Session 5 Flashcards
• 76 year old man attends with
central crushing chest pain
radiating down the left arm. • PMH: mild osteoarthritis • DH: Ibuprofen PRN • SH: Non-smoker, jogs and plays
golf four times a week. • O/E: Pale and clammy. p110
regular, BP 164/102.
Chest/heart/abdo – NAD. • ECG shows ST elevation in V1-V3
and he has a raised troponin
level.
• What is the diagnosis?
• Acute Myocardial Infarction
• He is discharged from hospital after a few days later, what four
medications should he start?
MI
Statin, aspirin, ace-inhibitor,
What is the clinical frailty score
Insert image from slide 4 lec 1
• 50 year old man attend with right lower chest well pain – pleuritic, breathlessness and haemoptysis • Has a fever, bronchial breathing and dullness to percussion at the right base • CXR • Diagnosis?
Pneumonia
• Risk stratify e.g. CURB-65 • Antibiotics • Stop smoking • Follow up CXR
1 week: fever should have resolved 4 weeks: chest pain and sputum production should have substantially reduced 6 weeks: cough and breathlessness should have substantially reduced 3 months: most symptoms should have resolved but fatigue may still be present 6 months: most people will feel back to normal
What questions to consider when looking at complicated frail patients?
• Should we treat? • What treatments will be needed? • Who will be involved? • What is his prognosis? • What will happen next?
which of these meds may increase likelihood of fall and why • Amoxicillin (from GP) • Aspirin • Statin • ACE inhibitor • Furosemide • ISMN • Oxybutynin • Digoxin • Apixiban
panopt
Frailty – clinical relevance and implications for practice
Manifestations of frailty Delirium (dementia) Falls & fractures Immobility & pressure sores Incontinence & dipstick +ve ‘UTI’ Iatrogenesis
• Use frailty to differentiate and prognosticate
• Tailor management accordingly – person (not condition) centred care; shared decision making
• Frailty complex, solutions will need to be complex… Comprehensive Geriatric Assessment
Characteristics of complex systems
panopto
Causal pathways
panopto
Comprehensive geriatric assessment
CGA allows a care plan to be generated that can modify trajectories
• At 6 months, NNT of: • 17 (1 unnecessary death or deterioration); • 20 (1 institutionalisation) • NNT 25 at 12 months
Problem lists
• Delirium due to: • Aspiration pneumonia • Anticholinergic Burden Score of 6 • Urinary retention • Constipation • Acute on chronic kidney injury • Underlying vascular dementia
• Polypharmacy • Anaemia on NSAID & DOAC • Swallowing difficulties • Possibly – probably approaching end of life; CFS 8, NEWS 8
“If you only have one cause for a geriatric syndrome, then you have missed at least four others”
Emerging service model…
fit/mild frailty
• Care as usual but address reversible issues – sarcopaenia (“prehabilitation”), nutrition and social prescribing
Moderate frailty • Actively seek out and manage geriatric syndromes – falls, cognitive impairment, continence, polypharmacy (Comprehensive Geriatric Assessment)
Severe Frailty - • Think about supportive care vs. cure, advance care planning, recognition that enhanced supportive care is an active intervention in itself offering improved QoL, sometimes quantity of life.
define some key objectives of palliative care
1
Be able to list several specific challenges in achieving a ‘Good Death’
2
describe the importance of holistic approach in palliative and end-of-life care
3
Be able to list several specific distinct services or interventions offered by many modern UK hospices to patients with life limiting illnesses (using an example of end stage heart failure or end stage COPD as an example)
4
