Other Flashcards
Fitness to drive - assessment (points to consider)
Useful points to consider
- Driving history: Have they been involved in any driving incidents?
- Vision
- Hearing
- Reaction time: Can they turn, stop or speed up their car quickly?
- Problem solving
- Coordination
- Insight: Are they aware of the effects of their dementia? Is there denial?
- Other:
Can they tell the difference between left and right?
Do they become confused on a familiar route?
Can they comprehend road signs?
Can they respond to verbal instructions?
Do they understand the difference between ‘stop’ and ‘go’ lights?
Are they able to stay in the correct lane?
Can they read a road map and follow detour routes?
Are they confident when driving?
Fitness to drive - steps in assessment and reporting process
Steps in the assessment and reporting process
- STEP 1: Consider the type of licence held or applied for
- STEP 2: Establish relevant medical and driving history
● Previously been found unfit in the past and reasons
● History of epilepsy, syncope, sleep disorders, CVD etc
● History of motor vehicle incidents
● Medications that may affect driving ability
● Degree of insight the patient has into their ability to drive safely
● Nature of their current patterns and needs
What to do if an objective assessment is unable to be made
Potential strategies:
● Contact professional indemnity insurer
● Refer the person for specialist opinion
● Contact the relevant driver licensing authority, without identifying the patient, to discuss the problem and
document the advice
Fitness to drive - roles and responsibilities of HCP
Key point
● HCPs have an ethical and legal obligation
● Advice given re: driving should be documented in patient’s records
● It is preferable that any action taken in the interest of public safety should be taken with the consent of the patient whenever possible with the patient’s knowledge of the intended action
Confidentiality
● HCPs have an ethical and legal obligation to maintain patient confidentiality
● On rare occasions it is justifiable to breach confidentiality and report to driver licensing authorities in good faith:
○ Unable to appreciate the impact of their condition
○ Unable to take notice of the health profession’s recommendations due to cognitive impairment, or
○ Continues to drive despite appropriate advice and is likely to endanger the public
● Useful for HCP to consider:
○ Seriousness of situation
○ Risk associated with disclosure without the individual’s consent
○ Ethical and professional obligations
○ Serious and imminent threat to the health, life or safety of any person
Fitness to drive - mobility assessment
** Refer to page 163 of GP Study Notes
83M, presenting with daughter following advice from the aged care team for assessing his driving ability. Has a history of Alzheimer’s disease, type 2 diabetes, Parkinson’s disease and atrial fibrillation. Medications: insulin,
warfarin, donepezil, levodopa/carbidopa and atorvastatin. MMSE is 24 out of 30. He believes he is a competent
driver.
- What history and examination would you need to assess for fitness to drive?
- Apart from history and examination, what are the other measures you can take for further assessment of his fitness to drive?
- You reach the conclusion that he is not fit to drive. What are the next three steps in the management?
What history and examination would you need to assess for fitness to drive?
History
● Driving history - history of accidents, pattern of
driving
● How often he loses his way
● Recent hypoglycaemic episodes - frequency,
severity
● Hypoglycaemic awareness
● Compliance with medications
● Any recent black out or syncope
● History or signs of cerebrovascular disease
Examination
● Hearing assessment/impairment
● Visual acuity
● Visual field
● Assessing coordination, balance, mobility
● Signs of peripheral neuropathy
Apart from history and examination, what are the other measures you can take for further assessment of his fitness to
drive?
● Collateral history/information from relatives about his driving ability with his consent
● Practical driving assessment with an occupational therapist
● Assessment of cognition via neuropsychiatric assessment by a geriatrician, neurologist, memory clinic,
general physician
● Anonymous enquiry from Driving Licensing Authority about the requirements
You reach the conclusion that he is not fit to drive. What are the next three steps in the management?
● Advise him that his medical conditions have impaired his ability to drive safely
● Advise him to inform the Driving License Authority
● Notify the next of kin that he is not fit to drive
● Offer assistance and support to look at alternative transport options
Insomnia - indications for pharmacotherapy
Key point: Avoid using pharmacotherapy as the sole treatment for insomnia.
Acute insomnia criteria:
● Likely benefit exceeds the possible harms
● Patient is significantly distressed by lack of sleep, or significantly impaired by daytime sequelae
● Nondrug interventions are impractical or unacceptable
Chronic insomnia criteria:
● In addition to acute insomnia criteria, if CBT for insomnia is ineffective or not preferred by the patient
MBS - GPMP (criteria, billing)
Criteria
● At least one medical condition likely present for 6 months or is terminal
● TCA - above + requires ongoing care from at least three collaborating HCPs
○ Carer can be included in planning but does not count towards minimum of three collaborating providers
Timing
● 721 (preparation), 723 (TCA) - 12 month
● 732 (review) - 3 months
MBS - MHCP
Billing: 2715 (standard), 2717 (long)
MBS - asthma cycle of care
Criteria:
● 2 asthma related consultations within 12 months (moderate to severe asthma)
● Documentation of diagnosis and assessment of level of asthma control
● Review use and access to asthma-related medication
● Asthma action plan
● Self-management education
Narcolepsy (key points, features, symptoms, diagnosis, treatment)
Key points
● Brief spells of irresistible sleep
Features: teens to 20s
Symptoms: hypersomnolence, cataplexy, sleep paralysis, hypnagogic (terrifying) hallucinations
Diagnosis: history, EEG, sleep studies
Treatment: Modafinil 200mg PO mane or 100mg mane + midi
Perioperative - anti-coagulants
DOAC
- Cease 3 days if high risk bleed, 2 days if low risk bleed
- Restart 2-3 days if high risk bleed, 1 day if low risk bleed
Aspirin
- 7 days prior (non-cardiovascular)
- Resume with oral intake
Clopidogrel
- Cease 7-10 days prior
- Resume with oral intake
Perioperative - diabetes
Key points
● Goal is to avoid hypoglycemia, prevent ketoacidosis and avoid marked hyperglycemia.
● Aim for surgery before 9am to minimise disruption of regular routine
● Oral hypoglycemic or non-insulin injectables should be withheld on the morning of surgery
● Continue subcutaneous insulin preoperatively at a reduced dose for simple and non-complex procedures
● SGLT2 (e.g. empagliflozin, dapagliflozin) to be ceased 3 days prior to procedures that require >1 day in
hospital including colonoscopy. Can be withheld on the day for day procedures.
● Can restart all agents when patient is eating well
Smoking cessation
Nortriptyline
● ADRs: dry mouth, constipation, nausea, sedation and headache, risk of arrhythmia with CVD history
● Timeline: start 10-28 days before quit date and continue for 12 weeks after stopping smoking
● Interaction: carbamazepine (reduce efficacy)
● Dose: 25mg PO daily, increasing gradually to 75mg
Bupropion
● Efficacy: similar to NRT
● ADRs: seizure
● Contraindications: history of seizure, eating disorders
● Timeline: Quit date set for second week of therapy
● Dose: 150mg PO daily for 3 days, then 150mg BD for remainder of 9 week course
Varenicline
● Efficacy: can double chances of success
● ADRs: nausea (can be reduced by taking with food), neuropsychiatric (mood change, behaviour
disturbance, suicidal thoughts)
● Contraindication: end stage renal failure
● Dose: 0.5mg PO daily for 3 days, then 0.5mg BD for 4 days, then 1mg BD for remainder of 12 week course
(keep as daily for CrCl <30)
Nicotine patches
● If >45kg and smoker >10 per day:
○ 21mg/24hr daily for 24 hours OR 15mg/16hr daily for 16 hours in 24 hour period
○ ** if <45kg then dose is 14 and 10 respectively
● Stop treatment at 12 weeks by either tapering or stopping abruptly
Standards for GP - follow up tests and results
Key point
● In cases where a GP suspects that the results will be clinically significant, the practice needs to create
additional safeguards to ensure that potentially clinically significant information does not get ‘lost in the
system’
AMA position
● Practitioners may request patient to return for consultation and should clearly inform the patient why the
follow up consultation is needed and the potential consequences of not proceeding
● Means of contact should be clarified and documented during the consultation
● Documentation of phone calls should include the date
● Copies of letters sent should be included in the record
● Appointment system should allow a permanent record of all cancellations and failures to attend
MIGA
● Three attempts by a mix of methods. One of the methods should be in writing and for recalls detailing the
potential implications of failing to return.
● Avoid using clinical information in SMS or email communications.
Substance use - stimulant
e.g. Amphetamine
Symptoms: CNS excitation and peripheral sympathomimetic response: Euphoria, apprehension, agitation, altered mental state. Mydriasis, diaphoresis, hyperpyrexia.
Treatment: DRS ABCD Transfer to ED for monitoring IV sedation + fluid resus
