Elderly Neuro MSK HS Flashcards
(247 cards)
1
Q
when does a LPA kick in
A
when the person loses capacity
2
Q
LPA does not mean the person can
A
demand Tx
3
Q
a doctor provides a patient with the means to end her life=
A
assisted suicide (they are ending their own life but with help)
4
Q
ending patients life who lacks capacity to consent with the aim of relieving suffering =
A
non-voluntary euthanasia
5
Q
directly ending a patients life who has capacity for this decision to relieve suffering =
A
active voluntary euthanasia (it is being done to them rather than them doing it themselves which makes this euthanasia)
6
Q
what is diagnostic momentum
A
Diagnostic momentum isa type of cognitive bias that occurs when a diagnosis is accepted without enough evidence.
7
Q
confirmation bias =
A
when a doctor selectively chooses evidence that supports their existing beliefs, and ignores evidence that contradicts them
8
Q
anchoring =
A
narrow focus on a single feature in a patients presentation to support diagnosis, even if other concurrent features refute the hypothesis
9
Q
premature closure =
A
making a diagnosis before it has been fully verified
10
Q
affective bias =
A
when a doctor’s decisions are influenced by their feelings about a patient, rather than rational thought.It can also be called visceral bias.
11
Q
framing effect =
A
how a case is presented can generate bias in the listener
12
Q
system 1 thinking
A
automatic, unconscious, and effortless.It’s based on intuition and subconscious processes.
13
Q
system 2 thinking
A
conscious, effortful, and deliberate.It’s used for complex problem-solving and analytical tasks.
14
Q
system 1 vs system 2 thinking
A
system 1: quick decisions
system 2: complex problem solving
15
Q
hindsight bias
A
tendency to overestimate our ability to predict a patients outcome after knowning the actual result
16
Q
what is the terminally ill adults bill
A
> a bill to allow adults who are terminally ill subjet to safeguards to request and be provided assistane to end their own life
private members bill
17
Q
which bill proposes to legalise assisted suicide for terminally ill adults and England and Wales
A
terminally ill adults (HAS NOT BEEN PASSED YET)
18
Q
Conditions for assisted dying bill
A
- first declaration by patient (Capacity)
- 18
- prognosis of less than 6mo
- informed wish, capacity
- no coercion
19
Q
Steps in the assisted dying bill
A
- first doctor assessment, does the patient meet criteria
- talk through diagnosis and prognosis, palliative care options for Tx
- Tx options
- how they will die with AD
- 2nd doctor after 7 days reflection -> repeat process
20
Q
after both doctors have assessed,
A
> if they both agree, it goes to the High Court for approval
2nd reflection (14 day period) - 2 day period if a prognosis less than 1 month
21
Q
after high court approval,
A
- the co-ordinating doctor can prescrivbe the substance for self admin
- CANNOT ADMINISTER IT
- this dr must remain with the ppt
22
Q
assisted dying is
A
AGAINST THE LAW
23
Q
Respect form
A
- documents ACP
- Lasts months to years
- records DNACPR
24
Q
core principles of ethical research
A
> protection from harm
voluntary and informed conset
special consideration for vulnerable groups
25
protection from harm - researcher responsibilities
- weigh up costs and risks to ppts > expected positive outcomes for society
- avoid all unecessary suffering and injury
- avoid exp expected to cause death/ disabling injuries
- be prepared to terminate research in order to avoid causing harm
26
voluntary and informed consent - researcher resp
> ask pppl if they wish to take part
> give clear info
> give people choice abt taking part, right to say no w/o this affecting their care
> ensure people have legal capacity to conset
> obtain consent from each person in writing ot verbally
27
28
special consideration for vulnerable groups - researchers must
> undertake research in a way that does not exclude
> adapt research processes and methods
> offer tailored support to their eeds
> develop strategies for dealing w safeguarding issues
29
who funds research in the UK
NIHR - National Institute for Health and Care Research.
30
# Health research authority
ROLE
Health research authority - ethical approval for research
31
sponsor =
institution/organisation hat takes on legal resp for the research (not the funder)
32
funder =
organisation that provides money for the research to be undertaken
33
chief investigator=
overall lead researcher for the research project
34
principal investigator =
indiv responsible for the research conduct at a paticular site
35
research protocol =
doc detailing recruitment and processes according to ethical rpproval
36
ethical approval
All research involving energy patients staff or results says human tissue or other biological samples requires ethical approval from the health research authority (HRA)
37
HRA ethical approval requires a submission to the
REC - research ethics committee
38
REC will then look at
All aspects of the ethical burden risk to participants and the value of the study
39
what happens in ethical approval
- sponsors and ethics committee evaluate if the proposed research is ethical, possible and has value
- research myst be feasible in the timeframe and must show potential to improve healthcare
- burden of research is cons against the benefits of the sudy
40
research =
designed and conducted to generate new knowledge
41
service evaluation =
designed to answer the question 'what standard does this svc achieve'
42
audits =
designs to find out whether the quality of a svc meets a defiend standard
43
NHS ethics committee is only required for
only for research
44
what is a PROM
patient reported outcomes measure. Types of questionnaires that patients complete to assess their own health and QOL
45
E.g. of PROM
PHQ9 for depression
46
inducement to consent
ppts may be reimbursed (travel etc) but not paid to participate which would be considered inducement to consent
47
right to withdraw
paticipants have the right to withdraw from a study at any point w/o impacting their care
48
informed consent =
patients can only concept when they are fully informed. This includes having the opportunity ti ask questions
49
right to receive their usual care =
paticipants in research is not a route to receive Tx
50
CTIMP trial
clinical triadl of investigational medicinal product = any clinical trial testing a new drug ot Tx that needs reg approval from the MHRA
51
non-CTIMP trial
refers to clinical trials that do not involve investigational medicineal products like studies using standard Tx or observational research where no new drug is being tested
52
ideal process for recruiting to a RCT
screening, eligibility, approach, randomisation
53
screening =
accurate recording of patients monitoring of patients receiving tx/ care
54
eligibility =
looking at patient information to see which see who is eligible for
the study (e.g., BMI, PSA blood, etc.)
55
approach =
when someone approaches an eligible patients with information
about the study
56
randomisation =
formal randomisation of participants to a treatment
57
papworth principle =
do to a patient as you would have done to yourself or a member of your family
58
equipose =
Equipoise refers to a genuine uncertainty within the expert medical or scientific community regarding the most effective treatment among multiple options. It serves as an ethical foundation for randomized controlled trials (RCTs), ensuring that no participant is knowingly given an inferior treatment.
59
what makes RCT ethical
equipoise, the idea that there is genuine uncertainty as to which treatment is most beneficial
60
individual / theoretical equipoise
when an indiv clinician is genuinely uncertain abt the available Tx
61
collective/ clinical equipoise
when the profession as a whole is uncertain about available Tx
62
absolute equipoise =
comparing like for like outcomes
63
effective equipoise =
when u are comparing different outcomes
64
PSIRF airms
> proportionate resp to patient safety incidents
> supportive oversight focused on strengthening response system
65
what does PSIRF do
> multi site
> involves ICB
> promotes accountability
66
aims in PSIRF
- No blame culture
- systems based approaches to learning from patient safety incidents
67
PSIRF approach
> focuses on improvement
> detailed Ix not done
68
PSIRF responses
> hot debrief
> cold debrief
> AAR
69
after action review
> get stakeholders together
> figure out what happened, what was supposed to happen, why the difference ocurred, what learning/ actions are there
70
hot debrief =
- in the moment, whole team, checking how everyone is
- is there any immediate learning
- does anyone need to leave to gather their thoights
- considers psychological disress of staff after an event
71
cold debrief =
- 48+ hrs aftrr events
- focus on what happened
- not used for psych trauma - need to know earlier
- can be undertaken as an AAR
72
Pathway review =
> review of an overall process
> can be MDT
> reviews processes/ policies/ procedures
> 60 day limit
73
duty of candour
> must be candid w patients
> sorry is not an admission of liability
> right to PSIR reports
74
near miss =
no harm this time due to chance but may cause harm if repeated
75
no harm =
no additional care required, patient not impacted
76
low harm =
> additional care req, doesn't inc length of strau
77
moderate harm
Significant additional care required (e.g., admission to ICU)
. Delays discharge due to harm causing increased length of stay
78
death is also known as
catastrophic harm
79
severe harm
Error/incident results in long-term negative impact on health (e.g., long-term morbidity, reduction in lif
expectancy).
80
diagnostic errors
misdiagnosis, delayed, failure to diagnose, overdiagnose
81
Tx errors
medication, surgical, procedural
82
preventative error
· Failure to provide prophylactic treatment
. Inadequate monitoring or follow-up
83
systemic error
Communication failures
. Documentation errors
. Coordination errors between diff departments
84
envir/ organisation errors
> Inadequate staffing
. Working conditions
. Equipment failures
85
patient related errors
non concordance, failure to provide complete info
86
human errors
technical, judgement, skill based
87
considering human factors
> staffing, staff absence
> fatigue levels
> staff rotas
> barriers to communication
88
BERWICK REPORT
> Review into safety culture
> recommendations: continual learning as an organisation, safety as system priority, resources made available nationally, responsiveness of the organisation is mandatory
89
gmc GMP 5 criteria
> creating a fair and respectful workplace
> promoting patient centered care
> helping to tackle discrim
> championing for fair and inclusive leadership
> supporting continuity of care
90
when can be prescribe for family/ ourself
only when no on eelse is available to assess and prescribe or its an emergency
91
what must we inform the GMC of
* caution from a prosecuting authority
- charged w a criminal offense, found guilty of a crime, critisised by an official inquiry, another proffessional body has made a finding against ur registration as a result of fitness to practice procedures
- anywhere in the world
92
chaperones for intimate exams
SHOULD be offered
93
criteria for chaperone
have to understand the examination and be familiar with the procedure
94
What is gross neglicence manslaughter
- that the defendant owed a duty of care to the deceased
- the duty of care was breached by the defendanr
- the breach caused the death of the defendanr
- at the time of the neglience thwere was obv risk of death
- the nature of the defendants neglicence was so gross it amounts to criminal offence
95
human tissues act 2004
* Relates to removal and retention of organs and tissues from both living and dead
96
Section 2 of the suicide act
a person who aids, abets the suicide of another or an attempt by another to commit suicide is liable to conviction
97
essential elements of negligence
> duty of care
> breach of duty
> causation of loss or damage
> quantificiation of that loss
98
burden of proof
> on claimant
99
negligence - quantification of loss
> general damages = pain suffering and loss of amennity
> special damages = actual loss until date of trial
> future loss = predicted future loss
100
impact of back pain
> sig time off work -> social isolation, personal/ community, economic, psych impact
> loss of ADL
> stigmatisation
> May become dependent on family → care stress & role
reversal, relationship stress/ resentment
101
Psychosocial factors/ yellow flags in back pain
- Belief is due to serious underlying pathology
- Negative attitude that back pain is HARMFUL/ SEVERELY DISABLING
- Fear avoidance behaviour and reduced activity levels =
avoiding activity will improve
- An expectation that passive, rather than active, treatment will be beneficial
- Seeking treatments that seem excessive/inappropriate
- Overbearing/unsupportive family
- Tendency for depression, low morale and social withdrawal
- Social or financial problems
- Negative feelings toward work (low support/dissatisfaction)
- Ongoing litigation
102
Mx of back pain
> MDT → PT, OT, social services, GP (NSAIDs)
● Focus on return to work & highlighting what patient can do instead of what they can’t do
103
tool for complicated lower back pain
STarT Tool Risk Stratification of complicated lower back pain
104
Mx of low risk back pain (<3)
> Very likely to improve so initiate self management
○ Education on exercise/ staying active, analgesia, avoiding complementary therapy
○ Refer for PT if not resolved by 6 weeks
105
Mx of medium risk back pain
> Aim to facilitate return to function
○ Early PT referral
○ Promote self management
106
Mx of high risk back pain
> Comprehensive biopsychosocial assessment
○ PT + CBT referral → identify yellow flags that will impact on recovery
107
issues w complementary and alt medicine
- Allergic & non-allergic (irritant dermatitis) reactions
● Mechanical injuries → acupuncture can lead to pneumothorax, spinal injury, infection
● Severe restrictions of certain recommended diets may cause deficiency
● Not all practitioners are well regulated/ registered
● Not cost effective/ lack of evidence = even ones showing utility are often of low quality
108
Acupuncture
> Needles shown to reduce blood flow to pain matrix in brain
109
chiropratic =
Manual adjustments of spine & joints, & soft tissue manipulation to relieve MSK mechanical disorders & nervous system
110
osteopaths =
Touch, physical manipulation & stretching to increase mobility & blood flow, relieving spasms
111
MDT members for inflammatory arthritus
> rheum
> SN
> physio, OT, podiatry, hand exercise programmes
112
Role of MDT in inflammatory arthritis
MDT provides the opportunity for periodic assessments of the effect of disease on their lives (e.g. pain, fatigue, everyday activities, mobility, ability to take part in social/leisure activities, quality of life, sexual relationships)
113
the impact of untreated inflammatory arthritis on function and quality of life
> functional impairment - walking, exercise, sleep. ADL, work
> negative impact on sexual relatopnships
> poor self image - deformity
> fatigue, psych impact of chronci pain
114
community support groups avail to ppts w neuro conditions
> spinal injuries association
> stroke association
> parkinsons UK
> muscular dystrophy UK
> Dementia UK
- The encephalitis society
115
MDT approach for xcomplex discharge planning
Social worker → helps allocate where they go
● If want to discharge → NOA (Notification of Assessment) to request social worker allocation
● NOD (Notification of Discharge) submitted = medically fit & social services is only delay
116
imp features to consider in complex discharge planning
● Pre-admission functional status, often OT assessment
● Where admitted from
● Current function → strength, transfers/ mobility, ADLs
● Compare this with baseline = identify potential for improvement/ how they’ve been improving
117
destinations for discharge - home
if function adequate and can mobilise
118
destinations for discharge - inpatient rehab
→ if good pre-admission potential but not achieved yet
119
destination for discharge - residential/ nursing home
→ can be to achieve potential = medically but not socially fit, or can be for further assessment, or may be permanent
120
dest for discharge - palliative fast tracl
= within last 6 weeks of life → funding applied for that allows prompter fast-track, to allow for chosen place of death.
121
Rf for stroke
> Lifestyle: smoking, alcohol misuse and drug abuse, physical inactivity, poor diet
> Established CVD e.g. HTN
> gender - men > women
> DM, sickle ccell, antiphospholipid syndrome, OSA, CKD
122
Which women have an increased risk of stroke
women who take COCP, have migraines with aura, in the immediate postpartum period and pre-eclampsia
123
risk of stroke and age
- risk of having a stroke doubles every decade after 55
124
Suspect stroke if
Presents w/ sudden onset, focal neurological deficit which is ongoing or has persisted for longer than 24 hours and cannot be explained
by any other conditions such as hypoglycaemia
- Clinical features include: confusion/altered consciousness/coma, headache (sudden, severe, unusual), Weakness, sensory problems
(paraesthesia or numbness), speech problems (dysarthria, dysphasia), visual problems (homonymous hemianopia, diplopia),
dizziness/vertigo/loss of balance, N&V, specific cranial nerve defects, gait problems
125
primary prevention for stroke
> identify and treatL HTN, DM, hyperlipaedmia
> CHADSVASC score used to calculate overall risk of stroke in pts with AF (offer anticoagulation if 2+)
126
primary prevention for stroke - lifestyle
> Smoking cessation
- Exercise encouragement (increases HDL, increases glucose tolerance)
- Health promotion initiatives - promoting healthy lifestyle
127
secondary prevention for stroke
> Control risk factors - significant benefit from lowering BP and cholesterol even if not particularly raised
- Antiplatelet agents after stroke if no primary haemorrhage seen on CT
128
SP - medications to give after a stroke
> Give aspirin 300mg for 2 weeks then switch to long term clopidogrel monotherapy (aspirin + > dipyridamole)
- If caused by AF use DOAC or warfarin
129
ethical issues of diagnosing a neuro condition like stroke
1. Autonomy and restraint e.g. with NG tubes
2. Capacity decisions with dysphasia
3. Maintaining patient dignity
4. End of life decisions
5. Safeguarding and best interests
130
effects of a nrueo disorder e.g. stroke
> loss of normal function e.g. walking
> loss of cognition -> anx
> job = loss of role
> Role = no longer supporting family, recipient of care rather than giver
6. Autonomy = dependent on carer (often husband/ wife) for various activities
7. & Direct damage to brain = could cause depression/ other psychiatric disorders
131
Employer support for a neuro condition like stroke
> Write to employer, explain circumstances and recommendations i.e. altered seating/
equipment, adjusted hours with regular short breaks
> Encourage potential of finding a new role within the organisation
132
employment support for a stroke - social services
> access to work system works with both pt and employer to find a role which best suits the pt
> Help to find alternative work, help accessing disability benefits, housing suitable for their
needs, help pay for transport costs
133
4 major themes of national service framework for the elderly
1. respect the indiv
2. intermediate care
3. provide evidence based specialist care
4. promote active healthy life
134
National Service Framework for the Elderly - respect the indiv
> NHS services based on need, not age
- Treatment is person centred care
135
National Service Framework for the Elderly - intermediate care
> Elderly people will have access to a new layer of care between primary and specialist services - at home or
in designated care settings
- Designed to reduce unnecessary hospital admission, increase independence and encourage earlier
discharge
136
National Service Framework for the Elderly - provide evidence based specialist care
> Specialist staff in hospitals for elderly (specialists on Geriatrics, Strokes, Falls, Mental Health(
- Specialist prophylaxis for stroke and specialists for treatment
- Action to reduce falls
- Integrated mental health services
137
National Service Framework for the Elderly - promote active healthy life
Promotion of healthy and active life via co-ordinated programme of action led by NHS in partnership with local councils
138
medical needs of an elderly person
> Mobility aids
- Medication
- Psychiatric and memory assessment
- Nutritional support
139
social needs of an elderly person
socialisation, transportation, personal care support
140
what are older men at risk of misuisng
l older men are considered to be at the greatest risk of substance misuse including alcohol and illicit drugs
141
what are older women at risk of misusing
Older women are more at risk of problematic use of sedative/hypnotic and anxiolytic medication
142
physical Sx that should trigger screning for substance misuse in the elderly
> sleep complaints
> cognitive impairment
> seizures, malnutrition, muscle wasting
> Unexplained chronic pain or other somatic symptoms
- Incontinence, urinary retention
- Poor hygiene and self neglect
- Unusual restlessness or agitation
- Complaints of blurred vision or dry mouth
- Unexplained nausea and vomiting
- Changes in eating habits
- Slurred speech
- Tremor, poor motor coordination, shuffling gait
- Frequent falls and unexplained bruising
143
social implications following an epilepsy diagnosis
* depression
* Reduction in social participation (if photosensitive epilepsy) → e.g. may not attend cinema, concerts,
bars etc.
* Stigma
* Pregnancy and breastfeeding risks (teratogenic medications)
144
driving (DVLA) rule for epilepsy
Must be seizure free for 12 months following epilepsy diagnosis
145
driving restrictions for stroke
- 1 month ban if no residual neurological deficits
● 3 month ban for multiple TIAs
146
driving restrictios for chronic neuro disorders e.g. MS PD
Complete DVLA PK1 form
147
1 provoked/ isolated seizure →
6 m ban
148
epilepsy > 1 seizure driving
Epilepsy (>1 seizure) & 12 months seizure free → can reapply for license → if no seizures for 5 years then a ‘til 70 license’ is restored
149
epilepsy and heavy good vehicle ban
If drive a heavy good vehicle → 10 year ban
150
syncope - simple faint restrictions
no restriction
151
single episode, unexplained & treated =
4 week ban
152
# Synccope
single episode, unexplained and untreated =
6m ban
153
2nd episode of syncope =
12 m ban
154
Syncope driving restictions
- Simple faint = no restriction
● Single episode, explained & treated = 4 week ban
● Single episode, unexplained/ untreated = 6 month ban
● 2nd episode = 12 month ban
155
visual problems - driving restrictions
> Field defect = stop driving & require assessment for suitability
● Monocular may drive if acuity/ visual field normal
156
most common cause of meningitis now
Most now due to Men B (because Men C vaccine is eradicating Men C). Men B vaccine was introduced in 2013, which should also reduce Men B rates.
157
prevention of meningitis
> Increased awareness of the symptoms of disease
2. Good hygiene measures = handwashing, good sanitation, avoid overcrowding
3. Isolate infected individual to limit spread
4. Avoid sharing towels
158
meningitis prevention - close contacts
> Identify close contacts in 7 days before onset (people in same household, sharing rooms, eating together or
any intimate contact)
> Abx chemoprophylaxis to close contacts → Ciprofloxacin (or Rifampicin) OR
● Vaccinate (any strain that has vaccine & person hasn’t had vaccine (ACWY))
159
meningitis - when is risk highest
first 7 days
160
elderly changes causing immobility
* physiological changes of ageing
- physical illness - HF, CVD, chronic resp disease
- psych illness - isolation, bereavementm dementia, poor accessibility of public buildings
161
index for ADL
Barthel index of ADLs assesses various areas important for independent living
162
Physical comps of falls
> fracture
> soft tissue laceration
> pressure sores
> rhabdo
> hypothermia
163
psych comps of falls
> loss of confidence
> fear of falling
> depression and anx
164
social comps of falls
> isolation
> increased dependence
165
RF for falls - DAME
- drugs
- ageing e.g. reduced vestibular function
- medical = neuro, CV, MSK
- envir - poor footwear, pets, poor lighting
166
consequences of falls
> 2.3 bn GBP/ yr of NHS money
> 2. Human cost: fracture (5% of falls), pain,
immobility, loss of confidence (‘fear of falling’)
& independence = isolation & depression (&
increased dependence on carers)
167
consq of prolonged immobility
Pneumonia, hypothermia, pressure sores, DVT
168
Mortality from a hip fracture
20-30%
169
multifactorial assessment for falls
- >65 and 1+ fall in last 12 months & risk
factors
- Multifactorial assessment → CV risk,
osteoporosis risk, gait/ balance, home
hazards, meds review, cognitive/ neuro
examination, visual impairment, urinary
incontinence
170
multifactorial asssessment for falls
> Strength and balance training
2. OT home hazard review
3. Podiatry improving foot wear
4. Improve vision
5. Medication review
6. Treatment conditions including bone
strengthening
171
falls MDT - aids to daily living
> mobility aids e.g. ramps, walking frames, commodes
> dressing
> feeding - adapted cutlery
> phones w large buttons
172
Falls MDT - OT
> ADL assessmsnt e.g. Barthel index to inform level of care
> help individuals adapt to their life with chronic pain → aim to gain independence,
confidence and control.
173
what can OT do
Home adaptations, ADL help, leisure and social activities, work and study skills.
174
Falls MDT - physio
> rehabilitation
> Exercises, manoeuvres to increase function and minimise impact of condition
175
Ix for cause of pain
> Bloods: FBC, ESR, CRP, U&E’s, ALP, PSA, LFT’s, TFTs
- Urine dip
- ECG
- Serum/urine electrophoresis - consider multiple myeloma
- Imaging - XR, US, CT, MRI
176
euthanasia vs assisted suicide
> Euthanasia - deliberately ending a person’s life to relieve suffering
> Assisted suicide - deliberately assisting/encouraging another to commit suicide
BOTH ARE ILLEGAL
177
active euthanasia
does the act of ending life
178
passive euthanasia
- withholds life-prolonging treatment - pt can consent to this as make advanced directives to refuse this
179
voluntary vs involuntary euthanasia
> Voluntary - when person dying consents
- Non-voluntary - when person dying can’t consent so another makes the decision for them, often based on statement of wishes
- Involuntary - against the person’s wishes (murder)
180
arguments for euthanasia
> Allows pt autonomy to control own body and how one dies
- Is already done in some sense - DNACPR is passive and sedation to shorten life by ending suffering in palliative
- Acts in beneficence of the pt
181
arguments against euthanasia
Religious - only god has right to end human life
- Could change attitudes regarding human life - very ill may feel they have to accept death, may hinder research into cures for conditions, misdiagnosis
could lead to euthanasia when death wasn’t imminent
- Violates non-maleficence- could lead to lack of respect for terminally ill/feel like doctor is encouraging killing them
- Detracts from instead of improving end of life care - good quality EOL care should remove suffering and thus solve the problem
182
physician assisted suicide =
“Suicide by a patient facilitated by means (as a drug prescription) or by information (as an indication of a lethal dosage) provided by a physician who is aware of the patient's intent”
183
How doctors should respond to requests for euthanasia / assisted suicide according to GMC:
> listen and discuss readons for the pts request
> exp it’s a criminal offence for anyone to encourage or assist a person to commit/ attempt suicide
> Objective advice about the lawful clinical options (e.g. sedation and other palliative care) which would be available if a patient were to reach a settled decision to kill them self.
> assess whether the pt has any unmet PC needs
184
principles of palliative care =
> early identification
> enhances Qol
> prevention, early diagnosis and treatment of serious or
life-limiting health problems
- Does not intentionally hasten death but provides whatever treatment is necessary to achieve an
adequate level of comfort for the pt in the context of the patient’s values
185
what is the end of life strategy
framework published by the Department of Health and Social Care promoting high quality care across the country for all adults approaching the end of life
186
what does the end of life strategy mean for pts
> The opportunity to discuss personal needs and preferences and for these to be recorded in a care plan so that all services are aware of a pt’s priorities
> Coordinated care and support - ensuring that pt needs are met, irrespective of who is delivering the service
> Rapid specialist advice and clinical assessment wherever the pt is - High quality care and support during the last days of a patient’s life
187
End of Life tools - used to identify adults who are likely to be approaching the end of their life
> The Gold Standards Framework
- The Amber Care Bundle
- Supportive and Palliative Care Indicators Tool (SPICT)
188
GSF - 3 triggers which suggest a pt is nearing the end of life
1) The surprise question: Would you be surprised if this pt were to die in the next few months, weeks, days?
2) General indicators of decline - deterioration, increasing need or choice for no further active care
3) Specific clinical indicators related to certain conditions
189
7 key tasks in the GSF
Communication
- Coordination of care
- Control of symptoms and ongoing assessment
- Continuing support
- Continued learning
- Carer and family support
- Care in the final days
190
limitations to successful rehab
> complex comorb
> psychological barriers can reduce adherence
> SE barriers - reduced transport, financial constraints
191
healthcare system challnges limiting success of rehab
> limited resources - long waiting times
> geographical disparities
> lack of intergrates care
192
components of a comprehensive geriatric assessment
- Med assessment
- functional assessment
- psych and cognitive assessment
- social assessment
- envir assessment
- advance planning and goals of care
- MDT
193
medical assessment in CGA
- full PMH
- polypharmacy review
- frailty assessment
- nutrition status
- Pain Mx
194
GCA - functional status
> ADL assessment
> mobility and falls risk assessment
195
GCA - psych and cognitive assessment
> cognitive screening - MMSE, MOCA
> mood assessment
196
GCA - social assesssmrnt
> support network, living sit and home safety, care needs assessmsnet, any safeguarding concerns
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GCA - env assessment
housing suitability and community svcs
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GCA - ACP and goals of care
> patient prefences
> adv directives
> end of life planning - PC needs, GSF
199
Outome of a GCA
- A structured care plan addressing medical, functional, psychological, and social needs.
- Improved quality of life and reduced hospital admissions for older adults.
- Support for independent living where possible.
200
Physical dimension of pain in cancer pt
> noncieptive vs neuropathic
> WHO pain ladder
201
social dimension of pain in cancer pt
> family and caregiver burden - strain on relationships
> financial impact
> isolation and support needs
202
spiritual dimension of pain in cancer pt
> existential distress - fear of death
> religious and cultural beliefs - influence on pain percception and DM
> need for spiritual care
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ix for referral to palliatie care svc
- complex sx mx
- Psychosocial or spiritual distress affecting quality of life.
- Difficulties with advance care planning or end-of-life decision-making.
- Carer distress and support needs beyond generalist services.
204
Non pharm methods of preventing cancer related distress
> psych support - CBT, mindfulness
> counselling and psychotherapy
> peer support grs
> faith based support
205
nutritional screening tool
Malnutrition Universal Screening Tool (MUST) to assess risk.
206
dietary strategies to support nutrition in the elderly
- small freq meals rich in protein and calories
- fortified foods
- hydration focus
- vitamin D and Ca supplements
207
env support for nutritiion in the elderly
- encourage family meal settings or mealtime assistance for those w mobility issues
- adaptive utensils for those with dexterity issues
- community meal svcs like meals on wheels
208
Medical interventions for nutrition
- SLT referral for dysphagia
- address dental issues
- prescribed oral nutritional supplemnts for thise at high risk of malnutrition
209
secondary care svcs for the elderly
- geriatric medicine dept - GCA, acute medical needs like delirium
- specialist clinics - falls clinic, memory clinics, continence services
- hosp based rehabilitation units e.g. stroke recovery
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social care in relation to the elderly
Social care supports older people with daily living when they cannot manage independently. Services are assessed under the Care Act 2014.
211
assessment process for social care
- needs assessment - identifies elgibility for social care svcs
- carers assessment - evaluates caregiver support needs
- Personal Budgets – Provides direct payments for self-directed care.
212
types of social care - home care
Personal care (washing, dressing), medication support.
213
reablement svc (social care)
Short-term support post-hospital to regain independence.
214
social care - residential and nursing
For those needing 24-hour assistance.
215
social care - respote
Temporary care for caregiver relief.
216
eligibility for social care
- Means-Tested – Local authorities assess financial eligibility.
- NHS Continuing Healthcare (CHC) – Fully funded for complex health needs.
217
ICS - elderly
> Coordinate health and social care services regionally.
Aim to provide seamless care across hospital, community, and social care sectors.
218
Ageing well program (NHS LTP)
> Prioritises proactive care for older adults.
Includes initiatives like Enhanced Health in Care Homes (EHCH).
219
managing behavioural and psych symptoms of dementia
> first line: non pharm
> severe sx: risperidone short term use
> antidepressants - for anx and depression
220
economic principles used in NICE Technolpgy Appraisals
> cost effectiveess analysis
> QALY = below £30k per QALY
> incremental cost effectiveness ratio
> budget impact analysis - affordability
221
CEA =
Measures the cost of a treatment relative to its clinical benefit (e.g., improvement in cognition, reduction in care needs).
222
icer =
ICER = (Cost of new treatment – Cost of standard care) ÷ Difference in QALYs.
Treatments with lower ICERs are considered more cost-effective.
223
sheltered accom =
where the resident will live in their own flat but there may be communal areas. Some have onsite carers, some have an onsite warden and others do not have any staff onsite but have pull cords with a responder system
224
residential homes =
staffed by carers (but not nurses), residents needs are usually required to be met with the assistance of 1 person. Any complex behavioural or mobility issues may not be suitable in this setting.
225
nursing homes =
staffed by nurses and carers, residents are usually much more dependent and have higher care needs.
226
therapy asssessments b4 discharge
- ability to perform transfers
- mobility
- stairs
- domestic tasks
- cog assessments
227
discharge destinations
> home (with or w/o additional support)
> inpatient rehab
> residential home
> PC
> nursing home
228
inpatient rehab
> aims to return to prev level of function
229
discharging to a residential home
- requires social svc input
- temporarily (e.g. respite for family/ carers, respite for ongoing assessment og needs)
- permanent - not safe for home and lacks rehab potential
230
discharge - PC
> When a patient is likely to be within their last 6 weeks of life, a medical decision
can be made to deem them FastTrack.
> once Fasttrack forms are completed, funding can be applied for which allows for prompter discharge to prefered plae of death
> packages of care are free
231
social care in discharge planning
> input is needed to organise packages of care or 24 hr placement
> Once a social worker is allocated, they will visit the ward to
review the medical notes, meet the patient and often
include the families/NOK in their assessments.
232
capacity and discharge planning
> if capacity: free to make unwise/ unsafe decisions
> lacks capacity: decision needs to be made in their best interests
233
purpose of screening
> early Tx and better outomes
> screening can prevent onset of disease through preventative tx
> ppl may be asymptomatic
234
breast screening
> 50-70 every 3 yrs
235
cervical screening
> 25-49: every 3 yrs
> 50-64: evert 5 yrs
236
who engages less w screening
low SES/ deprivaytion, minority groups, trans, disabled
237
what do we reduce with each type of prevention
> primary: incidence
> secondary: prev
> tertiary: impact
238
absolute risk =
> probability of a specific event occuring
> usually from cohort studies or RCTs
239
attributable risk
difference between exposed and unexposed
240
NNT
> absolute risk reduction (% of patients who did not get the bad outcome)
> 1/ ARR
> always rounded up bc whole patients
241
ICP =
each ICS has a committee resp for strategy in that area
242
ICB =
a statutory NHS organisation resp for meeting population health needs and managing budget for services
243
intercourse in <13
Children under 13 cannot give consent for sexual activity. All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor.
244
Possible Signs of Abuse
> Change in behaviour or extreme emotional states
Dissociative disorders (feeling separated from their thoughts or identity)
Bullying, self harm or suicidal behaviours
Unusually sexualised behaviours
Unusual behaviour during examination
Poor hygiene
Poor physical or emotional development
Missing appointments or not complying with treatments
245
prevention of dental decay
> oral hygiene education
> healthy eating campaigns
> reg dental checkups from 1
246
prevention of accidents
> education on safe practices - e.g. childproofing homes, weating helmets
> care safety - seat belts and car seats
> basic first aid training for parents
247
preventin obesity in children
- school and community programmes - after school fitness
- encouraging healthy eating
- media campaigns on education
