GP tutorial 4 - advanced care planning, falls, carers Flashcards
Resources for carers
- 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
Analysis of current services
- Need/demand vs current services
- Options - leave it as it is, add ons, start again and get rid of current process
Unique features of consulting with patient with concerns of cognitive impairment
- 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
Strategies to help consulting with those who have cognitive impairments
- Using family/carers for collaterals
- Asking more closed questions
- Slower pase
- More time to allow responses
- Checking understanding throughout - chunk and check
Multi-person consult techniques
- 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
Hollistic assessment of someone with cognitive impairment
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?
Physical exam for cognitive impairment
- Observations
- Falls assessment - injuries? weakness? systems review
- Check for head injury
Investigations for cognitive impairment
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
Collateral history Q’s for memory problems
- 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?
Dementia vs delirium
Cognitive screening tools in primary care
- 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
Management of cognitive impairement primary care whilst awaiting secondary care review
- 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
Management of each type of urinary incontinence
- 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?
Swallow assessment involves…
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
How is nutrition assessed?
- MUST - BMI, unplanned weight loss, acute illness effect)
- Bloods - albumin, electrolytes
