HCoLL Flashcards
Advanced Directives / Advanced decision to refuse treatment
Made when the patient has capacity for when they lose capacity.
Pt can set out the treatment they do not want and in which circumstances.
Cannot demand treatment or refuse basic care
Can a patient with an ADRT be treated when detained under the mental health act?
yes
What are things to consider when thinking about DNACPR?
- Survival chances
- QoL after resuscitation – hypoxic brain damage/pain/broken ribs/etc
- Will ITU be able to support this patient post-arrest
DNACPR
Only covers CPR and not any other treatments.
= A medical decision but should be discussed with the patient and family.
Needs a medical reason other than age to be valid (e.g. not fit for ITU post-arrest/frailty/terminal/etc).
ReSPECT form
= personalised recommendations for clinical care in a future emergency, where the patient is unable to make or express decisions.
A more holistic summary of end-of-life care than DNACPR
Relevant for people with complex health needs/nearing end of life/at risk of sudden deterioration.
What is mental capacity?
= a person’s ability to make their own decisions and choices.
Judged according to a specific decision and at the time at which the decision is being made.
Capacity can be regained (e.g. acute confusion/delirium)
5 principles of capacity
- Assume capacity unless proven otherwise.
- Individuals should be supported to make their own decisions where possible.
- Unwise decisions must still be respected.
- If someone lacks capacity, you must act in their best interests.
=> Consider person’s wishes, feelings, beliefs, values.
=> Consider the views of close friends/family (but if they are not acting in best interests, can refer to court of protection).
=> Consider whether they will regain capacity. - If someone lacks capacity, you must choose the least restrictive option.
Lasting Power of Attorney
A person is appointed to make decisions about a specific area of a patient’s life when they lose capacity (e.g. finances, health and well-being).
How do you assess capacity?
Stage 1: Does the person have an impairment of the mind or brain?
If no, there is no reason to question capacity.
Stage 2: can the person… • Understand information? • Retain information? • Weigh up consequences? • Communicate the decision?
If they cannot demonstrate these criteria, this indicates that they LACK capacity for this particular decision
What is elder abuse?
= a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.
Types of elder abuse
- Financial
- Emotional/psychological
- Physical
- Sexual
- Neglect/abandonment (not always intentional – passive neglect).
What should be done if elder abuse is suspected?
If you are concerned you MUST TAKE ACTION.
=> Document concerns and escalate to someone more senior.
=> Consider adults safeguarding referral
What is the difference between euthanasia and assisted suicide, and what are the laws in the UK surrounding these?
Euthanasia = the act of deliberately ending a person’s life to relieve suffering
Assisted-suicide = deliberately assisting another person to kill themselves
Both are illegal in UK law.
Euthanasia is considered manslaughter/murder.
Who is required for a MHA assessment?
2 doctors (who are deemed able to complete the assessment)
A specialist social worker.
what needs to be considered in a mental health act assessment?
Consider:
the previous nature of the illness, progression, the current severity of illness, risks to themselves/others, compliance with medication, engagement with healthcare professionals
Mental Health Act
Guides compulsory inpatient admission for assessment and treatment of people of and disorder/disability of the mind.
A last resort – the most restrictive way to take someone into hospital, does deprive the patient of their liberty.
Usually comes into play when a person is at risk of harming themselves/others/their own health and safety
ONLY applies to psychiatric disorders
What aspects of cognitive function are important for driving?
spatial awareness,
attention,
concentration
Deprivation of Liberty Safeguards (DOLS)
Used when it is necessary to deprive a patient of their liberty when they lack capacity to consent to their care and treatment, in order to keep them safe from harm.
If all of the following are true, you need to apply for a deprivation of liberty:
- Patient is deemed to lack capacity for self-discharge.
- Person is subject to continuous supervision and control
- If the person wishes to leave and you wouldn’t be happy with them doing so.
What is delirium?
a common clinical syndrome characterised by disturbed consciousness/attention, cognitive function or perception, which has ACUTE ONSET and FLUCTUATING COURSE
Causes of Delirium?
Drugs / dehydration Electrolyte disturbances Level of pain / lack of analgesia Infection / inflammation Respiratory failure Impaction of faeces / Intracranial Urinary retention Metabolism / MI
Risk factors for developing delirium
- Having dementia (~50% of delirium cases occur in patients with prior dementia)
- Over 65
- Frailty
- Multiple comorbidities
- Poor hearing/vision
- Polypharmacy
- Recent surgery
- Terminal illness
- Previous Hx of delirium
What are the types of delirium?
Hyperactive
Hypoactive
Mixed
Delirium - Sx
HYPERACTIVE
Abnormally alert, Agitation/restlessness, disorientation, hallucinations, aggression, wandering, inappropriate behaviour.
HYPOACTIVE:
Often unrecognised, presents similar to depression.
Withdrawn, not eating/drinking, drowsy, disorganised
?delirium - assessment
“Is the patient more confused than normal?”
CAM = Confusion Assessment Methods
- More confused than normal
- Inattentive
3a. Disorganised thinking
3b. Altered state of consciousness
If yes to 1 AND 2 AND 3a or 3b, then is the course acute and fluctuating?
If yes => DELIRIUM.
1st Line Investigations for Confusion
- Collateral Hx (establish baseline cognition).
- Physical examination (conscious level, ?infection, neurology).
- Confusion Bloods
- Urinalysis
- CXR, ECG, CT/MRI
- Assess nutritional status
- Medication review
What are “confusion bloods”?
FBC, CRP, U&Es, LFTs, TFTs, glucose, Ca, B12, folate
Delirium - Management
TREAT UNDERLYING CAUSE (if ignored => high mortality).
Reduce medications – avoid opiates, anticholinergics.
Reassure and keep orientated, active, hydrated, nourished.
Optimise senses and promote good sleep hygiene.
Only use drugs if other interventions have failed and patient is a risk to themselves or others.
=> Haloperidol 0.5mg = 1st line
=> Lorazepam 0.5mg (if haloperidol is contraindicated – Parkinson’s, LB dementia).
=> Only use short-term (usually 1 week or less).
What is the 1st line drug in management of delirium?
What are some contraindications of this drug?
Haloperidol 0.5mg
CIs - Parkinson’s, LB dementia
Delirium vs Dementia
DELIRIUM Develops over hours/days Fluctuating course Altered consciousness Usually reversible Psychomotor changes – increased/decreased Impaired attention
DEMENTIA
Develops over years/months
Progressive
Consciousness usually clear
Irreversible
No psychomotor changes (until late disease)
Often good attention (until late disease)
What is dementia?
Dementia is a PROGRESSIVE and IRREVERSIBLE syndrome describing a set of symptoms due to degenerative changes in the brain.
It causes impaired function with no other medical explanation
Dementia - symptoms
- Memory Loss
- Difficulties with higher cognitive processes (at least 1 of):
- Impaired executive function (e.g. problem solving, emotions).
- Apraxia (difficulty motor planning)
- Agnosia (difficulty recognising objects)
How long must the symptoms have been going on for a possibility of a diagnosis of dementia?
At least 6 months
How common is dementia?
~7% of people aged >65 have dementia
Affects F>M
What are the different types of dementia?
How common are they?
- Alzheimer’s Disease – 2/3rd
- Vascular Dementia – 20%
- Lewy Body Dementia – 5%
- Frontotemporal Dementia – 2%
- Other rarer causes
What are the other rarer causes of dementia?
- Wernicke-Korsakoff Syndrome
- Down’s Syndrome
- Huntington’s
- Multiple Sclerosis
- Parkinson’s Disease Dementia
- Creuzfeldt-Jakob disease
- Pugilistic Dementia (repetitive head trauma).
What is the most common type of dementia?
Alzheimer’s Disease
Alzheimer’s - Pathophysiology
- Characteristic beta-amyloid plaques and neurofibrillary tangles.
- Brain atrophy, particularly the hippocampus.
- Enlarged ventricles
Alzheimer’s - Symptoms
= Progressive memory loss that affects function.
Later on - Problems finding words, Mood/behaviour problems
There tends to be a gradual, progressive decline.
Cause of Alzheimer’s
Cause is unknown.
Early onset (<65) there is some familial risk
Association with APO-E gene
Association with CVD risk factors.
What is the average life expectancy of someone diagnosed with Alzheimer’s
7 years
Vascular Dementia - cause
Caused by reduced blood supply to the brain (due to diseased blood vessels)
Vascular Dementia - symptoms
Usually stepwise progression - stable and then sudden decline
Symptoms = problems with memory, thinking and reasoning.
Often overlaps with symptoms of Alzheimer’s.
Risk factors for vascular dementia
HTN, cholesterol, alcohol, smoking, DM, male, etc
Lewy body Dementia - pathophysiology
Characterised by alpha-synuclein deposits in the brain
Lewy body Dementia - early and late symptoms
Early stages – hallucinations and delusions, mood swings/ short tempered, short attention span, fluctuating alertness.
Late stages – Motor deterioration, similar to Parkinson’s.
Lewy body Dementia - differentials
Parkinson’s (but here the motor problems develop before cognitive decline.
Alzheimer’s
Schizophrenia – hallucinations/delusions
Fronto-temporal Dementia - pathophysiology
Involves damage to upper and middle frontal lobe and temporal lobe
Fronto-temporal Dementia - variants
Behavioural (2/3)
Progressive non-fluent aphasia
Semantic dementia
Fronto-temporal Dementia - symptoms of behavioural variant
Loss of inhibition – rude and compulsive
Personality changes – loss of interest in people, loss of sympapthy/empathy
Crave food – often sweet/fatty, eat until vomit.
Speech, language difficulties
(A cognitive deficit is not so obvious).
Dementia - investigations/diagnosis
Detailed History (often collateral) => Duration of Sx, effects on ADLs
Physical examination
=> CNS/PNS, gait, CVS, thyroid.
Blood tests +/- lumbar puncture
Medication Review
=> Look for any correlation of medications and duration of symptoms
Cognitive tests
CT/MRI
=> To exclude other causes.
Dementia - differentials
- Delirium
- Other mental illness (e.g. depression)
- Substance misuse
- Traumatic brain injury
- Metabolic (hypothyroidism, B12 deficiency).
- Medications (steroids, anti-depressants).
Dementia - management
There is NO CURE – eventually progresses to dependence and palliative care.
- Referral to Memory Clinic / RRLP
- Pharmacological – alleviate symptoms/slow progression
- Non-pharmacological
=> Social services care plan – home help, equipment, meals on wheels, day care.
=> Consider capacity – organise ADs/LPAs/DNACPRs while the patient still has capacity.
Dementia - pharmacological options
Cholinesterase Inhibitors – e.g. donepezil, rivastigmine, galantamine.
=> Alzheimer’s, LBD and Parkinson’s (mild-moderate disease).
NMDA Receptor Antagonists – e.g. Memantine
=> Alzheimer’s only (moderate-severe disease).
What is the pharmacological treatment for vascular dementia?
There isn’t one
What is the pharmacological treatment for FT dementia?
There isn’t one
What is the pharmacological treatment for Alzheimer’s disease?
Cholinesterase Inhibitors
NMDA Receptor Antagonists
What are the components of a mini-ACE ?
Patient Demographics - include occupation, handedness, age at leaving full-time education
Orientation - day, date, month, year
Memory - address
Fluency – Animals
Visuo-spatial – Clock drawing
Memory Recall - address
What is the mini-ACE?
A cognitive assessment
Used as a SCREENING TOOL to identify cognitive impairment.
What are the cut-off scores in the mini-ACE?
<25 - likely to have come from a dementia patient
<21 - almost certainly a score to have come from a dementia patient
Charles-Bonnet Syndrome
= Hallucinations
Often associated with diminished eyesight (e.g. macular degeneration), due to overcompensation of the brain.
Patients will mostly still have insight into these hallucinations
Old Age Psych History components
Demographics + reason for referral
PC and HPC
=> Onset – insidious vs. rapid.
=> Non-cognitive symptoms.
=> Impact on ADLs
Hx of psychiatric illness
PMHx
=> Pre-morbid personality.
=> Hx of delirium?
=> Vascular risk factors – stroke, TIA, MI, peripheral vascular disease, HTN, diabetes, falls.
DHx
FHx
SHx => Current living arrangements => Amount of care – family/friends or district nurses/day care? => Drugs/smoking/alcohol/benzodiazepines => Driving – concerns, incidents?
What are the things to assess in a Mental State Examination ?
Appearance and Behaviour
Speech
Emotion
=> Mood/affect
Perception
=> auditory/visual/olfactory hallucinations
Thoughts
=> content and expression
Insight
Cognitive Function
=> mini-ACE
How common is later life depression?
affects 1 in 5 in the community (more common in nursing homes)
affects F > M.
“monoamine hypothesis” of depression
Depression results as a deficiency of one or more of Dopamine, Noradrenalin and Serotonin.
=> Anti-depressants increase the levels of these neurotransmitters
Risk factors for later life depression
- Chronic Pain/Long-term conditions
- Loss – spouse/job/independence
- Isolation
- PMHx or FHx of depression/anxiety
ICD-10 Diagnostic Criteria for Depression - core and other Sx
CORE SYMPTOMS
- Low Mood - worse in the morning
- Anhedonia
- Fatigue
OTHER SYMPTOMS • Guilt/hopelessness • Suicidal thoughts/self-harm • Psychosis (hallucinations/delusions) • Sleep disturbance/poor memory • Change in appetite • Agitation • Psychosomatic (pain/GI complaints, excessive concern over physical health)
Severity of depression by ICD-10 criteria
Mild – 2 core and 2 other Sx.
Moderate – 2/3 core and 3 other Sx.
Severe – 3 core and 5 other Sx.
Agitation as a Sx of depression
Usually depression presents as slowing of everything (speech, movement, thinking, etc.) but, in the elderly, agitation is often seen (inability to relax).
Psychosis as a Sx of depression
If the mood symptoms start before the psychosis, then it can be considered depression.
If the psychotic symptoms start first, then it’s more likely to be a psychotic disorder
Geriatric Depression Scale
= 15 yes/no questions to help screen for, assess severity of and monitor clinical depression in an older person.
DDx for depression
Endocrine/metabolic
- Hypothyroidism
- Anaemia
- Hypercalcaemia
- Malignancy
Dementia
Parkinson’s Disease
What are important things to assess when assessing for suicide risk?
Risk to self Risk to others Non-compliance with medication Self-neglect Exploitation/vulnerability Driving Physical Health/Falls
Suicide assessment - risk to self
Previous Hx or attempted self-harm/suicide
FHx of suicide
Current episode – ongoing thoughts (frequency, severity, intrusiveness), planning, final acts, the future
Suicide assessment - risk to others
Verbal/physical threats of harm to others
Thoughts or attempted harm
