Integrated Care Flashcards
What does the Comprehensive Geriatric Assessment involve?
Identify physical, socio-economic, functional, mental/psychological and environmental issues to formulate management plan.
What are the two types of communication models between doctor and patient?
Questioning model - completely doctor-led conversation
Exchange model - share conversation, patient is expert in their own situation.
Describe the model of communication?
Speaker has a thought, then has linguistic representation for which they have facial movements and acoustics to express their thought.
At the same time they have haptic feedback and auditory feedback of what they’re saying.
Perceiver uses audition and vision for linguistic representation and figures out meaning of what has been said.
Different ways to measure functional ability? Who measures this usually?
Occupational therapist. Feet and footwear Gait and balance Pain and joint assessment Lying and standing blood pressure Sensory loss Weight and nutrition PR and genitalia
More info about feet and footwear?
- condition of feet and toenails. Oedema and ulcers.
- Peripheral sensory testing, warmth, pulses, peripheral oedema.
- Recommend well fitting, secure footwear to minimise falls risk.
More info about gait and balance?
- Can walk outdoors? How far? Do they need aid?
- Can patient walk distances needed to go indoors?
- Any changes to walking pattern? Shuffling? Initiating movement? Can’t stop walking? Fall backwards? Feet too wide apart? Swinging on leg out to side? Inability to walk in straight line?
- Restricted activity?
- Had any falls recently?
- Feel off balance, unsteady or dizzy?
How to assess gait and balance?
Watch gait
Timed up and go test:
- sit in knee height chair, stand up, walk 3 meters, turn around, walk back, sit back down.
- normal for over 65s is 8-11 seconds
- > 11 seconds indicates impairment
- if they use arms of chair to help them stand, indicates lower limb weakness.
- Not suitable for patients who need walking aids.
180 degrees turn test:
- Patient stands in position where they are surrounded by potential support.
- Stand behind patient and ask them to turn to face you.
- they shouldn’t need any support to do this.
- patients who take >5 steps are at increased risk of falls.
- Not suitable for patients with walking aids.
Gait speed:
- Should take less than 5 seconds to walk 4 meters.
Referral options for someone with gait and balance problems?
Outpatient service for second medical opinion.
Physiotherapy
Occupational therapy
Community based exercise options if fit enough
Social inclusion groups - psychological impact of poor mobility.
Important points in pain and joint assessment?
Many elderly patients deny pain, or unable to express it.
May be evident by observing patient.
Use other descriptors (stiffness, ache, etc)
May need a thorough assessment by physiotherapy.
Important points in lying and standing blood pressure?
Patient lies flat for 5 minutes -> check BP
Patient stands up -> immediately check BP
Recheck BP after 1 and 3 minutes of standing
Drop of more than 20 systolic or below 90 shows postural hypotension.
Important points in sensory loss?
Deficits can be compensated for. Eg lip reading in deafness.
Whisper in one ear and ask for them to repeat back, whilst rubbing trigs of other ear.
Gross visual testing - how many fingers? Read line from book.
Important points in weight and nutrition?
Check and record weight consistently.
Evidence of weight loss includes poor fitting clothes or loose skin.
Can also be seen in general condition of hair, nails, oral hygiene.
Important points in PR and genitalia?
PR exam - constipation, prostate, haemorrhoids, bleeding, rectal mass.
External genitalia and breast should be briefly examined.
What does social and environmental assessment include?
Live at home? Stairs at home? Stairlift? Toilet facilities easy access? Bathroom access? Access to home for health workers? Cooking facilities? Smoke detector? Does patient get out and about? How do they mobilise outside house? Is patient a carer? Benefits? Health care funding? Capacity? DOLS? Power of attorney? Funeral plan?
Assessment of mood?
Expression and affect?
Depression symptoms?
5-10% of elderly patients have depression.
Risk factors for depression and suicide?
Older age Male Social isolation History of suicidal attempts Chronic pain Chronic illness Drug or alcohol abuse Sleep disorders
Screening questions for depression?
During last month have you ever been bothered by feeling down, depressed or hopeless?
Do you ever sit and cry for no reason?
Do you ever worry about the future?
During the last month have you found little interest in things you used to enjoy?
Do you feel lonely?
What is the formal questionnaire for depression in elderly?
Geriatric depression score.
Assessment of cognition?
Collateral history
Rate of decline
Montreal cognitive assessment (MOCA)
Appreciated mental test
Assessment of medication review?
Full drug history
Review use of drugs - what they take, how much, any problems?
NO TEARS
Need and indication Opinion of patient (do they take it?) Tests and monitoring Evidence and guidelines Adverse effects Risk reduction or prevention Simplification/switches
What would you consider prescribing to reduce effects of fractures?
Calcium and vitamin D for frail, elderly, housebound patients with history of falls.
Bisphosphonates for secondary prevention of osteoporosis - risk of atypical femoral fractures with long term use - FRAX tool to calculate osteoporosis risk.
Drug classes that may increase risk of falls?
Antidepressants Antipsychotics Antiemetics Sedatives and hyponotics Parkinson's drugs Muscle relaxants Drugs with anticholinergic side effects Cardiovascular drugs Analgesics Anticonvulsants
What is involved in the assessment of falls?
History of falls:
- how? What were they doing?
- Blacked out?
- Syncope or LoC?
- Screen for conditions that may cause falls.
Co-morbidities
Examination:
- vision
- HR and rhythm
- Neuro exam - muscle strength, peripheral sensation, etc.
- knee exam
- Feet/footwear
- lying and standing BP
- Get up and go test
- cognitive assessment
Assessment of home
Risk factors for falls?
Previous falls Female Age >80 Impaired mobility Hazards in home Urinary incontinence Visual impairment Gait/balance problems Cognitive impairment Postural hypotension Polypharmacy Low mood/depression Foot problems/inappropriate footwear Lower limb weakness/stroke.PD/neuropathy/proximal myopathy Alcohol Infection
Management of falls?
Refer to falls clinic:
MDT - consultant, nurse, PT/OT, social workers, pharmacists, podiatrists.
Multicomponent programmes:
- strength and balancing training
- home hazards assessment and intervention
- Medication review
- cardiac pacing if required
- visual assessment and referral
- education and information - how to cope with a fall, what changes to make, fear of falling, prevention, assistance
Referral:
- A&E
- Acute elderly admission
- Outpatient referral elderly
- Community OT/PT, falls clinic, age concern.
What clinical conditions are indicators for palliative care?
Heart disease - HF, valve disease, CAD, SOB Renal disease Respiratory disease - COPD Liver disease Cancer Neurological disease Dementia
What is advanced care planning (ACP) and what does it involve?
Voluntary process of conversation between patient and health professional.
Opportunity to discuss possible future situations and understand patient preferences.
Documentation on those preferences and circulation.
Updated at intervals - eg after sentinel event, as patient changes.
Discussion of: Preferred place of care Preferred place of death DNA CPR Advanced decision to refuse treatment Power of attorney Crisis management - breathlessness, bleeding, infection, pain Anticipatory medications.
MDT specialties in end of life care?
Doctors Community nurses PT/OT Social workers Chaplains Lymphoedema team Complimentary therapist Clinical psychologist Family bereavement support
Useful questions for patients with capacity towards end of life?
How do you feel things are going?
What do you feel is causing you most problem/bother at the moment?
How do you see the future?
Do you feel you have enough info on what is happening/might happen in the future?
Have you thought about where you’d like to be if things take a turn for the worse?
What is involved in spiritual history?
What else is going on in your life at the moment? What support do you have? People you can talk to? Greatest worry? Most important issue in your life? What would be the most helpful thing for you? What gives your life meaning? Where do you get your strength from? Is religion or faith important to you?
HOPE FICA Source of Hope Organised religion Personal spirituality and practices Effect on medical care and end-of-life issues Faith and belief Importance Community Address these issues in patient's care
What is a lasting power of attorney?
Acts on behalf of person if they should lose capacity in future.
Can make decision on property, financial affairs, health and welfare.
The attorney only has authority to make decisions about life-sustaining treatment if LPA specifies that.
Before it can be used as LPA, must be registered with Office of Public Guardian.
Features of advance decisions to refuse treatment?
Made by anybody with capacity to specify treatment they would not want if they were to lose capacity.
Refusing life-sustaining treatment must be written, signed and witnessed to be valid.
Cannot demand treatment.
Statement must be applicable to current situation.
What is an independent mental capacity advocate?
If person lacks capacity and has no effective next of kin, friends or relation to speak on their behalf, consider appointing in IMCA.
Features of DOLS?
People who lack capacity should only be deprived of liberty when it is in their best interest, and in least restrictive way possible.
Nurse in charge must apply to Court of Protection for authority to ensure loss of liberty is lawful.
Provide person with representation
Give person right to challenge a deprivation through court of protection
Regularly review and monitor the deprivation of liberty.
Organisation and agencies involved in care of patients with cognitive impairment?
Single health or social care professional responsible for coordinating their care.
Admiral nurses
Memory services/clinics
Local support groups
Online forums - talking point
National charities - Alzheimers society, dementia UK, AgeUK, Carers UK, Carers trust.
Financial and legal advice services.
Screening tools for cognitive impairment?
Montreal Cognitive Assessment - out of 30
- >= 26 is normal.
Mini-mental state examination (MMSE) - out of 30.
- >= 24 is normal.
Mini-Cog assessment - out of 5.
- >= 3 is considered low risk.
What are the features of confusion assessment method (CAM)?
Acute onset or fluctuating course
Inattention
Disorganised thinking
Altered level of consciousness
Needs presence of 1 and 2, plus 3 or 4 to diagnose delirium.
What scale is used to measure performance of Activities of Daily Living?
Barthel Index.
What is the pain scale for cognitive impairment called? What are the scoring ranges?
Abbey pain scale for dementia patients.
0-2 - no pain
3-7 - mild pain
8-13 - moderate pain
14-15 - severe pain
What are the categories of abbey pain scale?
Each scores out of 3.
Vocalisation Facial expression Body language Psychological changes Physical changes
Carer’s allowance features?
Payable if:
- aged 16 or over
- spend at least 35 hours a week caring for someone
- been in england, scotland or wales for at least 2 of the last 3 years.
- normally live in england, scotland or wales, or live abroad as a member of armed forces.
- not in full time education or studying for 21+ hours a week
- earn no more than £110 a week (after taxes, care costs while at work and 50% of what you pay into pension).
Therefore carer’s allowance is means tested benefit.
How can childs health be impacted from caring responsibilities?
Social isolation Low school attendance Educational difficulties Impaired development of their identity and potential Low self esteem Emotional and physical neglect
What is the social model of disability?
Disability is caused by unaccommodating environment, negative attitudes and organisational structures.
- inaccessible transport
- poorly designed buildings
- Stereotyping
- Segregated services
- Lack of understanding
- Too few sign language interpreters.
What is the medical model of disability?
Disability is caused by conditions/impairments which people have.
What are the sociological factors that contribute to illness?
Income and social status. Education. Physical environment. Employment and working conditions. Social support networks. Culture. Personal behaviour and coping skills. Health services.
What are the problems with inequality in health?
Income distribution theory.
Black report.
What does black report involve?
Reasons for socioecenomic differences in health.
Artefect
Social selection - ill health causes lower class
Behavioural - ill health due to people’s choices and decisions.
Materialist - low income allows less money to be spent on health.
What are the aims and solutions of inequality in health?
Marmot - aim for fair society
Give every child best start
Enable children and adults to maximise their capabilities and have control over their lives
Create fair employment and good work for all
Ensure healthy standard of living for all
Create and develop healthy sustainable places and communities
Strengthen role and impact of health prevention.
How can community groups/charities help with inequality with health?
Food
Housing
Transport
Debt advice
Older patients who are housebound and can’t collect medication
Isolation
Drug and substance abuse help and advice.
What are the consequences of urinary incontinence?
Skin rashes, infections and sores from constant wet skin.
UTIs
Impact on social, work and personal relationships
Depression, loss of interest, social isolation, anxiety, frustration, embarassment
Sleep disturbance
Disturbs sex life
Everyday life can become stressful.
What tool is used for malnutrition?
Malnutrition Universal Screening Tool (MUST)
Features of MUST?
5 step tool.
Measure height and weight to get BMI
Note percentage unplanned weight loss
Establish acute disease effect
Add the scores from above 3 steps to obtain overall risk of malnutrition.
Use management guidelines to develop care plan.
Management of malnutrition based on MUST tool?
Low risk - 0
- repeat screening weekly in hospitals, monthly in care homes, annually in community.
Medium risk - 1 - observe.
- document dietary intake for 3 days.
- If adequate, repeat screening weekly in hospitals, at least monthly in care homes, at least every 2-3 months in adults.
- If inadequate - set goals, improve and increase overall nutritional intake, monitor and review care plan regularly.
High risk - 2 or more.
- Treat
- Refer to dietician, nutritional support team or implement local policy.
- Set goals, improve and increase overall nutritional intake.
- Monitor and review care plan weekly in hospitals, and monthly in care homes and community.
If patients need to be treated, what are they given for malnutrition?
First line - maximise oral intake by having more food.
Fortify diet by adding additional energy and protein.
Prescribe oral nutritional supplements:
- Fortisip, Fortijuice, Forticreme, Calogen.
Enteral feeding - NG tube, nasojejunal.
Parental feeding last line.
Criteria for enteral tube feeding?
Patients who are malnourished or at risk of malnutrition, AND
have inadequate or unsafe oral intake AND
have functional, accessible GI tact.
Which patients are identified as being malnourished? Meet criteria for MUST tool?
BMI <18.5
Unintentional weight loss >10% over 3-6 months
BMI <20 and unintentional weight loss of >5% over 3-6 months.
Which patients are at risk of being malnourished?
Eaten nothing or little >5 days, who are likely to eat little for further 5 days.
Poor absorptive capacity.
High nutrient losses.
High metabolism.
