GP tutorial 4 - advanced care planning, falls, carers

Question 1

Resources for carers

Answer 1

• Carers UK
• Age UK
• NHS support and benefits for carers website - goes through who is entitled to what
• Citizens advice - financial support etc
• GP - for MH support and physical conditions of carers

Question 2

Analysis of current services

Answer 2

• Need/demand vs current services
• Options - leave it as it is, add ons, start again and get rid of current process

Question 3

Unique features of consulting with patient with concerns of cognitive impairment

Answer 3

• May not be able to answer questions - varied degree of impairment
• Collaterals often needed
• Steps can be taken to manage acute causes of delirium before conversations if in hospital

Question 4

Strategies to help consulting with those who have cognitive impairments

Answer 4

• Using family/carers for collaterals
• Asking more closed questions
• Slower pase
• More time to allow responses
• Checking understanding throughout - chunk and check

Question 5

Multi-person consult techniques

Answer 5

• Establish roles
• Clarify who
• Patient centred - maintain eye contact, open body language, face them, avoid discussing in 3rd person
• Equal opportunity for relative/carer to speak - explain input is valued but need to speak with patient first
• Work collaboratively - mediate conflict

Question 6

Hollistic assessment of someone with cognitive impairment

Answer 6

Biopsychosocial

Biological:
* Continence
* Falls
* PMH
* DH

Psychological:
* Coping
* Worries
* Carer support
* Anxiety and depression management - screen for this

Social:
* ADLs
* Environment at home
* OT/PT?

Question 7

Physical exam for cognitive impairment

Answer 7

• Observations
• Falls assessment - injuries? weakness? systems review
• Check for head injury

Question 8

Investigations for cognitive impairment

Answer 8

Bedside:
* Urine MSU
* ECG
* Lying and standing BP
* Cognitive assessment - MSE/AMTs/4AT

Bloods:
* FBC
* LFT
* U&E
* Glucose
* Lipids
* B12 + folate
* TFTs
* Bone profile

Imaging:
* CXR - ?pneumonia
* CT head - for trauma/bleed

Question 9

Collateral history Q’s for memory problems

Answer 9

• ODPARAS
• Onset (triggers), duration, progression (progressive vs stepwise vs fluctuating)
• Associated - hallucinations?
• BRIMS
• Behaviour - aggression/agitation/disinhibition/personality changes
• Risk assess - ever put themselves in danger at home? Driving?
• Incontinence - any problems with bowels or bladder/waterworks?
• Mood - low mood, self harm, suicide risk
• Sleep - sundowning? problems sleep? REM sleep disorder?

Question 10

Dementia vs delirium

Answer 10

Question 11

Cognitive screening tools in primary care

Answer 11

• Montreal cognitive assessment (MoCa) - visuospatial, naming, memory, attention, language, abstraction, recall, orientation
• Mini mental state exam (MMSE)
• Addenbrookes cognitive exam ACE-III - 82-88 is cut off for dementia
• GP assessment for cognition (GPCOG) - includes pt assessment and informant (family, carer)
• 4AT - delirium
• Confusion assessment method (CAM)
• AMTS - <6 = dementia/delirium

Question 12

Management of cognitive impairement primary care whilst awaiting secondary care review

Answer 12

• Safety - risk assess, still driving? leaving hob on? hazards house?
• Safeguarding - finances? abuse?
• Support - for carer and patient
• Medication management - review and check
• Encourage socialisation - isolation can worsen
• Screen for depression/anxiety - self harm and suicide risk

Question 13

Management of each type of urinary incontinence

Answer 13

• Stress - pelvic floor exercises, lifestyle (reduced caffeine, no overhydration, stop drinks 2 hrs before bed etc), mid urethral sling, duloxetine
• Urge - bladder training, oxybutynin/mirabegron, botox injections
• Overflow - treat cause eg BPH
• Neurological - intermittent catheterisation?

Question 14

Swallow assessment involves…

Answer 14

SALT will:
* Observe alertness
* Oral motor exam - lips, tongue, palate, jaws, cheeks, cough and voice
* Trial swallows - saliva, liquid, pureed, solid
* Observe - cough? throat clear? wet voice? breathing problems? reduced O2 sats

Special:
* Video fluoroscopic swallow study
* Fibreoptic endoscopic evaluation of swallowing

Question 15

How is nutrition assessed?

Answer 15

• MUST - BMI, unplanned weight loss, acute illness effect)
• Bloods - albumin, electrolytes

Question 16

Options from MUST score re management

Answer 16

• Low risk - do nothing but repeat screening regularly (weekly in hosp)
• Medium risk - observe - dietary intake for 3 days, if inadequate set goals etc
• High risk - refer to dietcian, set goals and improve intake

Question 17

Options for managing malnutrition - general

Answer 17

• Fortify meals - with butter, cream, cheese or added drinks eg Fortisip
• Monitor intake
• Focus on foods they enjoy
• Frequent snacks rather than larger meals can be beneficial

Question 18

Managing swallowing difficulties and feeding

Answer 18

• Upright position
• Chin tuck
• Good mouth care after eating
• Thickened liquids / ice chips or jelly
• Changing foods - eg minced and moist, pureed
• Can consider enteral feeding (NG/PEG) or paraenteral (IV)

Question 19

Anticipatory medications for EOL

Answer 19

• Morphine - breathlessness and pain
• Midazolam - anxiety and agitated
• Haloperidol/levomepromazine - N+V
• Glycopyrronium - secretions