Older persons care & Learning Disability Flashcards

Question

What are some risk factors for developing pressure ulcers?

Answer 1

* Seriously ill * Neurological condition * Impaired mobility, inability to reposition themselves * Impaired nutrition * Poor posture or deformity * Significant cognitive impairment * Incontinence * Pain (leads to reduction in mobility)

Answer 2

* Those assessed to be at risk need to change position frequently, at least every 6 hrs- if unable to do themselves, offer help to do so, & document repositioning * Those at high risk- every 4 hrs * High-specification foam mattress * Barrier creams in those with high risk of developing moisture lesion or incontinence-associated dermatitis, eg those with incontinence, oedema, dry or inflamed skin

Answer 3

* Buttocks area (on tailbone or hips) * Heels of feet * Shoulder blades * Back of head * Backs and sides of knees

Answer 4

1. Braden scale 2. Norton scale 3. Waterlow scale

Answer 5

* 6 factors that contribute to either higher intensity & duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development 1. Sensory perception 2. Nutrition 3. Friction and shear 4. Mobility 5. Moisture 6. Activity * Each item is scored between 1 and 4, lowest score = greatest risk

Answer 6

* Measure ulcer * Categorise ulcer according to a validated classification tool * Nutritional assessment * Pressure-redistributing devices- foam mattress, seating pads * Assess need for debridement- necrotic tissue, size and extent, co-morbidiites * Evidence of cellulitis/ osteomyelitis/ systemic sepsis- over systemic abx * Dressing that promotes warm, moist wound haling environment (do not offer gauze dressing) * Strategies to offload heal for heal ulcers

Answer 7

* Occurs when 6 or more drugs are prescribed at any one time * Not all drugs are positive and may interact & have side effects

Answer 8

* Older people are known to have increased risk of adverse effects with drugs due to age related alteration in PK and PD * STOPP: Screening Tool of Older Persons’ potentially inappropriate Prescriptions * Can be found in BNF cautions section * START: Screening Tool to Alert to Right Treatment * Can be used to prevent omissions of indicated, appropriate medicines in older patients with specific conditions

Answer 9

* Stress incontinence (increased intra-abdo pressure) * Triggered by coughing, sneezing, exertion * Risk factors- age, pregnancy, vaginal delivery, constipation, obesity, fhx * Ix- bladder scan * Mx- lifestyle (lose weight, avoid caffeine & smoking), pelvic floor muscle training, surgery, intramural bulking agent, duloxetine * Urge incontinence (overactive bladder) * Detrusor muscle overactivity leads to involuntary bladder contractions, can be idiopathic or secondary to neuro conditions * Mx- lifestyle, bladder training, anticholinergic (oxybutynin first-line; S/E: dry mouth, constipation, UR, constipation- oxybutynin not preferentially prescribed in the elderly ) * Mixed incontinence (stress and urge) * Mx- bladder training 6 weeks * Treat according to the predominant type of incontinence * Overflow incontinence (urinary retention) * Bladder outlet obstruction eg from prolapse, fibroids, following pelvis surgery * Detrusor underactivity eg in peripheral neuropathy, spinal cord pathologies such as MS, secondary to antimuscarinics * Ix- bladder scan, cytometry * Mx- surgical intervention for obstructive causes, intermittent/ indwelling/ suprapubic catheterisation * Functional incontinence * Normal bladder & urethral function but pt has difficulty getting to the toilet in time * Causes- physical, intellectual, environmental issues * Problems with walking (arthritis, cerebral palsy), memory problems (dementia, intellectual disability) * Mx- bladder training (schedule trips), pelvic floor muscle training

Answer 10

* Avoid caffeine and alcohol * Avoid smoking * Improve oral intake * Regular toileting * Pelvic floor exercises * Bladder retraining

Answer 11

* Useful for monitoring effects of treatment * Helps understand when urgency or leakage occurs, which is important when considering mx options * Lifestyle advice can be given * Minimum of 3 days need to be completed

Answer 12

* Teaches pt how to hold more urine in bladder to reduce the number of times they need to pass urine * Teaches pt to urinate on schedule rather than urgency * Includes lifestyle advice on the amount & type of fluids to drink and coping strategies to reduce urgency * First-line treatment for mixed urinary incontinence alongside pelvic floor training

Answer 13

* Onset- acute: UTI, renal stone, gradual- neuro, idiopathic detrusor instability, incompetent sphincter * Intermittent or continuous dribble (stress or overflow) * Frequency during daytime, explore effects on lifestyle * Nocturia- diabetes/ organic causes of UI * Enuresis- UTI, diabetes, cancer, psychological * Volume- little (stress) or lots (urge) * Triggers (stress- increased abdo pressure) * Associated symptoms- haematuria, painful urinating, fever, poor flow/ terminal dribble (BPH), night sweats (renal cancer), constipation, symptoms of prolapse, weight loss * Smoking and occupation- bladder cancer risks * Explore fluid intake & what fluids * Red flags- cauda equina syndrome

Answer 14

* Review of bladder and bowel diary * Abdominal examination & PR examination including prostate in male * Urine dipstick & MSU * External genitalia review particularly looking for atrophic vaginitis in females * Post micturition bladder scan

Answer 15

* Bladder ultrasound, can detect urinary retention, residual urine * If post-voiding residual urine is found, renal function and LUTS are assessed, catheterisation may be implemented * A PVR \< 50ml is normal, 50-100ml in elderly is acceptable. In general \>200ml PVR is abnormal and could be due to incomplete bladder emptying or bladder outlet obstruction

Answer 16

* Check anal sphincter tone, faecal impaction, presence of occult blood or rectal lesions, BPH or prostate cancer * All these things can cause overflow incontinence

Answer 17

* Absorbent products, hand-held urinals, toileting aids * Offered as a temporary coping strategy or as long-term management if treatment is unsuccessful

Answer 18

* No * For those \>65 do not perform urine dipstick, up to 50% of them will have a positive dipstick w/o infection * Only treat symptoms of UTI with abx

Answer 19

* Faecal impaction with overflow diarrhoea- 50% cases * Other causes- severe haemorrhoids, IBD Crohn’s, diabetes, stroke (affecting nerves controlling anal sphincter), muscle damage (damage during episiotomy or forceps in childbirth)

Answer 20

1. **_Very Fit_**- People who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age 2. **_Well_**- – People who have no active disease symptoms but are less fit than category 1. Often, they exercise or are very active occasionally, e.g. seasonally 3. **_Managing Well_**- People whose medical problems are well controlled, but are not regularly active beyond routine walking 4. **_Vulnerable_**- While not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up”, and/or being tired during the day 5. **_Mildly Frail_**- These people often have more evident slowing, and need help in high order IADLs (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework 6. **_Moderately Frail_**- People need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing 7. **_Severely Frail_**- Completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying (within ~ 6 months) 8. **_Very Severely Frail_**- – Completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness 9. **_Terminally Ill_**- Approaching the end of life. This category applies to people with a life expectancy \<6 months, who are not otherwise evidently frail ***_Scoring frailty in people with dementia:_*** The degree of frailty corresponds to the degree of dementia. * Common symptoms in **mild dementia** include forgetting the details of a recent event, though still remembering the event itself, repeating the same question/story and social withdrawal. * In **moderate dementia**, recent memory is very impaired, even though they seemingly can remember their past life events well. They can do personal care with prompting. * In **severe dementia**, they cannot do personal care without help.

Answer 21

* Loss of resilience that means people don’t bounce back quickly after a physical or mental illness, an accident or another stressful event

Answer 22

1. **Falls** eg collapse, legs gave way, found lying on floor 2. **Immobility** eg sudden change in mobility, gone off legs, stuck in toilet 3. **Delirium** eg acute confusion, muddledness, sudden worsening of confusion in someone with dementia/ known memory loss 4. **Incontinence** eg new onset or worsening 5. **Susceptibility to side effects of medication** eg confusion with codeine, hypotension w/ antidepressants

Answer 23

* Comprehensive Geriatric Assessment * Multidimensional, interdisciplinary diagnostic process to determine medical, psychological & functional capabilities of a frail older person to develop a coordinated & integrated plan for treatment & long term follow up * Emphasises QoL & functional status, prognosis, outcome

Answer 24

* When an older person presents to their GP with 1+ obvious frailty syndromes ie falls, confusion, reduced mobility, increasing incontinence * When a GP or community team learns of an incidence which implies frailty- eg ambulance called after a fall * When an older person is discharged from hospital after presenting with a frailty syndrome even if another diagnosis has been offered as the cause * In care homes- most residents have frailty

Answer 25

* Disturbance of higher cortical functions including memory, thinking, judgement, language, perception, awareness * Description of someone’s condition, not a specific illness

Answer 26

* Persistent cognitive impairment: decline in both memory and thinking sufficient to impair personal ADLs * Problems with processing of incoming information- problems maintaining & directing attention * Clear consciousness * Above syndrome present \>6 months

Answer 27

* Diet- healthy balanced diet can prevent dementia progression * Exercise * Social interaction * Learning new things- cognitive stimulation

Answer 28

* \>65: * Alzheimer’s dementia * Vascular dementia * Cerebrovascular disease- multi-infarct dementia * \<65: * Frontotemporal dementia * Dementia with Lewy bodies * Alcoholic * Huntington’s Disease

Answer 29

* Early stage: * Forgetfulness & other memory symptoms * Subtle changes in mood & behaviour eg loss of motivation/ interest * Mid stage: * More prominent memory problems * Changes in behaviour more marked * Other cognitive difficulties may emerge eg difficulty w/ language & executive function * Disability more obvious- problems with complex ADLs- finances, planning activities, dealing w/ unexpected events becomes a problem * Awareness of disability diverges from reality * Late stage * Severe & pervasive memory problems accompany major cognitive disabilities eg severe disorientation, failure to recognise familiar people * Marked (+ve & -ve) changes in behaviour eg agitation or restlessness, irritability, disinhibition, severe apathy * Disability is severe, basic aspects of personal ADLs are failing, require continuous supervision

Answer 30

* Alzheimer’s dementia * Second most common: Vascular

Answer 31

* Hx * Course of symptoms over time * Evidence of disability/ impact on day-to-day life * Why have they come now- anything happened? * Changes in general health * Examination * Cognitive screening- GPCOG, AMT, 6-CIT, MMSE etc * Check for new physical findings if prompted by hx

Answer 32

* Normal ageing: difficulty finding words, forgetting things and events, not being able to remember the name of an acquaintance, family not worried about memory, not remembering conversations which occurred \>1 year ago * Dementia is different because of the effect on ADLs (activities of daily living)

Answer 33

* Behavioural and Psychological symptoms in Dementia * Include a range of neuropsychiatric disturbances such as agitation, aggression, depression, apathy * Affects up to 97% of community-dwelling pts with dementia * Significant impact on prognosis, caregiver well-being * 5 domains 1. Cognitive/ perceptual- delusions, hallucinations 2. Motor- pacing, wandering, repetitive movements, physical aggression 3. Verbal- yelling, calling out, repetitive speech, verbal aggression 4. Emotional- euphoria, depression, apathy, anxiety, irritability 5. Vegetative- disturbances in sleep & appetite

Answer 34

* Age * Genetics * Mild cognitive impairment * PD * Cerebrovascular, cardiovascular * Smoking * DM * Lack of exercise, obesity

Answer 35

* Dementia screen bloods- screening for other active contributing problems * Structural brain imaging- CT or preferably MRI * Functional brain imaging- perfusion, glucose metabolism, dopamine transporter turnover * Specialised tests- ECG, LP

Answer 36

* Using a recognised cognitive assessment tool * Mini-cog: 3 item word memory & clock drawing, done in GP * Abbreviated mental test score (AMTS): 10 scoring tool used in hospital * If pt \> 65 and AMT \<4 – consider high risk for delirium * MMSE: 11 items, measures cognitive function, done in memory clinic or hospital

Answer 37

* NICE recommend offering a range of activities to promote wellbeing that are tailored to patient’s preference * NICE recommend offering group cognitive stimulation therapy for mild-moderate dementia * Other options to consider include group reminiscence therapy & cognitive rehabilitation * Manage physical health needs * Inform DVLA * End of life care

Answer 38

* Pharmacological agents primarily for patients with AD, should not be used in pts with mild cognitive impairment * Mild to moderate AD: acetylcholinesterase inhibitors eg donepezil, rivastigmine * Memantine monotherapy can be used if pt is intolerant of/ have a contraindication to AChE inhibitors * Moderate to severe AD: N-methyl-D-aspartic acid receptor antagonist eg memantine, may be used in combination w/ AChE inhibitors

Answer 39

* 10 Qs to rapidly assess elderly pts for possibility of dementia 1. Age 2. Time 3. Address 4. Year 5. Location 6. Recognise 2 persons eg nurse, doctor 7. DoB 8. When did WW1 begin 9. Name the current PM 10. Count backwards down from 20 to 1 * Score \<6 suggest delirium or dementia * Score \<4, pt \> 65- consider high risk for delirium

Answer 40

* Impairment of cognition; disturbances of attention & conscious level; abnormal psychomotor behaviour & affect; disturbed sleep-wake cycle * Acute onset- hrs/days * All symptoms fluctuate during daytime & are typically worse at night

Answer 41

1. Hyperactive- heightened arousal, restlessness, irritability, wandering, carphologia (picking at clothing) 2. Hypoactive- quiet, sleepy, inactive, unmotivated & easily overlooked

Answer 42

* Impairment of consciousness * Fluctuations of symptoms: worse at night, periods of normality * Abnormal perception: illusions, hallucinations * Agitation, fear * Delusions- talking about things that haven’t happened or happened years ago

Answer 43

***THINK DELIRIUM***: * **T**rauma- head injury, intracranial event * **H**ypoxia- PE, CCF, MI, COPD, pneumonia * **I**ncreasing age/ frailty * **N**eck of femur fracture * smo**K**er or alcohol withdrawal * **D**rugs- opioids, sedatives, L-dopa * **E**nvironment, **e**yes, **e**ars, other sensory deficits * **L**ack of sleep * **I**nfection- UTI, pneumonia, sepsis * **R**etention of urine/ faeces * **I**mbalanced electrolytes- renal failure, sodium, calcium, glucose, liver function * **U**ncontrolled pain * **M**edical conditions- dementia, PD

Answer 44

* Previous dementia * Severe trauma eg #NOF * \>65 yrs * Polypharmacy * Increased frailty

Answer 45

* Psychotropic drugs- antidepressants, antipsychotics, benzodiazepines * Antiparkinsonian drugs * Anticholinergic drugs * Opiates * Diuretics * Recreational drug intoxication & withdrawal

Answer 46

* Tool for identifying delirium * 4 criteria 1. Acute onset or fluctuating course = 2 2. Inattention- counting from 20-1 is a simple test for this =2 3. Disorganised thinking =1 4. Altered levels of consciousness =1 * Score of 5 or more- think delirium

Answer 47

* Collateral hx- GP, relatives, carers- new or worsening confusion, falls, mobility, continence, hallucinations * Identify and treat underlying causes * SIRS criteria- sepsis pathway? * Cognitive assessment- AMT 10/ MMSE * Medication review- refer to STOPP/START * Heighten level of supervision & position pt in high visibility bed * Refer to FOPAL/ mental health for complex and challenging pts * Update & involve relatives with care, provide delirium leaflet

Answer 48

Can take up to 3 months

Answer 49

* There is a presumption that every adult patient has capacity to make decisions about their treatment care * A person has capacity if they can do all of the following * ***_Understand_*** information relevant to the decision in question * ***_Retain_*** that information * ***_Use_*** that information to make their decision * ***_Communicate_*** a decision * Capacity is decision specific and is for that decision alone at that point of time * Capacity can fluctuate with disease severity

Answer 50

* Express consent is valid consent given in writing or orally * Implicit consent occurs through the actions or conduct of the pt rather than direct communication through words * Eg from pts nodding of head or by them showing up at the agreed time for surgery

Answer 51

* 5 key principles- 1. A person must be assumed to have capacity unless it is established he lacks capacity 2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success 3. A person is not treated as unable to make a decision merely because he makes an unwise decision 4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests 5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

Answer 52

* The Mental Capacity Act sets out a clear test for assessing whether a person lacks capacity * Decision specific & time specific test * An adult can only be considered unable to make a particular decision if: 1. They have an impairment of, or disturbance in, the functioning of the mind or brain whether permanent or temporary AND 2. They are unable to undertake any of the following- * ***_Understand_*** the information relevant to the decision * ***_Retain_*** that information * ***_Use***_ or _***weigh_*** that information as part of the process of making the decision * ***_Communicate_*** the decision made by talking, sign language or other means * No individual can be labelled incapable simply because of a particular medical condition * Lack of capacity cannot be assumed by age, appearance, or any other aspect of behaviour

Answer 53

* Make the care of the patient your first capacity * Treat patients as individuals & with dignity * Support patients in their decisions * Do not discriminate against patients * Consider whether the lack of capacity is temporary or permanent * Consider which option provides the best clinical benefit * Consider the views of anyone with legal authority to make decisions on behalf of the patient * Consider any advance statements or opinions on treatments already offered by the patient

Answer 54

* Dementia * Severe learning disability * Brain injury * Mental health illness * Stroke * Unconsciousness caused by anaesthetic or sudden accident

Answer 55

* An act done, or decision made, under the Mental Capacity Act, for or on behalf of a person who lacks capacity must be done, or made in his best interests

Answer 56

* Practitioner or team responsible for providing health or social care intervention * Attorney appointed by the individual * Court Appointed deputy

Answer 57

* Deprivation of Liberty Safeguards * These relate to people who lack the mental capacity to make decisions about their care & treatment and who are deprived of their liberty in a care home or hospital 1. Definition of deprivation of liberty: the person is under continuous supervision & control & is not free to leave, and the person lacks consent to these arrangements * A set of checks that ensure that a person who is deprived of their liberty is protected and that this course of action is both appropriate and in the person’s best interests 1. Part of the Mental Capacity Act 2005 * Key elements of these safeguards are- 1. To provide the person with a representative- a person who is given certain rights & who should look out for & monitor the person receiving care 2. To the give the person (or their representative) the right to challenge a deprivation of liberty through the Court of Protection 3. To provide a mechanism for deprivation of liberty to be reviewed & monitored regularly

Answer 58

* DoLS assessments are carried out by at least 2 people 1. The best interests assessor 2. The mental health assessor * The assessment process has 6 parts- 1. Age- \>18? 2. Mental health disorder? 3. Mental capacity 4. Best interests 5. Eligibility 6. No refusals * DoLS authorisation should last for as little time as possible and only for a maximum of 12 months

Answer 59

* Appointed by patients under the Mental Capacity Act when pt has capacity to make decision * The LPA cannot make treatment decisions if the pt still has capacity * Separate applications for health and welfare and property and financial affairs * Have to be registered with the office of the public guardian * If concern not acting in best interests of donor would need to apply to court of protection

Answer 60

* Conditions that affect mood, thinking, feeling, behaviour

Answer 61

* Carer strain is experienced when a caregiver feels overwhelmed & is unable to perform their role to the best of their ability

Answer 62

* Play a role in intermediate care * Inpatient rehabilitation * Outpatient consultations

Answer 63

* NHS continuing healthcare checklist * Screening tool for eligibility for continuing healthcare * The needs assessed are breathing, nutrition, continence, skin (wounds and ulcers), mobility, communication, psychological and emotional needs, cognition, behaviour, drug therapies and medication, altered states of consciousness, other significant care needs

Answer 64

* When people who are clinically optimised & do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting * Assessment for longer-term care & support needs is then undertaken in the most appropriate setting and at the right time for the person * Essential criteria- * Supporting people to go home as the default pathway * Free at point of delivery regardless of ongoing funding arrangements * Safe if the person is going home, assessment within 2 hours with rapid access to care and support if required * Support services should be time limited- up to 6 weeks * Nonselective, a service that tries to always say yes- to include support for end of life care

Answer 65

* Seamless discharge from hospital to preferred place of care within normal working hours * Provide support for family and carers * Facilitate a peaceful death at preferred place of care * It is used if pt has urgent health needs or nursing needs and is rapidly deteriorating or in the terminal phase of life * It allows a quick decision to be made about Continuing Healthcare funding * The Fast Track assessment should be carried out by GP, consultant, registered nurse, hospice clinician etc

Answer 66

* Both provide 24hr care with trained staff * Nursing home: always staffed by registered nurses supported by care assistants, people in nursing home need nursing intervention * Residential care home: staff trained but not in nursing care

Answer 67

* IMPAIRMENT * Pathological defect in an organ/ tissues * Any loss or abnormality of psychological, physiological, anatomical structure or function * Eg dementia, impairment to move legs due to cerebral palsy * DISABILITY * Restriction of functional ability due to an impairment * Eg inability to walk * HANDICAP * A mental, physical, or social disadvantage as a result of disability

Answer 68

* When a person continues to eat & drink despite a significant risk of aspiration or choking * The option is often appropriate when ensuring QoL is the highest priority * Allows continued enjoyment, comfort, pleasure, social interaction associated with eating & drinking * May be appropriate in the following situations- * Advanced stage of illness * Person’s swallow safety is not likely to improve * When the preference to eat and drink takes priority over swallow safety * Tube feeding options are declined or inappropriate

Answer 69

* Those living independently * Limited transport to local shops * Underlying disease * Decreased mobility * Poverty

Answer 70

* BMI of \< 18.5; or * Unintentional weight loss \>10% within the last 3-6 months; or * BMI \< 20 & unintentional weight loss \>5% within the last 3-6 months * Those at risk of malnutrition- * Not eaten for \>5 days or anticipated to not eat for next 5 days * Have poor absorptive capacity or high nutrient losses or nutritional needs increased from causes such as catabolism

Answer 71

* Using MUST: Malnutrition Universal Screening Tool * Should be done on admission to care/ nursing homes & hospital, or if there is concern eg elderly, thin pt w/ pressure sores * Takes into account BMI, recent weight change & presence of acute disease * Categorises pts into low, medium & high risk

Answer 72

* Reduced dietary intake * Malabsorption * Increased losses or altered requirements- burns * Energy expenditure

Answer 73

* Muscle function decline * Cardio-respiratory function * GI function * Immunity & wound healing * Psychological- apathy, depression, anxiety, self-neglect

Answer 74

* Dietician support if high risk * Food first approach with clear instructions eg add full fat cream to mashed potato, rather than just prescribing oral nutritional supplements (ONS) such as Ensure * If ONS are used they should be taken between meals rather than as meal supplementation

Answer 75

* 25-35 kcal/kg/day * 0.8-1.5g protein/kg/day * 30-355 ml fluid/kg * Adequate electrolytes, minerals, micronutrients, fibre if appropriate * (This is for patients not at risk of re-feeding syndrome or severely ill or injured)

Answer 76

* High risk if any of the following: * BMI \< 16 * Unintentional weight loss \> 15 % over 3-6 months * Little nutritional intake \> 10 days * HypoK, hypophosphataemia, hypoMg prior to feeding * If two of the following: * BMI \< 18.5 * Unintentional weight loss \> 10% over 3-6 months * Little nutritional intake \> 5 days * Hx of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids

Answer 77

* The metabolic abnormalities which occur on feeding someone following a period of starvation * Occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism * Hypophosphate, hypoK, hypoMg (torsades de pointes), abnormal fluid balance

Answer 78

* Involves helping people to plan for their future care & support needs, including medical treatment, and therefore to exercise their personal autonomy as far as possible * This is offered to everyone who is at risk of losing capacity (eg through progressive illness), as well as those with fluctuating capacity (eg through mental illness) * Written record should be made by practitioner * Advanced refusals of treatments eg ventilation must be recorded, signed & witnessed * Advance decisions cannot demand treatment

Answer 79

* A Do Not Attempt Resuscitation form is a document issued & signed by an appropriate health professional, which tells the medical team not to attempt CPR * It is not a legally binding document * Should be discussed with pt & family * Ultimately is a medical decision

Answer 80

* Department of Health definition of learning disability: significant reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning) which started before adulthood * Most cases unknown aetiology * Causes: * Inherited condition eg Fragile X * Chromosome abnormality eg Down’s syndrome * Very premature birth * Mother’s illness during pregnancy * Foetal Alcohol Syndrome * RTA or child abuse during early childhood which affected brain development * Contact with damaging material like radiation * Neglect or lack of mental stimulation early in life

Answer 81

* Fragile X syndrome

Answer 82

* Down’s syndrome

Answer 83

* Malnutrition

Answer 84

* Normal IQ: 100 +/-15 * Borderline: 70-84 * 50-70 = mild learning disability * 35-49 = moderate learning disability * 20-34 = severe learning disability * \<20 = profound learning disability

Answer 85

* Not classified as LD but still vulnerable due to cognitive status * Living independently * Subtle communication difficulties * High school drop out or special education * Difficulty keeping a job, receiving government assistance * At risk of abusive relationships, challenges rearing children

Answer 86

* Mild * Relative independence in self-care and daily living skills * Can hold a conversation and engage in clinical interview * Abstract concepts eg time are difficulty * Requires varying levels of service support * May have paid employment * Moderate * Basic communication skills * Requires supervision with self-care * Living in supported accommodation * Can engage in a structured day programme or workshop activities * Community access with staff * Severe * Limited communication * Motor impairment * Needs supervision in daily activities * Living in 24 hour staffed home * In alternative day programmes w/ combination of skills- based & recreational activities * Profound * 24 hour supervised care * Living either with family or in-group home or nursing home * Multiple medical problems * Inner world largely unavailable to others due to communication difficulty

Answer 87

* No, it is a learning difficulty

Answer 88

* A learning disability constitutes a condition which affects learning and intelligence across all areas of life * A learning difficulty constitutes a condition which creates an obstacle to a specific form of learning but does not affect the overall IQ of an individual * Eg Down’s syndrome = learning disability * Dyslexia = learning difficulty, in that it only affects an individual’s relationship to the processing of information, usually manifested in problems with reading, writing, spelling

Answer 89

* Dyslexia * Dyspraxia * Dyscalculia

Answer 90

* Schizophrenia * Mood disorder * Anxiety

Answer 91

* Lifelong neurodevelopmental condition, the core features of which are persistent difficulties in social interaction and communication and the presence of stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests

Answer 92

* No, it is a neurodevelopmental disorder * But around half of autistic people may also have a learning disability

Answer 93

* 20-30% * In comparison to 1% of general population

Answer 94

* Activities of daily living- ADLs * a series of activities people should be able to do without assistance * These can be broadly divided into personal tasks and domestic tasks * Personal: washing, dressing, toileting, continence, transferring (eg from bed to chair) * Domestic: cooking, cleaning, shopping, managing finances, taking medications

Answer 95

* Microscopic: neurodegeneration secondary to altered amyloid and tau protein metabolism… * Senile plaques: deposits of beta-amyloid, dense, insoluble, extracellular (outside of neurones) * These can also be seen in normal ageing * Neurofibrillary tangles: aggregations of hyperphosphorylated tau proteins, typically in areas of brain involved in memory, promotes neuronal cell death, intracellular (form inside neurones) * Macroscopic changes: widespread cerebral atrophy, particularly involving the cortex and hippocampus * Biochemical changes: deficit of acetylcholine from damage to an ascending forebrain projection

Answer 96

* Alzheimer’s Disease * Early impairment of memory * Manifests as short term memory loss and difficulty learning new information * Vascular Dementia * Typically a stepwise decline in function * Predominant gait, attention and personality changes * May have focal neurological signs (eg previous stroke)

Answer 97

* Attention & concentration * Recent & remote memory * Language * Praxis- planned motor movement (eg perform a task) * Executive function * Visuospatial function

Answer 98

* Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) * To put simply, there are 3 key components * Functional ability: inability to carry out normal functions, represents a decline from previous functional level * Cognitive domains: impairment involving 2 or more cognitive domains * Differentials excluded: other psychiatric disorders or delirium cannot explain these clinical features

Answer 99

* Regular follow up * Advise to undertake healthy brain activities- exercise, socialising

Answer 100

* Depression, psychosis * Drugs- anti-cholinergic effects eg anti-histamines, anti-psychotics, anti-epileptics * Delirium

Answer 101

* To assess the volume change in characteristic locations which can yield a diagnostic accuracy of up to 87% * The diagnosis should be made on the basis of 2 features * Medial temporal lobe atrophy- particularly the hippocampus * Temporoparietal cortical atrophy

Answer 102

* Donepezil (commonly), Rivastigmine, galantamine as monotherapies as options for managing mild to moderate Alzheimer’s disease * These drugs improve cognition, neuropsychiatric symptoms and ADLs * Common S/E: nausea, diarrhoea, vomiting are the most common adverse effects from increased cholinergic activity in the peripheral nervous system * Pts with asthma/ COPD may have exacerbation of their symptoms * Less common S/E: peptic ulcers, bleeding, bradycardia, heart block * Conduct ECG prior to starting donepezil * Relatively contraindicated in pts with bradycardia * Adverse effects include insomnia * Rivastigmine worsens Parkinson tremor

Answer 103

* N-methyl-D-aspartic acid receptor antagonist * Memantine reduces functional decline * Caution in epilepsy

Answer 104

* Characteristic pathological feature: alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas * Relationship with Parkinson’s disease * Progressive cognitive impairment- early impairments in attention and executive function (compare to AD- where just memory loss) * Cognition may be fluctuating * Usually develops before PD * Parkinsonism * Visual hallucinations

Answer 105

* Diagnosis: Usually clinical, single-photon emission computed tomography may be used (DaTscan) * Management: AChE inhibitors- donepezil and rivastigmine- and memantine can be used * Avoid neuroleptics (dopamine antagonists)- may develop irreversible parkinsonism * Neuroleptics could also cause neuroleptic malignant syndrome which is a psychiatric emergency- fever, encephalopathy (confusion), tachycardia, fluctuating BP, rigidity

Answer 106

* Baseline cognition * Do they usually have problems with memory, how long has this been going on for? * Has there been a change in behaviour- aggression, hallucinations? * Is there a diagnosis of dementia? * Baseline mobility * How far can they walk when well? * Assistance required- walking stick, frame, wheelchair? * Indoors and outdoors * Living arrangements * Who do they live with? * Carers- how often do they visit, can they address all the pt’s needs? * What type of home do they live in- house, flat, care home * Stairs? * Continence * Urine & faeces * How is any incontinence managed? * Activities of daily living * Washing, dressing, toileting, managing medications * Cooking, cleaning, shopping, finances * Driving * Alcohol, smoking * Advance care planning * Thoughts about CPR- ever been discussed with GP or someone close to them? * Medical treatments they wouldn’t want? * Lasting power of attorney for health and welfare? * What is the most important to the patient?

Answer 107

* Lower intellectual ability (IQ \< 70) * Significant impairment of social or adaptive functioning * Onset in childhood

Answer 108

* Chromosomal & genetic anomalies- Down’s syndrome, William’s syndrome, Rhett syndrome, fragile X syndrome * Some non-genetic congenital malformations- spina bifida, hydrocephalus, microcephaly * Prenatal exposures- alcohol, sodium valproate, congenital rubella infection, zika virus * Birth complications resulting in hypoxic brain injury/ cerebral palsy * Extreme prematurity (usually \<33 weeks gestation) * Childhood illness- meningitis, encephalitis, measles * Childhood brain injury caused by accidental/ physical abuse * Childhood neglect/ lack of stimulation in early life

Answer 109

* Frontotemporal dementia

Answer 110

* Onset before age 65 * Insidious onset * Relatively preserved memory & visuospatial skills * Personality change & social conduct problems

Older persons care & Learning Disability Flashcards

TOPICS COVERED: Falls Pressure ulcers Polypharmacy Continence Frailty Dementia Delirium Capacity and Best Interest Decision making Community hospitals/ care Nutrition Advance care planning Learning disability