and social care facilities with a focus on long-term care and ensuring interagency coordination (healthcare and social services). The high rate of re-hospitalizations, as well as the high prevalence of loneliness and living alone against the backdrop of dependence on outside assistance, require continuity of care and close cooperation between medical and social services at all stages of care for patients with FS. Coordinating the patient's management plan upon discharge home from the hospital or during transfer from one facility to another is especially important.

3.2 Non-pharmacological treatments for frailty

Level of Reliable Evidence (LRE): A (Level of Data Validity: 1)

Comments: Chronic physical inactivity in elderly and senile individuals is one of the significant pathogenetic mechanisms in the development of FS. The benefits of physical exercise for elderly and senile individuals have been proven to enhance functional activity, mobility, and quality of life, and to reduce the risk of falls. Exercise programs are an effective means of preventing the progression of FS and prefrailty, as well as other GS [73, 76].

GCR A (LEL 1)

Comments: Physical activity and exercise programs for patients with frailty syndrome must be regular and long-term, tailored to the individual patient, and of sufficient intensity to improve muscle strength and balance. The intensity and/or duration of training must be increased gradually. To improve functional activity, resistance and strength exercises should be combined with exercises that simulate daily activities, such as sit-to-stand exercises, tandem walking, stair climbing, weight-shifting from one leg to the other, straight-line walking, and single-leg balancing. Training programs must be designed by qualified specialists (exercise therapy physicians). The training program must be regularly reviewed and adjusted depending on the patient's progress and changes in their condition.

GCR C (LEL 5)

Comments: The diet of a patient with frailty syndrome must include meat and fish dishes, and dairy products (cottage cheese, cheese, and yogurt are preferred). Total fluid intake should be at least 1.5 liters (including food and beverages), with pure fluids accounting for at least 800 ml. Due to decreased carbohydrate tolerance with age, it is recommended to consume foods containing complex carbohydrates and rich in dietary fiber. The diet should contain sufficient amounts of fresh vegetables and fruits. Sodium chloride intake should not exceed 5.0 g per day, but if an older person has not previously adhered to this salt intake level, abrupt restrictions should not be introduced. Detailed nutrition issues are set out in the clinical guidelines "Malnutrition in Older and Senile Age Patients", which must be used in the management of elderly and senile patients.

GCR C (LEL 5)

Comments: Protein requirements in older adults are higher than in young and middle-aged adults. Consuming an adequate amount of protein and essential amino acids is of paramount importance for the treatment and prevention of frailty syndrome and sarcopenia. Increasing protein intake helps increase muscle mass and function. The amount of protein required to maintain muscle mass in old age is 1.0–1.5 g/kg of body weight per day. Consuming this amount of protein is safe provided the GFR is not less than 30 ml/min/1.73 m². The optimal intake per meal is 25–30 grams of high-quality, easily digestible protein. Detailed information is provided in the clinical guidelines "Malnutrition in Older and Senile Age Patients".

Level of Evidence B (Strength of Recommendation 2)

Comments: The use of enteral nutrition products (sip feeds) in patients with frailty syndrome has a positive effect on slowing the progression of frailty and sarcopenia without a negative impact on serum urea levels and creatinine clearance [82, 86, 87].

Absolute indications for prescribing active nutritional support in the form of sip feeding include [86]: the presence of a relatively rapidly progressive and significant weight loss of more than 2% in a week, 5% in a month, 10% in a quarter, or 20% in 6 months; existing baseline signs of hypotrophy in the patient: body mass index less than 19 kg/m², arm circumference < 90% of standard (less than 26 cm in men and 25 cm in women), hypoproteinemia (< 60 g/l), hypoalbuminemia (< 30 g/l), absolute lymphopenia (< 1.2* 10⁹/l).

Detailed information is provided in the clinical guidelines "Malnutrition in Older and Senile Age Patients".

GCR C (LEL 5)

Comments: Despite the fact that the prevalence of overweight and obesity increases with age, older adults are characterized by the development of sarcopenic obesity with a decrease in muscle mass [92-95]. Unlike middle-aged people, in older people, an increase in body mass index to 25–29.9 kg/m² compared to its normal values is associated with a decrease, rather than an increase, in the risk of death [91, 93]. Overweight is associated with greater bone mineral density, a lower risk of osteoporosis and hip fracture, whereas weight loss is associated with a decrease in bone mass [94]. In senile individuals, any weight loss (intentional or not) can have potentially dangerous consequences in the form of the development and/or progression of sarcopenia, malnutrition, bone mass loss, and increased mortality [88, 94]. If the advantages of a weight loss strategy are obvious, the most acceptable therapeutic approach is a moderate restriction of the energy value of the diet, aimed at moderate weight loss. The assessment of the benefits of interventions in patients with frailty and obesity should be based on changes in body composition and improved functional capabilities, rather than on weight loss. Protein intake in this case should be at least 1 g/kg of body weight/day, accompanied by an adequate intake of micronutrients and necessarily combined with regular physical activity.

GCR A (LEL 1)

Comments: Elderly and senile patients, especially in the presence of frailty syndrome, and their relatives/guardians/caregivers should be given necessary recommendations on organizing a safe home environment to reduce the risk of falls. Assessing the safety of living conditions along with behavior modification have proven effective in reducing both the number of falls and the number of elderly people who fall. Multifactorial interventions to organize a safe home environment should be carried out with the participation of a geriatrician and other specialists (nurse, social work specialist) after assessing the patient's living conditions.

Recommendations that can be given to relatives of a patient with frailty syndrome: selecting a comfortable height for furniture (beds, armchairs, toilet, etc.); ensuring furniture stability; installing handrails, especially in the bathroom; using non-slip floor coverings; choosing traumatic-safe floor coverings (e.g., wall-to-wall carpeting); eliminating thresholds where possible; adequate, but not too bright lighting; contrast markings on stairs and steps.

GRL B (LEL 2)

Comments: Improperly fitted footwear can increase the risk of falls and reduce the stability of an older person. Improperly fitted footwear is considered to be: footwear with a heel height exceeding 4.5 cm; slingback shoes; footwear with a heel counter that can be compressed by more than 45°; completely worn-out footwear or footwear with an absolutely flat sole.

GRL B (LEL 2)

Comments: The use of clinical and psychological training and teaching the patient's relatives the tactics and methods of restoring cognitive functions in patients has a positive effect on the course of frailty syndrome for community-dwelling older adults. Conducting clinical and psychological training in older people helps improve mobility and functional activity indicators. Complex interventions including short-term memory and attention training, physical exercise, and nutritional interventions are most effective.

Level of Evidence A (Grade of Recommendation 2)

Comments: Loneliness and social isolation are risk factors for the development and progression of frailty syndrome.

3.3 Pharmacotherapy

GCR C (LEL 5)

Comments: Drug therapy for patients with frailty syndrome should be prescribed taking into account the results of comprehensive geriatric assessment (CGA), the patient's life priorities, and should be oriented towards optimal quality of life and maintaining the patient's independence from outside help.

LeV B (LoE 3)

Comment: In elderly patients, the use of certain medications can lead to the development or worsening of geriatric syndromes or the development of potentially hazardous conditions, the appearance of which may require the withdrawal/modification of drug therapy and the transition to other treatment regimens, including non-pharmacological ones. Special attention should be paid to assessing the anticholinergic burden. Systemic, peripheral, and central anticholinergic effects can lead to adverse clinical consequences in older adults (cognitive decline, visual impairment, increased risk of falls, etc.). Anticholinergic activity is possessed not only by drugs that directly affect the cholinergic system, but also by drugs whose mechanism of action is not directly related to this system, but which have demonstrated anticholinergic activity in experiments or clinical studies. It is important to understand that while the use of a single medicinal product with anticholinergic activity may not have a significant negative impact, the combination of several drugs makes the impact clinically significant. If there are several medicinal products for the treatment of a disease/condition, it is reasonable to prefer the drug with the lowest anticholinergic activity or a different mechanism of action (for example, in the treatment of urge urinary incontinence, mirabegron, whose mechanism of action is related to selective beta-3 adrenergic receptor agonism, has a better safety and tolerability profile compared to drugs with m-cholinolytic effect [338, 339]). Scales for assessing the anticholinergic burden are presented in Methodological Guidelines MP103 "Pharmacotherapy in Elderly and Senile Patients".

Level of Reliability of Evidence B (Confidence Level of Evidence 3)

Comment: Polypharmacy is associated with a significant increase in the risk of adverse events, an increase in the duration of hospitalization, and an increased risk of adverse outcomes. A thorough analysis of indications, contraindications, potential drug-drug interactions, and drug dosages should be regularly performed. For the screening of potentially inappropriate prescribing of medications, it is advisable to use STOPP/START criteria to identify unjustified prescriptions and inappropriately omitted medications.

Level of Reliability of Evidence B (Confidence Level of Evidence 1)

Comment: Vitamin D deficiency corresponds to a 25(OH)D₃ concentration of <20 ng/mL (50 nmol/L), vitamin D insufficiency to 25(OH)D₃ from 20 to 30 ng/mL (from 50 to 75 nmol/L), and an adequate level to more than 30 ng/mL (75 nmol/L). The recommended target level of 25(OH)D₃ for correcting vitamin D deficiency is 30-60 ng/mL (75-150 nmol/L) [112]. To prevent vitamin D deficiency, it is recommended to prescribe at least 800-1000 IU of vitamin D and its analogues per day; to maintain a 25(OH)D level above 30 ng/mL, a consumption of at least 1500-2000 IU of vitamin D per day may be required. The recommended drug for treating vitamin D deficiency is cholecalciferol**. Treatment of vitamin D deficiency in adults should be initiated with a total loading dose of cholecalciferol** of 400,000 IU using one of the proposed regimens (Appendix A3-7) followed by a transition to maintenance doses [112].

Level of Evidence A (Grade of Recommendation 2)

GRL B (LEL 2)

GCR A (LEL 1)

GRL B (LEL 2)

3.4 Features of the treatment of comorbid diseases and conditions in patients with frailty syndrome

GRL B (LEL 2)

Comment: Individually tailored management of diseases and clinical conditions is effective in improving physical and functional activity indicators in patients with frailty syndrome, improves the quality and prognosis of life, allows for a more rational use of healthcare resources by reducing treatment costs for community-dwelling elderly people without increasing inpatient and outpatient management costs.

A practical approach to managing such patients implies:

- identifying a priority disease, the treatment of which at the given time will improve the patient's quality of life and health prognosis;

- determining which treatment can be discontinued due to limited benefit or high risk of adverse events;

- using non-pharmacological therapy methods as a possible alternative to certain medicinal products.

3.4.1 Arterial hypertension

Level of Reliability of Evidence B (Confidence Level of Evidence 3)

Level of Reliability of Evidence C (Confidence Level of Evidence 5)

Level of Reliability of Evidence C (Confidence Level of Evidence 5)

Level of Recommendation A (Level of Evidence 2)

Level of Recommendation B (Level of Evidence 3)

• It is recommended to initiate antihypertensive therapy with a single drug at a low dose, switch to combination therapy only if monotherapy is ineffective, and use no more than 3 antihypertensive drugs in patients with frailty to ensure treatment safety [125, 126, 128-130].

Level of Recommendation C (Level of Evidence 5)

Level of Recommendation B (Level of Evidence 1)

Comment: There are no unified guidelines for the treatment of arterial hypertension in patients with frailty syndrome. However, available data support prescribing antihypertensive therapy to "robust" elderly and senile patients, with a management approach similar to younger patients with hypertension, but aiming for a more liberal target blood pressure level. Regarding patients with severe frailty, there is no evidence that antihypertensive therapy reduces the risk of cardiovascular outcomes, but there is evidence of its lack of safety regarding the maintenance of the patient's cognitive functions and functional abilities.

3.4.2 Atrial fibrillation

Level of Recommendation C (Level of Evidence 4)

Comments: In elderly patients with non-valvular atrial fibrillation and CrCl >30 ml/min, it is preferable to prescribe apixaban**, rivaroxaban**, or dabigatran etexilate** rather than warfarin** [137]. Apixaban** and rivaroxaban** are not recommended when CrCl <15 ml/min, and dabigatran etexilate** when CrCl <30 ml/min (Appendix A3-8). In case of renal impairment (CrCl <30 ml/min), warfarin** is the drug of choice. When using warfarin** in elderly patients, lower doses may be required to achieve target INR values, along with more frequent INR monitoring. Target INR values during warfarin** therapy are 2.0-3.0 (for all indications except the prevention of thromboembolism in patients with artificial heart valves) regardless of age. When treating VTE, dose adjustment of apixaban**, rivaroxaban**, or dabigatran etexilate** depending on age is not required.

3.4.3 Antithrombotic therapy

GCR C (LEL 5)

Level of Evidence A (Grade of Recommendation 2)

GRL B (LEL 2)

Comments: The duration of DAPT in patients with acute coronary syndrome (with or without PCI) is 12 months; in patients with stable coronary artery disease undergoing elective PCI, it depends on the type of implanted stent (1-6 months). In acute coronary syndrome and high bleeding risk, clopidogrel** is preferred over prasugrel or ticagrelor**. A loading dose of clopidogrel** during thrombolytic therapy is not recommended in patients ≥75 years old, regardless of the presence of frailty syndrome.

GCR C (LEL 5)

3.4.4 Prescription of HMG-CoA reductase inhibitors for primary and secondary prevention

Level of Evidence A (Grade of Recommendation 2)

Level of Evidence A (Grade of Recommendation 2)

Comment: it is not recommended to initiate therapy with HMG-CoA reductase inhibitors for the primary prevention of cardiovascular diseases in patients aged 75 years and older due to the lack of convincing data on the benefit of initiating such therapy in this age group. In patients aged 75 years and older, therapy with HMG-CoA reductase inhibitors previously prescribed for the primary prevention of cardiovascular diseases may be continued, provided it is well tolerated and aligns with the patient's preferences. The prescription of HMG-CoA reductase inhibitors for the secondary prevention of cardiovascular diseases is carried out taking into account relevant clinical guidelines, the patient's general geriatric status, polymorbidity and polypharmacy, life expectancy, and patient preferences.

3.4.5 Treatment of heart failure

Management of patients with frailty syndrome and heart failure should be carried out by a multidisciplinary team (cardiologist, geriatrician, other specialist physicians depending on identified geriatric syndromes and concomitant conditions, social work specialists) based on a domain-based approach that takes into account the clinical, functional, cognitive, and social status of the patient [154, 155]. Drug treatment of heart failure in elderly and senile patients should be carried out in accordance with current clinical guidelines with careful monitoring of clinical safety parameters (blood pressure level, geriatric syndromes) and laboratory safety parameters (glomerular filtration rate, blood levels of potassium, sodium, chlorine) due to the increased risk of adverse events in frailty.

LeV B (LoE 3)

GCR A (LEL 1)

3.4.6 Diabetes mellitus

GCR C (LEL 5)

Table 5. Individualized selection of the target HbA1c level in diabetes mellitus in elderly and senile patients (with a low life expectancy <5 years, treatment goals may be less stringent)

Comment: Treatment goals for elderly patients with diabetes mellitus depend not only on life expectancy, but also on the cardiovascular system status, the risk of hypoglycemia, preserved cognitive functions, and the ability to perform regular self-monitoring of blood glucose. When choosing oral glucose-lowering therapy, it is necessary to consider the risk of hypoglycemia, nephro-, hepato-, and cardiotoxicity, the risk of drug interactions, and convenience of use for the patient, relatives, or caregivers. In elderly and senile patients, metformin**, dipeptidyl peptidase-4 (DPP-4) inhibitors (alogliptin**, vildagliptin**, linagliptin**, saxagliptin**, sitagliptin**), or glucagon-like peptide-1 (GLP-1) receptor agonists (insulin glargine + lixisenatide**) can be used as the safest options regarding the risk of hypoglycemia. Sulfonylurea derivatives should be prescribed with caution due to an increased risk of hypoglycemia with aging. Glibenclamide** is not recommended for patients over 60 years of age. Sodium-glucose cotransporter-2 (SGLT2) inhibitors (empagliflozin**, dapagliflozin**) are used with caution and should not be used with diuretics due to the risk of hypovolemia and orthostatic hypotension.

Insulin therapy does not differ from the regimens proposed for younger patients with type 2 diabetes mellitus. However, it should be borne in mind that elderly patients should start insulin therapy with long-acting insulins and their injectable analogues, or long-acting insulins and their injectable analogues in combination with short-acting insulins and their injectable analogues. Intensified insulin therapy is possible only if the elderly patient's cognitive functions are preserved, and after training in the basic rules of insulin therapy and blood glucose self-monitoring.

3.4.7 Pre-dementia cognitive impairment and dementia

Dementia is one of the main causes of dependence on outside assistance and reduced quality of life worldwide. The most common cause of dementia in patients with frailty syndrome is Alzheimer's disease. Considering the specifics of coding Alzheimer's disease in ICD-10, the diagnosis can be established by a psychiatrist, neurologist, or geriatrician. The management of patients with frailty syndrome suffering from dementia includes close contact with relatives and caregivers, taking into account the possible development of emotional and behavioral disorders, the high prevalence of other geriatric syndromes such as malnutrition and dysphagia, pressure ulcers, delirium, social isolation, and abuse. The management of such patients should be based on the clinical guidelines "Cognitive Impairment in Elderly and Senile Patients" and include pharmacotherapy for dementia, correction of behavioral and psychological symptoms of dementia, addressing patient safety issues, and providing care. It should be taken into account that the treatment of emotional and behavioral disorders in patients with senile asthenia and dementia is carried out using lower doses of medicinal products.

Level of Reliability of Evidence B (Confidence Level of Evidence 1)

Comments: There is evidence of the efficacy of combination therapy (concurrent administration of memantine** and anticholinesterase agents) compared to monotherapy. It is believed that this increases efficacy, temporarily improves cognitive functions and daily activity, and reduces the severity of behavioral disorders, agitation, and aggression. It is advisable to prescribe combination therapy when the efficacy of monotherapy decreases, as well as in moderate and severe dementia.

3.4.8 Depression

Leveled Clinical Effectiveness (LCE) A (Level of Reliable Evidence [LRE] 1)

Level of Evidence A (Grade of Recommendation 2)

GCR C (LEL 5)

Comments: the prevalence of depression increases with age due to common pathogenetic links with senile asthenia. The development of depression in an elderly person worsens the quality of life, leads to a decline in functional status, and increases the risk of death. In the presence of suicidal thoughts and/or a history of suicide attempts, the risk of suicide increases in the first weeks of treatment, so such patients must be treated only under the supervision of a psychiatrist. The following antidepressants can be used to treat depression in elderly and senile patients: sertraline**, citalopram, escitalopram, venlafaxine, duloxetine, mirtazapine. Treatment should be started at very low doses. The listed drugs should not be combined with non-selective monoamine oxidase inhibitors and type A monoamine oxidase inhibitors—there must be an interval of at least 2 weeks before prescribing them.

Leveled Clinical Effectiveness (LCE) C (Level of Reliable Evidence [LRE] 5)

Comment: in elderly and senile patients, the prescription of these drugs is associated with the development of angle-closure glaucoma, urinary retention, cardiac arrhythmias, delirium, cognitive decline, etc.

3.4.9 Chronic pain syndrome

Treatment of chronic pain syndrome in patients with senile asthenia is carried out based on the clinical guidelines "Chronic Pain in Elderly and Senile Patients". Pharmacological treatment methods must take into account STOPP/START criteria when prescribing analgesics and be based on Methodological Guidelines MR103 "Pharmacotherapy in Elderly and Senile Patients". It must be taken into account that the efficacy and toxicity of drugs, as well as the sensitivity of pharmacological targets for the treatment of chronic pain in patients with senile asthenia, differ from those in younger patients. Multidisciplinary management of patients with difficult-to-control/uncontrolled chronic pain syndrome is advisable, involving a geriatrician, neurologist, general practitioner/internist, and rheumatologist, and a psychiatrist if a psychogenic pain component is present.

GCR C (LEL 5)

GCR C (LEL 5)

GCR C (LEL 5)

GCR C (LEL 5)

3.4.10 Anemia

GCR C (Leveled Evidence 3)

Comments: The presence of anemia is associated with the risk of development and progression of SA. The use of antianemic drugs and an increase in hemoglobin concentration by 10 g/L are associated with a reduced risk of SA development and its progression [325,326]. To normalize hemoglobin levels and improve functional status in patients with SA syndrome and confirmed iron deficiency, it is preferable to prescribe parenteral trivalent iron preparations with [327-329]. Oral administration in elderly patients with SA syndrome may be ineffective, since SA is associated with excessive synthesis of pro-inflammatory cytokines, which contributes to functional iron deficiency due to increased hepcidin synthesis, decreased ferroportin activity, and reduced iron absorption in the small intestine [330,331].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Patients with FS syndrome who have undergone an acute illness or surgical intervention require longer rehabilitation due to a decrease in functional activity and the onset/increase of dependence on external assistance.

Rehabilitation can be carried out in a rehabilitation center/department (if a geriatric rehabilitation specialist is available) or in a geriatric department after receiving specialized or high-tech medical care. The goal of rehabilitation programs is to maximally restore the functional capacity of older and elderly patients to ensure their maximum independence from external assistance. Comprehensive rehabilitation programs are developed based on Comprehensive Geriatric Assessment (CGA) [299,300].

GCR C (LEL 5)

5. Prevention and Dispensary Observation

Level of Evidence A (Grade of Recommendation 2)

Comment: Conducting group educational programs for patients without FS syndrome, as well as individual educational programs for patients at risk of developing FS, is an effective intervention for the prevention of FS development.

Questions from the "Age Is No Obstacle" scale for FS screening are included in the questionnaire for citizens aged 65 and older to detect chronic non-communicable diseases, risk factors, and frailty, filled out during routine health check-ups (dispensarization). Patients with a score of 5 or more are referred to a geriatrician (if possible).

During preventive counseling of older and elderly individuals, age-related features of correcting risk factors for chronic non-communicable diseases and the high probability of polypharmacy should be taken into account. The patient should be guided not only toward eliminating disease symptoms (if present), but also toward healthy aging, longevity, and an active lifestyle as a whole. All counselees should be given recommendations, taking into account the age factor and the severity of frailty, regarding regular physical activity, nutrition, clinical and psychological training, safe household organization, and medication intake rules. If sensory deficits (hearing or vision loss), chronic pain, or signs of depression are detected, consultation with relevant specialists should be recommended [19].

In older and elderly patients, especially those with prefrailty and frailty, vulnerability to infections increases, the consequences of which are functional decline and accelerated loss of autonomy. Vaccinations for older and elderly patients are carried out in accordance with the national immunization schedule and the immunization schedule for epidemiological indications. Of particular importance is the vaccination of older and elderly individuals (65 years and older) against pneumococcal infection, which is a highly cost-effective intervention providing a substantial reduction in the incidence of pneumococcal infections (pneumonia, meningitis) and associated mortality [320], as well as seasonal influenza vaccination [321].

A patient with prefrailty is monitored by a general practitioner (district physician) in accordance with the current procedure for preventive examinations and health check-ups. During patient monitoring, the general practitioner evaluates the dynamics of identified geriatric syndromes and the effectiveness of measures for their correction.

Dispense monitoring of older and elderly patients is carried out taking into account identified diseases, and in the presence of FS, in cooperation with a geriatrician and in accordance with an individual management plan developed on the basis of CGA. It is recommended to perform CGA at least once a year. CGA may be performed earlier if an acute functional decline develops.

6. Organization of Medical Care

The attending physician for a patient with FS syndrome is a general practitioner (family physician) who, together with a geriatrician, implements the individual patient management plan. When necessary, but at least once a year, a patient with FS syndrome is referred for consultation with a geriatrician to monitor their geriatric status.

6.1. Indications for hospitalization in a medical organization

For the majority of patients with FS syndrome who experience an exacerbation of chronic diseases, it is preferable to provide medical care at home, provided that the necessary volume of diagnostic and therapeutic care can be ensured. In case of difficulties associated with conducting necessary examinations and selecting therapy at home, it is recommended to consider hospitalizing the patient with FS into a geriatric department.

If specialized or high-tech medical care is required, a patient with FS is hospitalized in the appropriate specialized department. The presence of FS syndrome cannot be a reason for refusing specialized, including high-tech, medical care. Performing CGA allows preparing the patient for surgical treatment, reducing its risks, and developing a post-intervention management plan.

Indications for patient hospitalization in a geriatric department

Referral of a patient with FS for hospitalization in a geriatric department is carried out by a general practitioner (family physician), geriatrician, or other medical specialists.

Indications for hospitalization in a geriatric department are:

1. Therapeutic profile diseases and certain neurological profile diseases in a patient with FS syndrome requiring hospitalization. Patients with post-stroke disorders (no earlier than 6 months after a stroke), discirculatory encephalopathy (cerebrovascular disease), dizziness, sleep disorders, neuromuscular diseases, chronic pain syndromes, mild to moderate depression, as well as patients with Alzheimer's disease and cognitive impairments of other origins at the pre-dementia stage and mild-to-moderate dementia in the absence of affective-behavioral disorders, may be hospitalized in the geriatric department.

2. The need to extend the period of inpatient treatment to restore lost self-care abilities after orthopedic or surgical interventions, as well as after hospitalization in therapeutic departments for patients with FS syndrome.

3. The need to examine patients with FS syndrome and dependence on external assistance when outpatient examination is not feasible.

Objectives of managing patients with FS syndrome in a geriatric department

1. Examination, treatment, and rehabilitation for the primary disease that caused the hospitalization.

2. Maintenance and restoration of the functional activity level of the patient with FS syndrome.

3. Prevention of hospitalization-related complications (falls, delirium, pressure ulcers, etc.).

Efforts should be made to minimize the duration of hospitalization for a patient with FS. The duration of hospitalization is determined individually depending on the goal and can be up to 2 weeks if it is necessary to restore lost self-care abilities.

During hospitalization, it is recommended to maintain nursing observation charts that reflect the dynamics of key geriatric syndromes (fall risk, delirium, chronic pain (if identified), chronic wounds/pressure ulcers, etc.). To ensure optimal functioning of the geriatric department and proper medical care for patients with frailty, protocols for the prevention and management of major geriatric syndromes and complications (falls, delirium, pressure ulcers, malnutrition, etc.) must be developed and implemented, including actions by both physicians and nursing staff.

Indications for discharging a patient from the geriatric department

1) Completion of examination, treatment, and rehabilitation for the underlying disease that caused the hospitalization.

2) Improvement of the patient's functional activity level with frailty syndrome or substantiation of the impossibility of improvement.

Discharge planning should begin from the moment the patient is admitted to the geriatric department, which will make this process more coordinated. In some cases, patient discharge issues should be discussed with family members. During hospitalization, the patient's need for social services is determined, and depending on this, discharge planning is carried out with the mandatory participation of a social work specialist.

The need for a consultation with a geriatrician after the patient is discharged from the geriatric department is decided on an individual basis and, if necessary, is indicated in the individual patient care plan in the discharge summary.

7. Additional Information

7.1. Risks associated with the hospitalization of patients with frailty syndrome

Adverse outcomes associated with the hospitalization of patients with frailty syndrome include [208-213]: decreased functional activity level; loss of muscle mass and strength; immobilization and increased risk of venous thromboembolic events; falls; delirium; hospital-acquired infections; pressure ulcers; malnutrition; functional urinary incontinence; sensory deprivation; sleep-wake cycle disturbance.

Changes in the environment, bed rest, new medications, catheterization, sensory deprivation, disruption of the normal sleep-wake cycle, dietary changes, functional, physical, and cognitive decline—all these are predispositions for the development of complications during hospitalization. Since patients with frailty are in the borderline zone between autonomy and dependence on outside help, even a slight decrease in functional activity during hospitalization can push them to the level of newly or re-acquired dependence on outside help. A certain decrease in the level of functional activity during inpatient treatment is often inevitable due to the acute disease or condition that caused the hospitalization. Adverse consequences of hospitalization can be avoided or minimized. To this end, it is recommended to develop and implement nursing protocols in departments providing care to patients with frailty for the prevention of falls, functional decline, delirium, pain syndrome, and pressure ulcers.

7.1.1 Delirium

Delirium in elderly patients often remains unrecognized because it most frequently occurs in the hypoactive form. The development of delirium increases the risk of death, increases the duration and cost of hospitalization, and the need for long-term care. Factors associated with hospitalization increase the risk of developing delirium—sensory deprivation (e.g., when an elderly person lacks access to glasses or a hearing aid), pain, sleep interruption, infectious diseases, certain classes of drugs, including those with psychotropic and anticholinergic effects [208-211]. In the postoperative period, delirium occurs more frequently in patients with frailty syndrome undergoing major surgical procedures. The incidence of delirium reaches 48–65% in the practice of abdominal, thoracic, orthopedic, and cardiovascular surgery. The development of postoperative cognitive dysfunction worsens the prognosis of a patient with frailty syndrome and increases mortality both during hospitalization and in the next 3–6 months. Patients who already have cognitive impairment are particularly prone to developing delirium during hospitalization or after surgery. The Confusion Assessment Method (CAM) is used for delirium screening (Appendix G16). Measures for the prevention and treatment of delirium include correction of pain, dehydration, constipation and urinary retention, sensory deficits, patient mobilization, and the creation of a "friendly environment" providing opportunities for sleep, contact with loved ones, and orientation in place and time [209].

Level of Evidence A (Grade of Recommendation 2)

GCR C (LEL 5)

Comment: The complex of non-pharmacological methods for the prevention and treatment of delirium includes measures aimed at patient orientation in time (a clock and a calendar with the current date should be in the patient's field of vision) and space, contact with the patient, ensuring daytime light access during wakefulness periods, compliance with wakefulness and sleep periods, creating a favorable environment for night sleep, correction of sensory deficits (providing glasses and hearing aids if necessary), the possibility of communication with relatives (after prior explanation of the patient's condition features), early mobilization of the patient after surgery, adequate drinking regimen, and ensuring comfortable psychological conditions (avoiding excessive noise, bright light, benevolent attitude) [211].

For the prevention of acute cognitive impairment after surgery, the use of drugs with neuroprotective and neurotrophic activity is promising, as they increase neurocognitive reserve—the brain's ability to resist damaging influences by compensating for cognitive decline caused by various factors [336].

Pharmacological treatment of delirium should be prescribed in exceptional cases in minimum therapeutic doses only in cases of aggressive patient behavior with a threat to their life or others, or active obstruction to treatment, due to the lack of convincing data on the efficacy of drug treatment for delirium regarding reducing its severity, decreasing duration, and improving disease prognosis [211, 213].

7.1.2 Immobilization and catheter use

Bed rest and restriction of physical activity lead to the development or progression of muscle weakness. Immobility is associated with the risk of falls, delirium, pressure ulcers, and venous thromboembolic events. The treatment of most diseases and conditions does not require restricting the physical activity of elderly patients; only a few conditions require bed rest. It is necessary to get low-mobility patients out of bed at least twice a day for meals and, whenever possible, encourage patients to walk. Early mobilization during hospitalization is a crucial measure for preventing the progression of functional decline. Increasing the mobility of elderly patients in the hospital is associated with a lower prevalence of functional deficits and a shorter duration of hospitalization [214]. Many patients with frailty need assistance for safe mobilization, especially in the presence of catheters.

GCR C (LEL 5)

Level of Evidence C (Reliability of Evidence Level 5)

7.1.3 Falls

Hospitalization of patients with frailty syndrome is associated with an increased risk of falls. Falls in elderly patients are associated with the development of functional dependence and the need for long-term care. Risk factors for falls in hospitalized patients are numerous and include not only non-modifiable factors (age, history of falls), but also potentially corrigible factors: cognitive impairment, balance and mobility problems, muscle weakness, polypharmacy, use of sedative drugs, visual impairment, urinary incontinence, dizziness, and dehydration [211]. Patients should be encouraged to spend time out of bed to reduce the risk of muscle weakness and orthostatic reactions. At the same time, patients at high risk for falls may require supervision while moving. Exercise therapy sessions with an instructor are one of the most important interventions and should be included in the fall prevention program.

Level of Reliability of Evidence C (Level of Credibility of Data 4)

Comment: To determine the risk of falls in hospitalized patients, the Morse Fall Scale (Appendix G15) or other scales may be used, including those developed within the specific medical institution.

GCR C (LEL 5)

Comment: fall prevention programs and regulations must be well known to all medical staff of the healthcare organization.

7.1.4 Sleep

Factors that disrupt sleep during hospitalization include an unfamiliar environment, symptoms of the disease (breathing disorders, pain, etc.), and environmental factors (noise, light) [211]. Sleep disturbance is a risk factor for delirium [209, 211]. Creating a favorable environment—low ward lighting and silence, a regular schedule for medication administration, and planned diagnostic and therapeutic procedures—can improve patients' sleep in inpatient settings [210]. If there are complaints of poor sleep, it is advisable to assess sleep disturbances using the Insomnia Severity Index (Appendix G19) and, based on screening results, refer the patient for a consultation with a somnologist (if possible) and/or provide recommendations for improving sleep.

7.1.5 Malnutrition

Patients hospitalized with frailty syndrome, especially those with cognitive impairment, are vulnerable to developing malnutrition. The onset of an acute illness in an elderly person can lead to loss of appetite and weight loss. Malnutrition in hospitalized elderly patients can result from many factors: cognitive impairment and development of delirium, decreased appetite, nausea, constipation, poor oral hygiene, lack of dentures, adverse drug reactions (e.g., dry mouth), decreased physical activity, hand function problems, difficulties with self-care, and prescribed dietary restrictions.

Simple interventions, such as mobilization during meals and assistance with feeding, can improve a patient's nutritional status during hospitalization [214]. Correction of malnutrition may require a consultation with a clinical dietitian and the use of high-protein, high-calorie foods.

Oral nutrition is preferred. The decision to switch to tube feeding must be carefully weighed, especially in patients with multiple severe diseases and severe dementia.

7.1.6 Pressure ulcers

The risk of pressure ulcers in hospitalized patients is increased due to the following risk factors: restricted physical activity, malnutrition, urinary incontinence, and neurological disorders. Optimizing nutrition and limiting the time spent in one position can help prevent the development of pressure ulcers. It is important to remember that the body position of a bedridden patient must be changed at least once every two hours [217].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Tkacheva O.N. – Corresponding Member of the Russian Academy of Sciences, D.Sc. (Medicine), Professor, Director of the Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Head of the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, President of the Russian Association of Gerontologists and Geriatricians

2. Kotovskaya Yu.V. – D.Sc. (Medicine), Professor, Deputy Director for Research, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Vice-President of the Russian Association of Gerontologists and Geriatricians

3. Runikhina N.K. – D.Sc. (Medicine), Deputy Director, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Vice-President of the Russian Association of Gerontologists and Geriatricians

4. Frolova E.V. – D.Sc. (Medicine), Professor at the Department of Family Medicine, North-Western State Medical University named after I.I. Mechnikov of the Ministry of Health of Russia, Vice-President of the Russian Association of Gerontologists and Geriatricians

5. Naumov A.V. – D.Sc. (Medicine), Head of the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

6. Vorobyova N.M. – D.Sc. (Medicine), Head of the Laboratory of Cardiovascular Aging, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

7. Ostapenko V.S. – Ph.D. (Medicine), Head of the Department of Geriatrics, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Assistant Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

8. Mkhitaryan E.A. – Ph.D. (Medicine), Senior Researcher at the Laboratory of General Geriatrics and Neurogeriatrics, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Associate Professor at the Department of Aging Diseases, Faculty of Continuing Medical Education, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

9. Sharashkina N.V. – Ph.D. (Medicine), Senior Researcher at the Laboratory of Geriatrics, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

10. Dudinskaya E.N. – Ph.D. (Medicine), Head of the Laboratory of Age-Related Metabolic Endocrine Disorders, Russian Gerontology Clinical Research Center, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, Member of the Russian Association of Gerontologists and Geriatricians

Conflict of interest:

All members of the Working Group declared no conflict of interest.

Public discussion of the draft clinical guidelines took place from 29.08.2022 to 28.09.2022 via the Monitoring System for the Development of Clinical Guidelines.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Geriatricians

2. General practitioners (family physicians)

3. Internists

4. Cardiologists;

5. Neurologists

6. Trauma and orthopedic surgeons

7. Psychiatrists

8. Urologists

9. Obstetricians-gynecologists

10. Clinical pharmacologists

11. Dietitians

12. Endocrinologists;

13. Rheumatologists

Table 1. Scale for grading levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The updating of clinical guidelines involves their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of well-founded additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health of the Russian Federation No. 38n dated January 29, 2016, "On Approval of the Procedure for Providing Medical Care in the Field of 'Geriatrics'"

2. Order of the Ministry of Health of the Russian Federation No. 1067n dated December 20, 2019, "On Amendments to the Procedure for Providing Medical Care in the Field of 'Geriatrics', Approved by Order of the Ministry of Health of the Russian Federation No. 29 dated January 29, 2016"

3. Methodological Guidelines MP103 "Pharmacotherapy in Elderly and Senile Patients"

4. Clinical guidelines "Falls in elderly and senile patients"

5. Clinical Guidelines "Urinary Incontinence"

6. Clinical Guidelines "Cognitive Impairment in Elderly and Senile Patients"

7. Clinical guidelines "Malnutrition in elderly and senile patients"

8. Clinical guidelines "Chronic pain in elderly and senile patients"

9. Clinical Guidelines "Osteoporosis"

Appendix A 3-1. Methodology for performing the Short Physical Performance Battery and interpretation of results

1. Balance assessment

The nurse conducting the test explains to the patient: This test consists of three parts. In the first part, you must try to maintain balance in three different positions. I will first describe and then demonstrate each of these positions.

A. Side-by-side stand

Now I will show you the first position (demonstrate). I need you to stand in this position with your feet together for 10 seconds. You may use your arms to balance, bend your knees, or move your body to maintain your balance, but try not to move your feet or hold onto anything. Try to remain in this position for 10 seconds until you hear the command 'stop'.

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something for support.

B. Semi-tandem stand

The nurse conducting the test: Now I will show you the second position (demonstrate). You need to stand for 10 seconds with one foot placed forward so that the toe of one foot is at the level of the middle of the other foot and the inner surfaces of the two feet are touching. You may place either foot forward, whichever is more comfortable for you. You may balance with your arms, bend your knees, or move your body to maintain balance, but try not to move your feet and not to hold on to anything. Remain in this position until you hear the command "Stop".

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something in search of support, and say: "Stop".

C. Tandem stand

The nurse conducting the test: Now I ask you to assume the third position. (Demonstrate). Stand so that the heel of one foot is directly in front of the toe of the other foot and touching it. Stand like this for 10 seconds. You may place either foot forward, whichever is most comfortable for you. You may balance with your arms, bend your knees, or move your body to maintain balance, but try not to move your feet. Try to remain in this position until you hear the command "Stop".

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something in search of support, and say: "Stop"

2. 4-meter gait speed test

Required distance: about 6 meters (corridor, room). Measure a distance of 4 meters from the 'Start' mark. The patient should be able to continue moving for a few more steps past the finish line so as not to slow down prematurely due to an obstacle. The test is performed in the shoes the patient normally wears.

The nurse conducting the test: This test is necessary so that we can see how you usually walk. Start from here (patient's feet at the "Start" mark). If you use a cane (or any other assistive device) and feel that you need it to cover this distance, you may use it. You must walk without stopping at a normal pace, as if you were walking down a corridor or on the street. I will show you what I mean.

Demonstrate. Look forward and, maintaining an upright posture, walk at a normal pace to and past the finish line.

You will need to walk this distance three times. I will be right beside you. We will not talk while you are walking, but I will be there to support you so you do not fall.

The patient should stand without support at the starting line so that the toes of both feet touch the line or slightly cross it, standing at a comfortable distance from each other.

The first attempt is a practice run. During the second and third attempts, the time in seconds taken by the patient to walk 4 meters is measured. The best result is recorded.

3. Chair stands

Preparation: single rise from a chair. Chair without armrests.

The nurse conducting the test: "With this test, we will check the strength of your legs. Let me show you what you will do."

Demonstrate and explain the procedure while sitting on a chair opposite the patient.

First, fold your arms across your chest or abdomen and sit so that your feet are flat on the floor. Then stand up while keeping your arms folded across your chest or abdomen.

If the patient cannot perform a single chair stand without using their arms, the 5-repetition chair stand test is not performed.

Test performance: five repetitions of rising from a chair

The nurse conducting the test: Please now stand up five times in a row without stopping as fast as you can. After each rise, you need to sit down and then stand up again. Your hands should be crossed on your chest or abdomen. I will record the time it takes to complete the exercise.

The time taken by the patient to rise from the chair 5 times without using their arms is recorded. After the patient stands up for the fifth time (final position), stop the stopwatch.

Stop the test in the following cases:

- If the patient stands up using their arms

- After a minute, if the patient has not been able to complete the test by this time

- At your discretion, if required to ensure patient safety

If the patient stops without completing 5 rises and appears tired, clarify by asking: "Can you continue?" If the patient says "Yes", continue the test. If the patient says "No", stop and check the time on the stopwatch.

Interpretation of Short Physical Performance Battery results

Points are awarded for each stage of the test (Fig. 1) and summed up. If the patient scores 10–12 points, there is no frailty; 8–9 points indicate prefrailty; 7 points or less indicate frailty. A score of 1 point or less in the balance test, and/or 5 seconds or more in the gait speed test, and/or 1 point or less in the 5-repetition chair stand test indicates a high risk of falls.

Figure 1. Short Physical Performance Battery

Appendix A3-2. Dynamometry

Dynamometry is performed using an electronic or mechanical dynamometer.

Dynamometry procedure

The dynamometer is held in the hand with the dial facing inward. The arm is abducted away from the trunk until it forms a right angle with it. The second arm is lowered down along the trunk. The dynamometer is squeezed with maximum force for 3-5 seconds. To obtain more accurate results, it is recommended to perform three measurements of grip strength on the right and left hand. The rest time between attempts is at least 30 seconds. To evaluate the results, the average or maximum grip strength value of the strongest hand can be used.

Criteria for low grip strength according to gender and body mass index

Appendix A3-3. Vision assessment

Ask the patient to answer the questions:

1. Is it difficult for you due to poor vision (even with glasses, if you use them):

- to eat

- to recognize your medications and read labels

- to dress and not miss buttonholes and buttons

- to comb your hair, shave, and wash

- to count money

- to recognize people on the other side of the street or nearby

- not to bump into things when walking outside

- to find your way home when coming from the store or post office

- to read standard newspaper print

2. Please indicate what vision-enhancing devices you use:

- glasses

- contact lenses

- magnifying glass or loupe

- pocket flashlight

- special large-print books

- stencils for the visually impaired

The interpretation of the results of this questionnaire is qualitative and serves to determine the individual vision-related problems of the elderly person.

The Rosenbaum chart is used to determine near visual acuity. The chart is used in good lighting at a distance of 36 cm from the eyes. The test result is recorded separately for each eye with and without glasses. Farsighted people should read with near-vision glasses. Nearsighted individuals are examined only with glasses.

Appendix A3-4. Doses of cholecalciferol** for the correction of vitamin D deficiency and insufficiency

Appendix B. Physician Action Algorithms

Note: CGA – comprehensive geriatric assessment, FS – frailty syndrome

Appendix C. Patient Information

What is frailty?

Frailty reflects the state of an elderly person's body associated with aging. Frailty syndrome manifests as general weakness, decreased activity, reduced muscle strength, mobility difficulties, and unintentional weight loss. In older age, other pathological conditions associated with aging and frailty may also develop—geriatric syndromes: urinary incontinence, falls and fractures, hearing and vision impairment, memory and mood decline, and several others.

Who develops geriatric frailty?

The syndrome of geriatric frailty usually develops after 60–65 years of age, and the probability of its onset increases with age. It is estimated that geriatric frailty affects 10% of people over 65, and is more common in women than in men.

Predisposing factors for the development of geriatric frailty include low physical activity, social isolation, and certain conditions such as diabetes mellitus.

Why is geriatric frailty dangerous?

People with geriatric frailty gradually become dependent on external assistance—at an early stage, this manifests as difficulty walking or climbing stairs. At later stages, help is needed with basic activities of daily living, such as washing, dressing, and moving around the house. In addition, the risk of falls increases, leading to adverse outcomes such as fractures, contusions, and traumatic brain injuries.

How can geriatric frailty and other geriatric syndromes be detected?

If you are 60 years of age or older, please answer the following 7 questions:

- Have you lost 5 kg or more over the past 6 months? (meaning unintentional weight loss)

- Do you experience any limitations in daily life due to reduced vision or hearing?

- Have you had any fall-related injuries or falls without injuries within the past year?

- Have you been feeling depressed, sad, or anxious over the past weeks?

- Do you have problems with memory, comprehension, orientation, or planning ability?

- Do you suffer from urinary incontinence?

- Do you experience difficulties moving around the house or outdoors (walking up to 100 meters or climbing 1 flight of stairs)?

Show your answers to these questions to your attending physician. If you answered yes to 5 or more questions, you may need a consultation with a geriatrician. A geriatrician is a specialist who provides medical care to older adults.

Can the development of geriatric frailty be prevented or treated?

Geriatric frailty and many other geriatric syndromes can be prevented and brought under control.

For prevention, one must remain physically and socially active, eat a balanced diet, avoid bad habits, undergo regular preventive medical check-ups, and follow the doctor's recommendations for managing existing health issues.

Physical activity. One of the main mechanisms in the development of geriatric frailty is the loss of muscle mass and function. Therefore, regular physical activity and a varied diet with an adequate protein content (protein is an essential building block for muscle tissue) are of paramount importance for the prevention and management of geriatric frailty.

Physically active older adults have better cardiovascular and respiratory function, better memory and mental performance, better movement coordination, and a lower risk of falls. Regular exercise improves mood and treats depression, while group classes help relieve feelings of loneliness. Chronic diseases are not a contraindication to moderate physical activity, but it is best performed under the supervision of a specialist, such as an exercise therapy instructor.

Physical activity is not only sports, but also any daily activity (walking, housework, dancing, gardening, etc.). Physical activity should be regular (at least 3–5 times a week) and gradually increase in intensity—choose a type of physical activity that you enjoy.

Adults aged 60 and older are recommended to:

- Engage in moderate-intensity physical activity for at least 150 minutes per week, or high-intensity activity for at least 75 minutes per week, or an equivalent combination of both

- To gain additional health benefits, increase moderate-intensity physical activity to 300 minutes per week, or high-intensity activity to 150 minutes per week

- To prevent falls, perform balance exercises 3 or more days a week

- To prevent osteoporosis (bone fragility) and fractures, perform strength exercises 2 or more days a week

- If you cannot perform the recommended amount of physical activity, engage in exercises appropriate to your capabilities and health status

Dietary regimen for older adults must necessarily include three main meals (breakfast, lunch, and dinner), which may be supplemented by two light snacks. Total fluid intake should be at least 2 liters (including meals and food products), with pure fluids accounting for at least 800 ml. If you have heart failure, coordinate your fluid intake with your general practitioner or cardiologist.

Protein foods should be included in your daily diet. Optimal sources of animal protein include eggs, cottage cheese, fish, poultry (chicken, turkey), beef, veal, and rabbit; plant-based sources include grains, legumes, seeds, and nuts. In cases of malnutrition and significant weight loss, you may be prescribed specialized liquid oral nutritional supplements, which are balanced nutritional products.

Regarding cooking methods, gentle processing modes are recommended: boiling, baking, poaching, stewing, steaming, air-frying, etc.

Please note: if you begin to experience difficulty swallowing, or frequent choking when eating or drinking, consult a doctor so as not to miss a serious condition.

Vitamin D. Many people develop vitamin D deficiency with age, which increases muscle weakness, difficulty walking and maintaining balance, and raises the risk of falls and fractures. Vitamin D plays a vital role in calcium absorption and bone and muscle health. In young people, vitamin D is synthesized in the skin under the influence of ultraviolet rays—walking for 15–30 minutes with an exposed face and hands is enough to achieve adequate vitamin D levels. In older adults, the skin's ability to synthesize vitamin D declines, so an additional intake in the form of a supplement may be necessary.

Medication use. It is very important to use medications correctly, as taking a large number of drugs can lead to the progression of geriatric frailty and other adverse outcomes, such as falls and memory impairment.

Try to follow these recommendations:

• Take medications only as prescribed by a doctor, not on the advice of neighbors or mass media (even if it is a health program). Only your attending physician has complete information about your health to help select effective and safe treatment

• Do not rely on a "magic pill for all diseases". Some health problems resolve without treatment or can be managed through non-pharmacological methods. Discuss with your doctor how best to deal with your health issues and consider all treatment options

• Inform your doctor about all medications you are taking, including over-the-counter drugs, dietary supplements, and herbal remedies

• Inform your doctor about any allergies or adverse drug reactions you have experienced in the past

• Report any problems that arise after starting a new medication

• If you have been hospitalized, your previous treatment may have been modified. You need to know which medications to take after discharge. You can obtain this information from your attending physician

• Do not stop taking your prescribed medications without discussing it with your doctor first. Before starting any over-the-counter medication, supplement, or herbal remedy, consult your doctor or pharmacist to ensure the product is safe

• Every person should know details about each medication they take (verify this information with your doctor, and write it down if necessary):

- Name

- Indication for use

- How to take the drug (dose, timing, frequency, duration, and relation to meals)

- Most common and serious side effects

- What to do if problems related to the medication occur

- What to do if a dose is missed

Stay active both intellectually and physically! Remember that communicating with family and friends is an essential condition for maintaining active longevity!

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. «Age is No Obstacle» questionnaire for frailty screening

Russian title: "Age is No Obstacle"

Original title (if applicable): "Age is No Obstacle"

Source (official developer website, validation publication):

Developer: Pirogov Russian National Research Medical University of the Russian Ministry of Health – Russian Gerontology Clinical Research Center, www.rgnkc.ru

Tkacheva ON, Runikhina NK, Ostapenko VS, Sharashkina NV, Mkhitaryan EA, Onuchina YuS, Lysenkov SN. Validation of a screening questionnaire for geriatric frailty in outpatient practice. Advances in Gerontology. 2017;30(2):236-242.

Type: questionnaire

Purpose: screening for geriatric frailty syndrome

Content (template):

Key (interpretation): 1 point is awarded for each positive answer. A result of 2 points or less indicates no clinical frailty, 3–4 points indicate probable prefrailty, and 5–7 points indicate probable clinical frailty.

Appendix G2. Mini-Cog test

Russian name: Mini-Cog

Original name: Mini-Cog

Source: Borson S., Scanlan J.M., Chen P.J., et al. The Mini-Cog as a screen for dementia: Validation in a population-based sample. J Am Geriatr Soc 2003; 51: c. 1451 – 1454.

Type: rating scale

Purpose: screening assessment for the presence of severe cognitive impairment

Contents:

1. Instruct the patient: "Repeat these three words: lemon, key, ball." The words must be pronounced as clearly and legibly as possible, at a speed of 1 word per second. After the patient has repeated all three words, ask them: "Remember these words. Repeat them one more time." Ensure that the patient independently recalls all three words. If necessary, repeat the words up to 5 times.

2. Instruct the patient: "Please draw a round clock face with numbers and hands. All numbers must be in their proper places, and the hands must point to 1:45." The patient must independently draw a circle, place the numbers, and draw the hands. Prompts are not allowed. The patient must also not look at a real watch on their wrist or on the wall. Instead of 1:45, you can ask to set the hands to any other time.

3. Instruct the patient: "Now let's remember the three words we learned at the beginning." If the patient cannot recall the words independently, a prompt can be offered. For example: "You were remembering some kind of fruit... tool... geometric figure."

Key (interpretation):

Word recall. The patient receives one point for each word repeated without a prompt (total 0–3 points).

Clock drawing: the test result can range from 0 to 2 points: 1 point – all numbers are placed in the correct order and approximately in the position they occupy on the clock face; 1 point – the hands point to the correct time; the length of the hands (hour, minute) is not evaluated. Inability or refusal to draw a clock – 0 points.

Key (interpretation):

The total score is the sum of the results of the two tasks, "Word Recall" and "Clock Drawing," and ranges from 0 to 5 points. A score of less than 3 points is a reason to suspect dementia. A score of less than 4 points indicates the need for a more thorough assessment of cognitive functions.

Notes: performing this technique allows for a rapid assessment of the presence of overt cognitive impairment. It may be insufficiently sensitive to non-dementing cognitive disorders.

Appendix G3. Fracture risk assessment using the FRAX tool

Name in Russian: FRAX – Fracture Risk Assessment Tool

Original name (if applicable): FRAX ®

Source (official developer website, validation publication):

https://www.sheffield.ac.uk/FRAX/tool.aspx?lang=rs

Lesnyak O, Ershova O, Belova K et al. Epidemiology of fracture in the Russian Federation and the development of a FRAX model. ArchOsteoporos. 2012;7(1-2):67-73.

Type: rating scale

Purpose: fracture risk assessment

Contents:

To calculate the 10-year probability of fracture using bone mineral density, please answer the following questions.

Questionnaire:

Key (interpretation):

Fracture risk assessment result in the orange zone: Dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is recommended. If osteoporosis is detected (T-score ≤ -2.5), the prescription of anti-osteoporotic therapy is indicated without reassessing fracture risk.

Fracture risk assessment result in the red zone: dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is not indicated; the patient unequivocally requires the prescription of anti-osteoporotic therapy.

Fracture risk assessment result in the green zone: dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is not indicated; the patient does not require the prescription of anti-osteoporotic therapy.

Notes:

For clinical risk factors, answer "yes" or "no". If a field is left blank, the default answer is "no".

Risk factor notes

Previous fracture. A special situation is the case of a previous spinal fracture. If the fracture was detected only by X-ray examination (morphometric vertebral fracture), it is considered a previous fracture. At the same time, a particularly strong risk factor is a previous clinically manifest vertebral fracture, along with a hip fracture. Therefore, in this case, the calculated fracture probability may be artificially underestimated. In addition, the calculated fracture probability will be artificially underestimated in patients with prior multiple fractures.

Smoking, alcohol, glucocorticoids. These risk factors are likely dose-dependent. This is not accounted for in this model, and average values are assumed in the calculation. For small and large doses, a clinical evaluation should be used.

Rheumatoid arthritis. Documented diagnosis of rheumatoid arthritis is taken into account.

Bone mineral density. DXA densitometry data of the femoral neck are used.

Appendix G4. Mini Nutritional Assessment

Russian title: Mini Nutritional Assessment (Short Form)

Original name (if any): Mini Nutritional Assessment, MNA

Source (official developer website, validation publication):

Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782-8 

Type: scale

Purpose: Screening for malnutrition in elderly and senile patients

Content (template)

It is necessary to complete the screening part (from item "A" to item "E"), calculate and sum up the obtained points. If the result is less than 12 points, continue filling out the form by adding the subsequent points to the sum of the screening part

Total score: ___________/30

Interpretation of results (full scale from A to T):

>23.5 points – normal nutritional status

17–23.5 points – risk of malnutrition

<17 points – malnutrition

Appendix G5. Timed Up and Go test

Russian name: Timed Up and Go (TUG) test

Original title (if applicable): Timed “Up and go” test

Source (official developer website, validation publication):

Mathias S, Nayak USL, Isaacs 8. Balance in the elderly patient: The "Get-up and Go" test. Arch Phys Med Rehabil 1986;67:387.

Type: other - test

Purpose: assessment of gait, balance, and fall risk

Content (template):

Required equipment: armchaire, tape measure, colored tape or marker, stopwatch. Measure a distance of 3 meters from the chair and mark it with a marker or colored tape so that the mark is visible to the patient.

Testing conditions. The patient should be instructed that the test is timed. The first trial run can be performed without timing.

During the test, the patient should wear their usual footwear and may use any assistive devices they normally rely on (e.g., cane or walker). If necessary, the patient may pause to rest during the test.

Procedure

- The patient should sit in the chair with their back against the backrest and their thighs fully touching the seat. The chair must be stable. The patient is allowed to use the armrests while sitting and standing up.

- Patient instructions: When I say "Go", you must stand up, walk the marked distance, turn around, return to the chair, and sit down. You should walk at your usual pace.

- Start timing after saying the word "Go" and stop timing when the patient sits back down properly in the chair with their back resting against the backrest.

- During the test, pay attention to signs of gait and balance disorders.

Key (interpretation): Normally, healthy older adults complete the Timed Up and Go test in 10 seconds or less. A Timed Up and Go test result of more than 14 seconds in community-dwelling older and senile patients, along with signs of gait and balance disorders, indicates an increased risk of falls.

Appendix G6. Mini-Mental State Examination

Original title: Mini Mental State Examination (MMSE)

Source: Folstein M.F., Folstein S.E., McHugh P.R. «Mini-mental state». A practical method for grading the cognitive state of patients for the clinician. Journal of psychiatric research. 1975;12 (3): с. 189–198

Type: rating scale

Purpose: identification (screening) and assessment of the severity of cognitive impairment

Template:

Instructions for the Mini-Mental State Examination

1. Orientation in time. The maximum score (5) is given if the patient independently and correctly states the date, day of the week, month, year, and season. Each mistake or lack of response reduces the score by 1 point.

2. Orientation in place. The question "Where are we?" is asked. If the patient does not answer fully, additional questions are asked. The patient must name the country, region, city, institution where the examination is taking place, and floor. Each mistake or lack of response reduces the score by 1 point.

3. Registration. The instruction is given: "Repeat and try to remember three words: apple, table, coin." The words must be pronounced as clearly as possible at a speed of one word per second. 1 point is awarded for each correctly recalled word. The words should be presented as many times as necessary for the subject to repeat them correctly, but only the first repetition is scored.

4. Attention and calculation. The patient is asked to sequentially subtract 7 from 100. Five subtractions are sufficient. Each mistake reduces the score by 1 point. If the patient is unable to perform this task, they are asked to spell the word "world" backwards. Each mistake reduces the score by 1 point.

5. Recall. The patient is asked to recall the words learned in step 3. Each correctly named word is scored 1 point.

6. Language functions.

A. A pen is shown and the patient is asked, "What is this?", similarly for a watch. Each correct answer is worth 1 point.

B. The patient is asked to repeat the grammatically complex phrase mentioned above. Correct repetition is scored 1 point.

C. A verbal command is given that involves the sequential performance of the three actions mentioned above. Each action is scored 1 point.

G. A written instruction is given (e.g., "Close your eyes"), and the patient is asked to read and perform it. The instruction must be written in sufficiently large printed letters on a clean sheet of paper.

E. The patient must independently write a meaningful and grammatically complete sentence.

F. The patient is given a model (two intersecting pentagons with equal angles / two crossed rectangles with equal angles), which they must copy on blank unlined paper. If spatial distortions or unjoined lines occur during copying, the command is considered incorrectly executed. Figure distortions caused by tremor are not taken into account.

Key (interpretation):

28–30 points – normal,

27–25 points – non-dementing cognitive impairment,

24 points or less – dementia (approximately 20–24 points – mild dementia; 11–19 points – moderate dementia; 0–10 points – severe dementia).

Notes:

This scale is widely used as a screening method for diagnosing severe cognitive impairment, but it has its drawbacks. Frequent re-testing of the same patient is unacceptable due to potential learning effects. The scale has low sensitivity for diagnosing cognitive deficit in individuals with low and very high levels of education. It also lacks sufficient sensitivity in diagnosing pre-dementia cognitive impairment.

The scale allows for only an approximate assessment of the severity of cognitive disorders, particularly regarding the diagnosis of dementia, the verification of which requires confirming impairments in functional status and daily activities as a key component.

Appendix G7. Montreal Cognitive Assessment (MoCA test)

Original name: The Montreal Cognitive Assessment (MoCA test)

Source: www.mocatest.org

Type: rating scale

Purpose: identification (screening) of cognitive impairment

Template (Version No. 1):

Interpretation of results:

The Montreal Cognitive Assessment (MoCA test) was developed as a rapid screening tool for mild cognitive dysfunction. It assesses various cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructive skills, abstract thinking, calculation, and orientation. The MoCA takes approximately 10 minutes to administer. The maximum possible score is 30 points; a score of 26 and above is considered normal. A score of 25 and below indicates the presence of cognitive impairment.

1. Alternating Trail Making:

The examiner instructs the subject: "Please draw a line going from a number to a letter in ascending order. Start here [point to (1)] and draw a line from 1, then to A, then to 2, and so on. End here [point to (D)]".

Scoring: Allocate one point if the subject successfully draws the line in the following sequence: 1-A-2-B-3-C-4-D-5-E, without any intersecting lines. Any error that is not immediately self-corrected by the subject earns 0 points.

2. Visuoconstructive Skills (Cube):

Application: The examiner gives the following instructions, pointing to the cube: "Copy this drawing as accurately as you can in the space below it."

Scoring: One point is allocated for a correctly executed drawing:

- Drawing must be three-dimensional;

- All lines are drawn;

- No extra lines are added;

- The lines are relatively parallel, and their length is equal (a rectangular prism is acceptable).

A point is not awarded if any of the above-mentioned criteria are not met.

3. Visuoconstructive Skills (Clock):

Application: Point to the right third of the blank space on the form and give the following instructions: "Draw a clock. Put in all the numbers and set the time to 10 minutes past 11".

Scoring: One point is allocated for each of the following three criteria:

- Contour (1 point): The clock face must be a circle with only minor distortion (e.g., slight imperfection in closing the circle);

- Numbers (1 point): All clock numbers must be present, with no extra numbers; numbers must be in the correct order and placed in the appropriate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the clock face contour;

- Hands (1 point): There must be two hands jointly indicating the correct time; the hour hand must clearly be shorter than the minute hand; the hands must be centered with their junction close to the center.

No point is allocated for this item if any of the above-mentioned criteria are not met.

4. Naming:

Application: Starting from the left, point to each figure and say: "Name this animal."

Scoring: One point is allocated for each of the following responses: (1) camel or dromedary, (2) lion, (3) rhinoceros.

5. Memory:

Application: The examiner reads a list of 5 words at a rate of one word per second, giving the following instructions: "This is a memory test. I am going to read a list of words to you that you will need to remember. Listen carefully. When I am finished, tell me all the words you can remember. It does not matter in what order you tell me." Make a checkmark in the designated space for each word as the subject recalls it on the first trial. When the subject indicates they are finished (has named all the words) or cannot recall any more words, read the list a second time with the following instructions: "I will read the same words a second time. Try to remember and repeat as many words as you can, including the ones you repeated the first time." Make a checkmark in the designated space for each word the subject repeats on the second trial. At the end of the second trial, inform the subject that they will be asked to repeat these words again: "I will ask you to repeat these words again at the end of the test."

Scoring: No points are allocated for either the first or second trials.

6. Attention:

Forward Digit Span:

Application: Give the following instructions: "I will name a few numbers, and when I am finished, repeat them exactly as I said them." Read five numbers sequentially at a rate of one number per second.

Backward Digit Span:

Application: Give the following instructions: "I will name a few numbers, but when I am finished, you will need to repeat them in reverse order." Read a sequence of three numbers at a rate of one number per second.

Scoring: Allocate one point for each correctly repeated sequence (N.B.: the correct response for the backward recall is 2-4-7).

Vigilance:

Administration: The examiner reads a list of letters at a rate of one letter per second, after the following instructions: "I will read you a sequence of letters. Every time I say the letter A, tap your hand once. If I say a different letter, do not tap your hand".

Scoring: One point is allocated if there are zero errors or only one error (an error is considered when the patient taps the hand upon hearing a different letter or fails to tap upon hearing the letter A).

Serial 7 Subtraction:

Application: The examiner gives the following instructions: "Now I will ask you to subtract 7 from 100, and then keep subtracting 7 from your answer until I tell you to stop." Repeat the instruction if necessary.

Scoring: This item is evaluated out of 3 points. Allocate 0 points for no correct subtractions, 1 point for one correct calculation, 2 points for two to three correct calculations, and 3 points if the subject successfully makes four or five correct calculations. Count each correct 7-subtraction starting from 100. Each subtraction is evaluated independently; thus, if a participant gives an incorrect answer but then continues to subtract 7 accurately from that number, give a point for each accurate subtraction. For example, a participant may answer "92-85-78-71-64" where "92" is incorrect, but all subsequent values are subtracted correctly. This is a single error, and 3 points are allocated for this item.

7. Sentence Repetition:

Administration: The examiner gives the following instructions: "I am going to read you a sentence.

Repeat it exactly as I say (pause): I know that John is the only one who can help today". Following the response, say: "Now I will read you another sentence. Repeat it exactly as I say (pause): The cat always hid under the couch when the dogs were in the room."

Scoring: Assign 1 point for each correctly repeated sentence. Repetition must be exact. Listen carefully for errors due to word omissions (e.g., omitting "only", "always") and substitutions/additions (e.g., "Ivan is the only one who helped today"; substitution of "hides" for "hid", use of plural form, etc.).

8. Verbal fluency:

Application: The examiner gives the following instructions: "Name as many words as you can starting with a specific letter of the alphabet that I will tell you now. You can name any type of word, except for proper nouns (such as Peter or Moscow), numbers, or words that start with the same sound but have different suffixes, for example, love, lover, loving. I will stop you after one minute. Are you ready? (Pause) Now name as many words as you can think of starting with the letter S. (Time 60 sec). Stop".

Scoring: One point is awarded if the subject names 11 words or more in 60 seconds. Record the answers at the bottom or side of the page.

9. Abstraction:

Application: The examiner asks the subject to explain what each pair of words has in common, starting with an example: "Tell me what an orange and an apple have in common." If the patient answers in a specific manner, say only once more: "Name something else they share." If the subject does not give the correct answer (fruit), say "Yes, and they are also both fruits." Do not give any other instructions or explanations.

After the practice trial, say: "Now tell me what a train and a bicycle have in common." After the response, give the second task by asking: "Now tell me what a ruler and a watch have in common." Do not give any other instructions or prompts.

Scoring: Only the last two pairs of words are scored. 1 point is given for each correct answer.

The following answers are considered correct:

Train-bicycle = modes of transport, means of travel, you can ride on both;

Ruler-watch = measuring instruments, used for measuring.

The following answers are not considered correct:

Train-bicycle = they have wheels;

Ruler-watch = they have numbers on them.

10. Delayed recall:

Administration: The examiner gives the following instructions: "I previously read a list of words to you and asked you to remember them. Tell me as many words as you can recall". Make a mark for each correctly recalled word without a cue in the designated space.

Scoring: 1 point is awarded for each word named without any prompts.

Optional: After the unprompted delayed recall trial, provide the subject with a prompt in the form of a semantic category cue for each unremembered word. Make a mark in the designated space if the subject recalled the word using a category cue or multiple-choice cue. Prompt all words that the subject did not name in this manner. If the subject does not name a word after the category cue, give him/her a multiple-choice cue using the following instructions: "Which of the words do you think it was: NOSE, FACE, or HAND?" Use the following category cues and/or multiple-choice cues for each word:

FACE category cue: body part; multiple choice: nose, face, hand

VELVET category cue: type of fabric; multiple choice: denim, cotton, velvet

CHURCH category cue: type of building; multiple choice: church, school, hospital

DAISY category cue: type of flower; multiple choice: rose, tulip, daisy

RED category cue: color; multiple choice: red, blue, green

Scoring: No points are awarded for cued word recall. Prompts are used for informational clinical purposes only and can provide the test interpreter with additional information about the type of memory impairment. In memory impairment due to retrieval deficits, performance improves with prompting. In memory impairment due to encoding deficits, test performance does not improve after prompting.

11. Orientation:

Administration: The examiner gives the following instructions: "Tell me today's date". If the subject does not give a complete answer, give the appropriate prompt: "Name the (year, month, exact date, and day of the week)". Then say: "Now, tell me this place and the city it is located in."

Scoring: one point is awarded for each correctly named item. The subject must name the exact date and exact place (name of the hospital, clinic, outpatient department). No point is awarded if the patient makes a mistake in the day of the week or the date.

Total score: Sum all scores in the right column. Add one point if the patient has 12 or fewer years of education, up to a possible maximum of 30 points.

Alternative versions of the MoCA test (used when assessing a patient over time; scoring is carried out similarly to the methodology given above for Version No. 1)

Version No. 2

Version No. 3

Appendix G8. Frontal Assessment Battery

Original title: The Frontal Assessment Battery (FAB)

Source: Dubois B., Slachevsky A., Litvan I., Pillon B. The FAB: a frontal assessment battery at bedside. Neurology. 2000; 55: pp. 1621 – 1626.

Type: rating scale

Purpose: determination of the severity of cognitive impairment associated with dysfunction of the prefrontal areas of the brain and frontostriatal circuits

Content:

1. Conceptualization (similarities/abstract thinking).

The patient is asked: "What do an apple and a pear have in common?" An answer that contains a categorical generalization ("They are fruits") is considered correct. If the patient has difficulty or gives a different answer, they are told the correct answer. Then they are asked: "What do a table and a chair have in common?" .... "What do a coat and a jacket have in common?" Each correct categorical generalization (i.e., fruits, furniture, clothing) is scored 1 point. The maximum score in this subtest is 3, and the minimum is 0.

2. Lexical fluency.

The patient is asked to close their eyes and name words starting with the letter "s" for one minute. Proper nouns are not counted. Result: more than 9 words per minute - 3 points, 6 to 9 - 2 points, 3 to 5 - 1 point, less than 3 - 0 points.

3. Motor series (Luria's three-step test).

The patient is asked to repeat a series of three hand movements demonstrated by the examiner with one hand: fist (placed horizontally, parallel to the table surface) - edge (hand placed vertically on the medial edge) - palm (hand placed horizontally, palm down). During the first three demonstrations of the series, the patient only observes the examiner; during the second three demonstrations, the patient repeats the examiner's movements; finally, for the subsequent two times, the patient performs three series independently. No prompting is allowed during independent execution. Result: correct independent execution of six movement series - 3 points, three series - 2 points; if the patient cannot manage independently but performs three series together with the examiner - 1 point.

4. Conflicting instructions (Go-No-Go test).

The instruction is given: "Now I will test your attention. We will tap a rhythm. If I strike once, you must strike twice in a row. If I strike twice in a row, you must strike only once."

The following rhythm is tapped out: 1-1-2-1-2-2-2-1-1-2. Scoring: correct performance - 3 points, no more than 2 errors - 2 points, many errors - 1 point, perseverative repetition of the rhythm after the examiner - 0 points.

5. Complex choice reaction test.

The instructions are given: "Now, if I tap once, you tap once as well. If I tap twice in a row, you must do nothing". The rhythm is tapped out: 1-1-2-1-2-2-2-1-1-2. Scoring is similar to item 4.

6. Assessment of grasping reflexes.

The patient is seated, asked to place their hands on their knees with palms facing up, and the grasping reflex is tested. The absence of the grasping reflex is scored as 3 points. If the patient asks whether they should grasp, a score of 2 is given. If the patient grasps, they are instructed not to do so, and the grasping reflex is re-tested. If the reflex is absent upon re-testing, 1 point is given, otherwise - 0 points.

Key (interpretation):

Maximum score is 18 points.

16-18 points correspond to normal frontal lobe function;

12-15 points - moderate frontal lobe dysfunction;

11 points or less - signs of dementia.

Appendix G9. Geriatric Depression Scale

Original title: Geriatric Depression Scale, GDS-15

Source: Yesavage J.A., Brink T.L., Rose T.L., et al. Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research. 1983; 17: c. 37 – 49.

Type: rating scale

Purpose: screening for depression in elderly individuals

Template:

Key: 1 point is given for a "no" answer to questions 1, 5, 7, 11, 13 and for a "yes" answer to questions 2, 3, 4, 6, 8, 9, 10, 12, 14, 15

Key (interpretation):

0 - 4 points – absence of depression.

5 points or more - probable depression

Appendix G10. Patient Health Questionnaire (PHQ-2, PHQ-9)

Original title: Patient Health Questionnaire, PHQ-2, PHQ-9

Source: Spitzer RL, Kroenke K, Williams JBW. Patient Health Questionnaire Study Group. Validity and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;282:1737–44.

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13..

Type: rating scale

Template:

Over the last two weeks, how often have you been bothered by any of the following problems?

Total score: _________/27

Key (interpretation):

0-4 - no depression

5-9 – low risk of depression

10-14 - moderate risk of depression

15-19 - high risk of depression

20-27 - very high risk of depression

The PHQ-2 includes the first 2 questions of the PHQ-9. If the patient scores 0-2 points, the risk of depression is low. If the patient scores 3 points or more, there is a risk of depression, and administering the PHQ-9 is recommended.

Appendix G11. Cornell Scale for Depression in Dementia

Original title: Cornell Scale for Depression in Dementia

Source: Alexopoulos GA, Abrams RC, Young RC & Shamoian CA: Cornell scale for depression in dementia. Biol Psych, 1988, 23:271-284.

Type: rating scale

Purpose: diagnosis of depression in elderly and senile patients

Template:

For an objective assessment of the patient's condition, observations from people interacting with them in daily life can be used. Each response is rated on a three-point scale: 0 – absent, 1 – mild or intermittent, 2 – severe or regular.

A. Affective signs

1. Anxiety, worry. Was anxiety observed in behavior over the past week? Did the patient worry about things that usually do not cause them anxiety? Were they concerned about minor events and harmless situations?

2. Sadness, tearfulness. Was the patient in a depressed mood? How long did this state last? Did they cry? How many times over the past week?

3. Lack of response to positive events. Is the patient able to feel joy from pleasant events or news?

4. Irritability. How easily does the patient lose their temper? Has the patient shown irritability and intolerance this week?

B. Behavioral disorders

5. Agitation, restlessness. Has the patient shown restlessness manifesting as an inability to sit quietly for at least one hour? Have signs of restlessness such as hand-wringing, lip-biting, or hair-twisting been observed?

6. Retardation (movement, speech, reactions).

7. Physical complaints. Has the patient complained more often than usual of indigestion, constipation, diarrhea, muscle pain, frequent urination, sweating, headaches, or other problems? How serious were these complaints? How often did they occur? (If the problems exclusively involve the gastrointestinal tract, no points are awarded.)

8. Loss of interest, abandonment of usual daily activities. How did the past week go? Did the patient engage in routine activities? In the normal amount or less? (If interest in daily activities was lost long ago, no points are awarded.)

C. Physical symptoms

9. Decreased appetite. Has appetite decreased over the past week? Was it necessary to persuade the patient to eat (if yes, 2 points are awarded)?

10. Weight loss. If more than two kilograms are lost, 2 points are awarded.

11. Fatigue, rapid exhaustion. How often did the patient complain of tiredness? Did they need daytime sleep caused by fatigue? Did they experience heaviness in the limbs? (Evaluated only in case of noticeable changes occurring over the past month.)

D. Cyclic functions

12. Diurnal mood variations. Was a worsening of mood observed? At what time of day? How severe was the morning worsening? (Only evaluated for morning mood deterioration.)

13. Sleep onset problems, falling asleep later. (1 point is awarded if the problem occurred episodically, and 2 if the problem recurred every evening.)

14. Nocturnal awakenings. Did the patient wake up in the middle of the night? How long were they unable to fall back asleep afterward? Did they get out of bed? (Not evaluated if the patient woke up to use the restroom. One point for irregular and minor occurrences, two points for regular problems.)

15. Premature morning awakenings. If they occurred, how much earlier did the patient wake up? Did they stay in bed after waking or get up? (One point if the patient woke up ahead of time but fell back asleep. Two points for early rising due to the inability to fall back asleep.)

E. Ideational disorders

16. Suicidal ideation. Did the patient express the thought that life is not worth living? Did they show suicidal ideation? Did they make attempts to harm themselves or end their life? (One point for passive suicidal tendencies, two points for active manifestations.)

17. Reduced self-esteem, feelings of guilt, self-reproach. Did the patient tend to self-criticism? Did they evaluate their actions as unsuccessful or wrong? Did they express feelings of guilt for what they did or did not do? (One point for reduced self-esteem and self-criticism. Two points for feelings of failure, defeat, and worthlessness.)

18. Pessimism. Did the patient express expectations of the worst? Were they able to notice improvements in the situation? Were they receptive to positive support from loved ones? (One point for pessimism, two points for a sense of hopelessness and inability to accept support from others.)

19. Delusions of ruin, illness, or poverty. Did the patient express bizarre ideas? Do they consider their illness a punishment from above? Do they give other irrational explanations for the problem? Do they believe in non-existent financial or other material problems?

Key (interpretation):

If the total score exceeds 10, there is reason to suspect probable depression in the patient. A score of more than 18 points indicates severe depression.

Appendix G12. Numerical Rating Scale for pain

Russian title: Numerical Rating Scale for pain

Original title: Numeric Rating Scale

Source: Bijur, P.E., Latimer, C.T. and Gallagher, E.J. (2003), Validation of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department. Academic Emergency Medicine, 10: 390-392. doi:10.1111/j.1553-2712.2003.tb01355.x

Type: rating scale

Purpose: assessment of pain intensity

Content (template):

The scale consists of a sequential series of numbers from 0 to 10. Patients are asked to rate pain intensity using numbers: 0 – no pain, 5 – moderate pain, and 10 – the worst pain imaginable.

Key (interpretation):

Appendix G13. Wong-Baker FACES Pain Rating Scale

Russian title: Faces Pain Scale

Original title: Faces Pain Scale

Source: Fadayevatan R, Alizadeh-Khoei M, Hessami-Azar ST, Sharifi F, Haghi M, Kaboudi B. Validity and Reliability of 11-face Faces Pain Scale in the Iranian Elderly Community with Chronic Pain. Indian J Palliat Care. 2019;25(1):46–51. doi:10.4103/IJPC.IJPC_126_18

Type: rating scale

Purpose: assessment of pain intensity

Content (template):

The patient is presented with an image of 11 faces. The patient chooses the face that best corresponds to their condition.

Key (interpretation):

The patient is presented with an image of 11 faces. The first face from left to right is calm and happy, corresponding to the absence of pain; the last face expresses very severe pain.

Appendix G14. Pain Assessment in Advanced Dementia Scale

Russian title: Pain Assessment in Advanced Dementia

Original title: Pain Assessment In Advanced Dementia

Source: Warden V, Hurley AC, Volicer L. Development and Psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association. 2003;4:9–15. doi: 10.1016/S1525-8610(04)70258-3.

Type (underline): rating scale

Purpose: assessment of pain in severe dementia

Content (template):

The scale represents a set of criteria evaluated by a medical professional based on severity when relatives report patient deterioration, but the patient cannot communicate it independently.

Key (interpretation):

1 – 3 points – mild pain

4 – 6 points – moderate pain

7 – 10 points – severe pain

Appendix G15. Morse Fall Scale

Russian title: Morse Fall Scale

Original title (if applicable): Morse Fall Scale

Source (official developer website, validation publication):

Morse JM, Morse RM, Tylko S. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8(4):366-77.

Type: rating scale

Purpose: assessment of fall risk in hospitalized elderly and geriatric patients

Content (template):

Key (interpretation): 0-24 points – no risk of falls, 25-50 – low risk of falls, 51 points and more – high risk of falls

Appendix G16. Confusion Assessment Method (delirium)

Original title: Confusion Assessment Method, CAM

Source: Inouye S., van Dyck C., Alessi C. et al. Clarifying confusion: The confusion assessment method. Annals of Internal Medicine 1990; 113(12): pp. 941 – 948.

Type: rating scale

Purpose: Diagnosis of confusional states (delirium) in a patient

Template and interpretation of results:

The Richmond Agitation-Sedation Scale (RASS)

+4 COMBATIVE: overtly combative, violent, immediate danger to staff (notify physician immediately)

+3 VERY AGITATED: aggressive, attempts to pull out tubes, IV line or catheter (notify physician)

+2 AGITATED: frequent non-purposeful movement, fights ventilator

+1 RESTLESS: anxious, non-aggressive movements

0 ALERT AND CALM

-1 SOMNOLENT: not attentive, drowsy, but responds to voice

-2 LIGHT SEDATION: briefly awakens to voice (eye opening and contact) < 10 seconds

-3 MODERATE SEDATION: movement or eye opening to voice (but no eye contact)

-4 DEEP SEDATION: no response to voice, but some movement to physical stimulation

-5 UNAROUSABLE: no response to voice or physical stimulation

Appendix G17. Scale for Assessment of Instrumental Activities of Daily Living (Lawton Scale)

Title in Russian: Scale for Assessment of Instrumental Activities of Daily Living (Lawton Scale)

Original title: The Lawton Instrumental Activities of Daily Living Scale (IADL)

Source: Lawton M.P., Brody E.M. Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist 1969; 9(3): pp. 179 – 186.

Type: rating scale

Purpose: assessment of the severity of functional status impairment in a patient performing daily activities (home management)

Template:

Key (interpretation):

The total score can range from 0 points (dependence on external assistance, significant need for assistance in everyday life) to 8 points (patient independence from external assistance).

Appendix G18. Barthel Index of Activities of Daily Living

Title in Russian: Barthel Index of Activities of Daily Living (Barthel Index)

Original title: Barthel Activities of daily living Index (ADL Barthel Index)

Source: Mahoney F., Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal. 1965; 14: pp. 56 – 61.

Type: index

Purpose: assessment of the patient's daily living activities

Template:

Key (interpretation):

0 – 20 points: total dependence

25 – 60 points: severe dependence

65 – 90 points: moderate dependence

95 points: slight dependence

100 points: full independence

Notes:

When completing the questionnaire, adhere to the following rules:

• Reflect the patient's actual actions, not hypothetical ones

• The need for supervision means the patient does not fall into the category of those who do not need help (the patient is not independent)

• The level of functioning is determined in the most optimal way for a specific situation by questioning the patient and their relatives, however, direct observations and common sense are important. Direct testing is not required.

• Functioning is usually assessed over the preceding 24–48 hours.

• Middle categories mean that the patient expends more than 50% of the effort required to perform a given function.

• The "independent" category allows the use of assistive devices.

Appendix G19. Insomnia Severity Index

Russian title: Insomnia Severity Index

Original title: Insomnia Severity Index

Source: Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307

Type: rating scale

Purpose: assessment of insomnia severity

Template:

For each item, circle the number that best corresponds to your answer. Please rate your CURRENT (i.e., over the past 2 weeks) sleep problems:

1. Problem falling asleep: 0 1 2 3 4

2. Problem staying asleep: 0 1 2 3 4

3. Problem waking up too early: 0 1 2 3 4

4. How SATISFIED (or dissatisfied) are you with your sleep pattern?

Very satisfied 0

Somewhat satisfied 1

Satisfied 2

Dissatisfied 3

Extremely dissatisfied 4

5. To what extent do you think your sleep problems are NOTICEABLE to others in terms of impairing your quality of life?

Not at all noticeable 0

A little 1

Slightly 2

Much 3

Very much noticeable 4

6. To what extent are you CONCERNED (worried) about your current sleep problems?

Not at all concerned 0

A little 1

Slightly 2

Much 3

Very much concerned 4

7. To what extent do you think your sleep problems INTERFERE with your daily functioning (affecting, for example, daytime fatigue, ability to perform work/daily duties, concentration, memory, mood, etc.) AT PRESENT?

Not at all 0

A little 1

Slightly 2

Much 3

Extremely interfere 4

TOTAL SCORE:__________

Key (interpretation):

0 – 7 points - normal

8 – 14 points - mild sleep disturbances

15 – 21 points – moderate sleep disturbances

22 – 28 points – severe sleep disturbances