Neuro, MSK and Elderly Flashcards
What are the impacts of back pain?
- Significant time off work + hobbies
- Social isolation
- Major drain on benefits
- Loss of ADLs
- Stigmatised
- Dependent on family
- Reduced libido
Describe the chronic pain theory
- Also called yellow flags = things that may hinder effective recovery.
- Belief pain is secondary to serious illness.
- Negative attitude towards back pain. Environmental impacts = family attitude, work.
- Fear avoidance behaviour.
- Expectation to be passive instead of active = while active + using is better. Passive → disuse of muscles → nociceptors activated more easily → more pain felt.
- Tendency for depression = pessimistic views.
- Social or financial concerns.
Outline the holistic approach to the management of back pain
MDT approach = OT, PT.
Focus on return to work instead of what they cannot do now.
START Tool for risk stratification of back pain:
- Low risk (<3): Very likely to improve so enable self-management. Education on exercise/staying active, analgesia, avoiding complementary therapy. Refer for physical therapy if not resolved by 6 weeks.
- Medium risk: Aim to facilitate return to function. Early physio referral. Promote self-management.
- High risk: Comprehensive biopsychosocial assessment. Physiotherapy & CBT referral —> identify yellow flags that will impact on recovery.
Alternative therapies (chiropractors/acupuncture/osteopath) not highly recommend by NICE for sole treatment, but can be used as an adjuvant.
Outline the organisation of health services for people with chronic neurological problems
Stroke Unit:
- Integrated medical ward with special skills in the management of acute stroke.
- Main activities include: investigation of stroke, prevention of complications, secondary prevention, nursing care, rehabilitation - found to reduce death or dependency compared to care on regular ward.
- Emphasis is placed on PT/OT, SaLT, psychologists and social workers.
Other services:
- Neurological rehabilitations centres.
- Palliative care.
- Community services e.g. nursing, PT.
- Primary care services.
Outline the organisation of health services for elderly people including the provision of social care
- Inpatient elderly care/geriatric wards.
- Primary care services.
- Community e.g. nurses, carers, PT/OT.
- Social care: help from paid carers, meals on wheels, home adaptations, household equipment, personal alarms, supported living services and care homes.
4 Major Themes of National Service Framework for the Elderly:
- Respect the individual: NHS services based on need, not age. Treatment is person-centred care.
- 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.
- 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.
- Promote active healthy life: Promotion of healthy and active life via co-ordinated programme of action led by NHS in partnership with local councils.
Assess the medical and social needs of an elderly person
Medical:
- Mobility aids.
- Medication.
- Psychiatric and memory assessment.
- Nutritional support.
Social:
- Socialisation.
- Transportation.
- Personal care support.
Be aware of the community support groups available to patients with neurological conditions
- Spinal injuries association
- Stroke association
- The neurological alliance
- Parkinson’s UK
- Muscular Dystrophy UK
- Multiple sclerosis Trust
- Multiple sclerosis society
- Motor neurone disease association
- Independent neurorehabilitation providers alliance
- The Huntington’s Disease Association
- The brain injury association
- Guillain-Barre & Associated Inflammatory Neuropathies
- Dementia UK
- The encephalitis society
- Fighting strokes
- The brain tumour charity
Outline the social and medicolegal implications of a diagnosis of epilepsy
Social implications:
- Depression (often co-morbid).
- Reduction in social participation (if photosensitive epilepsy) → e.g. may not attend cinema, concerts, bars etc.
- Stigma.
- Pregnancy and breastfeeding risks (teratogenic medications).
- Driving (DVLA) - must be seziures free for 12 months following diagnosis.
- Employment restrictions.
Outline the prevention of spread of meningococcal disease including notification, chemoprophylaxis and immunisation
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.
Prevention:
1. 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.
5. 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 Vaccinate (any strain that has vaccine & person hasn’t had vaccine (ACYW). Chemoprophylaxis aims to prevent disease or infection. Highest risk to contact in first 7 days.
6. Childhood vaccinations.
7. Notifiable disease.
Recognise stroke and clinically assess its aetiology including risk factors
RFs:
- Lifestyle: smoking, alcohol misuse and drug abuse, physical inactivity, poor diet.
- Established CV disease: HTN, permanent/paroxysmal AF, Infective endocarditis, Valvular disease, Carotid artery disease, Congestive heart failure, Peripheral vascular disease, Congenital/Structural heart disease.
- Age: risk of having a stroke doubles every decade after 55.
- Gender: men > women (increased risk in women who take COCP, have migraines with aura, in the immediate postpartum period and pre-eclampsia).
- Hyperlipidaemia.
- Diabetes.
- Sickle cell disease.
- Antiphospholipid syndrome.
- CKD.
- Obstructive sleep apnoea.
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 probiems (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.
Outline the primary and secondary prevention of stroke, both individual and population strategies
Primary prevention:
- Identify and treat HTN, diabetes, hyperlipidaemia, cardiac disease.
- Smoking cessation.
- Exercise encouragement.
- Healthy lifestyle promotion.
Secondary prevention:
- Anti-hypertensives and statins.
- Anti- platelets: aspirin 300mg for 2 weeks then long-term clopidogrel.
- AF: DOAC or warfarin.
Discuss the options available for complex discharge planning
MDT approach:
- Social worker —> helps allocate where they go.
- Notification of Assessment to request social worker allocation.
- Notification of Discharge submitted = medically fit and social services is only delay.
Important features:
- Pre-admission functional status, often OT assessment.
- Where admitted from.
- Current function —> strengths, transfers/mobility, ADLs.
- Compare this with baseline = identify potential for improvement/how they’ve been improving.
Destination:
- Home +/- support —> if function adequate = mobilise.
- Inpatient rehab —> if good pre-admission potential but not achieved yet.
- Residential or nursing home —> can be to achieve potential = medically but not socially fit, or can be for further assessment, or may be permanent.
- Palliative fast track = within last 6 weeks of life —> funding applied for that allows prompter fast-track, to allow for chosen place of death.
Describe and recognise risk factors for falls
- Drugs.
- Ageing = age-related changed e.g. sarcopenia, decreased vestibular function, decreased visual acuity.
- Medical = neurological, CV, GU → incontinence, urgency. MSK = myopathy, arthritis, reduced cognitive function.
- Environment = poor footwear, pets, poor lighting, slippery floor, rugs.
Discuss the effects of polypharmacy in the elderly considering drug classes such as anticholinergics, antihypertensives and opioids
- Anticholinergics: urinary retention, constipation, delirium, confusion, dry eyes, dry mouth, blurred vision, tachycardia, dilated pupils.
- Antihypertensives: hypotension, syncope, dizziness.
- Opioids: nausea, drowsiness, constipation.
Appreciate the limitations to successful rehabilitation
- Capacity
- Injury
- Willingness to improve
Recognise substance misuse in the elderly
- Older men are considered the greatest risk of substance misuse including alcohol and illicit drugs.
- Older women are most at risk of problematic use of sedative/hypnotic and anxiolytic medication.
- Signs and symptoms may be attributed to or masked by other problems e.g. cognitive impairment.
- Addicted to prescription medications e.g. opioids.
- Not taking prescription medications.
Physical symptoms that should trigger screening:
- Sleep complaints.
- Cognitive impairment, memory or concentration disturbance.
- Seizures, malnutrition, muscle wasting.
- Liver function abnormalities.
- Unexplained medication interactions.
- Persistent irritability without obvious cause.
- 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.
Outline the pharmacological treatment of dementia and discuss the role of health economics in NICE technology appraisals to determine access to these, and other, new treatments
- Acetylcholinesterase (AChE) inhibitors e.g. Donepezil, Galantamine, Rivastigmine.
- Memantine (NMDA antagonist).
- Antipsychotics e.g. Haloperidol, Risperidone.
- Reduce polypharmacy if appropriate.
Must be considered cost effective to be implemented into national guidance.
Recognise the importance of the multidisciplinary approach in the assessment and management of inflammatory arthritis
- Primary care: usually first access to healthcare, refer to specialist, arrange investigations (blood tests, X-rays), measure functional ability with Health Assessment Questionnaire (HAQ).
- Secondary care (inc. Rheumatologists, specialist nurses) - provide treatment and education.
- Other: Physiotherapy, Occupational therapy, Hand exercise programmes, Podiatry, Psychological interventions, Diet and complementary therapies.
- 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). Allows rapid access to specialist care for flares and ongoing drug monitoring.
- Adults the inflammatory arthritis should have access to a named member of the MDT e.g. specialist nurse who is responsible for co-ordinating their care.
