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SocPop Phase 2 > SocPop > Flashcards

SocPop Flashcards

1
Q

Top 3 leading global causes of death by sex

A

Male

  • Ischaemic heart disease
  • Stroke
  • COPD

Females

  • Stroke
  • Ischaemic heart disease
  • Lower Respiratory Tract Infection
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2
Q

What are the leading risk factors for death?

A 
HTN
Tobacco
High cholesterol
Underweight
Unsafe Sex
High BMI
Physical Activity
Alcohol
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3
Q

Stages 1 of Demographic Transition and effects on population pyramids

A

Poor development

  • high birth rate
  • high death rate
  • high infant mortality
  • young population
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4
Q

Stage 2 and 3 of Demographic Transition and effect on population pyramid

A

Development and improvement in care

  • Fall in death rates
  • sustained birth rate
  • population growth
  • Young population base on pyramid with longer life expectancy.
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5
Q

Stage 4 of demographic transition and effect on population pyramid

A

High income countries

  • birth rates fall dramatically
  • Death rates continue to fall
  • slowing down of population growth
  • further increase in life expectancy
  • Ageing Population
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6
Q

Population Pyramid changes through stages of demographic transition

A

From High to low mortality (1-4) leads to a shift from a ‘pyramid’ with a young population base to the ‘diamond’ shape with a shrinking base and a growing top (Ageing population)

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7
Q

Stages in the epidemiological transition for cardiovascular risk

A

Increasing levels of acculturation, urbanisation, and affluence are initially associated with an increase in cardiovascular disease due to HTN and Atherosclerosis via increased smoking and fat and salt intake.

Hypertension begins to plateau and then decrease at high urbanisation and affluence

Atherosclerosis continues to increase.

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8
Q

Define Primordial Prevention

A
  • Focuses on the causes of the unequal distribution of health damaging exposures, susceptibilities and health protective resources across socal groups.
  • Addresses questions of why socioeconomic position is associated with health
  • Prevents the appearance of the mediating risk factors in the population
  • Focuses on social organisation
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9
Q

Define Primary Prevention

A

Reduction of incidence of disease among healthy individuals by:

  • Removing primary causative agents (Smoking)
  • Interrupting transmission of an infective agent (vaccine)
  • Protecting the individual from environmental hazards (Goggles)
  • improving host resistance (Supplements)
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10
Q

Define Secondary Prevention

A

Early detection of pre-clinical disease (screening)

Treatment to prevent progression or recurrence (chemotherapy)

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11
Q

Define Tertiary Prevention

A

Treatment of established disease to prevent complications or relieve distress (Asthma - Steroids)

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12
Q

What is the population strategy for reducing CVD?

A

Aims to reduce the risk factor of interest (e.g BP) in everyone in the population, on the knowledge that the risk of having CVD is directly related to the level of the risk factor and that a small reduction in the level of the risk factor will reduce the risk in everyone.

Implementation leads to a reduction in the proportion of people in the upper end of the distribution (diseased) –> reduction in incidence and prevalence

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13
Q

What is the High Risk strategy for reducing CVD?

A

Also known as the ‘medical approach’

Aims to treat those with a defined disease status (e.g HTN or DM)

Whilst these people have the highest risk of developing CVD, there are not many in the population, so the impact of the burden of CVD is small.

The high risk strategy will not reduce the ‘ incidence’ of disease since it will not address the causes but will deal with the consequences and manifestations.

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14
Q

Pros and Cons of the population strategy of disease reduction

A

Pros

  • Attempts to control the determinants of incidence rather than cases
  • Population based
  • More permanent

Cons

  • More radical
  • Harder to implement
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15
Q

Pros and Cons of the high risk strategy of disease reduction

A

Pros
-Extension of traditional clinical approach

Cons

  • Doesn’t produce lasting population changes
  • Needs to be repeated from generation to generation
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16
Q

Drivers reducing mortality from CVD in England and Wales

A 
Improvement in Pharmacological Therapy
- Statins
- Anti-hypertensives
Increase in invasive procedures
- Angioplasty
- PTCA
Therapy
- MECC
Primary Prevention
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17
Q

What is the double burden of communicable and chronic disease in low income countries

A

A high death rate occurring due to the presence of both communicable diseases and chronic disease, both of which are poorly controlled.

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18
Q

Why is CVD a problem?

A

Rising toll of non-communicable diseases

Growing economic burden

Spreading to the developing world

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19
Q

Outline the three connections of CVD drivers.

A

Dietary Connection

  • Shift from simple to processed food
  • Rise of fat production and consumption
  • Rise of soft drinks (childhood obesity

Physical Activity Connection
- Rise of cars
Rise of obesity (and underweight)

Cultural Connection

  • Supermarketisation
  • Lifestyle, especially smoking
  • Advertising
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20
Q

How has diet changed with nutritional transition?

A

More meat, fat, sugar, salt, soft drinks, energy dense food.

Less/not enough staples, fruit and vegetables, fibre, water

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21
Q

Briefly outline WHO’s Global Action Plan for non-communicable disease

A

Reduce premature mortality from CVD, cancer, DM, chronic respiratory disease (25%)

Reduce harmful use of alcohol (10%)

Increase exercise

Reduce mean population intake of salt/sodium (30%)

Reduce tobacco use in persons aged 15+ (30%)

Reduction in prevalence of raised BP or contain prevalence of raised BP (25%)

Halt the rise in DM and obesity

Increase eligibility of people to drug therapy and counselling to prevent MI and stroke

80% availability of affordable basic tech and medicines.

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22
Q

Outline the 4 domains to reduce population salt intake

A 
Communication
- Public awareness campaigns
- Food industry
-Media
-Health professionals
Reformulation
- Setting targets
- Food labelling
- Industry engagement
- motivation
-customer awareness
- corporate responsibility
- voluntary vs regulatory
Monitoring
- Population salt intake via urinary sodium and dietary surveys
- Reformulation progress via salt content of food checks
- Effectiveness of campaigns by measuring awareness and attitudes and behaviour changes
Research
- Epidemiology
- nutrition
- public health
- food tech
- behavioural
- evaluation
- policy
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23
Q

How effective was the 8 year national campaign to reduce salt intake?

A

Reduction in IHD, stroke, and BP

  • Reduction in salt –> reduction in BP
  • 5g/day decrease –> stroke decrease of 23%
  • Effective in both genders, any age, ethnic group, high, medium, or low income countries.
  • feasible and effective
  • programmes are cost saving
  • Policies are powerful, rapid, equitable, cost-saving.
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24
Q

Define Surveillance

A

Information for Action

The ongoing systematic collection, collation, analysis, and interpretation of data, and the dissemination of information (to those who need to know) in order that action may be taken.

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25
Q

Why is surveillance useful?

A

Early detection of outbreaks
Monitoring Trends
Early warning of changes in incidence
Guidance to public health programmes (identify high risk groups to receive neonatal BCG to prevent childhood TB).

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26
Q

Examples of Surveillance Systems

A 
Notification of Infectious Disease
Primary Care
- Remote health advice (NHS 111)
- GP in and out of hours
- RCPG consultations for influenza-like-illness
- COVER (immunisation data)
Secondary Care
- Emergency department syndromic surveillance to monitor ED attendances and triage severity ratio.
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27
Q

Outline the Notification of infectious disease protocol and why it is carried out

A

Enables prompt investigation, risk assessment and response to cases of infectious disease and contamination that present risk to human health

Registered medical practitioners have a statutory duty to notify the health protection team od suspected cases of certain infectious diseases.

Complete a notification form immediately on diagnosis of a suspected disease, do not wait for lab confirmation.

Send the form within 3 days, or notify verbally within 24hrs

32 notifiable disease, not including HIV as it has a separate mandatory surveillance system.

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28
Q

Outline the triad of concepts of spread of infectious diseases

A

Agent : Host : Environment Triad

Agent

  • Virus
  • Bacteria
  • Fungus
  • Protozoa

Host

  • Age
  • Gender
  • Socioeconomic Status
  • Ethnicity
  • Lifestyle factors
  • Immunological Status (immunisation, previous exposure, immunosuppression)
  • Level of inherent resistance

Environmental

  • Climate and temperature
  • Physical surroundings
  • Crowding
  • Sanitation
  • Availability of health services
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29
Q

Public Health England’s role in communicable disease control

A

Statutory responsibility to take notifications of infectious disease and manage outbreaks/chemical or environmental incidents

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30
Q

NHS England’s role in communicable disease control

A

Lead and co-ordinate the NHS response to large/significant outbreaks

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31
Q

Clinical Commissioning Groups role in communicable disease control

A

Support the role of NHS England and work with larger outbreaks/commission community and acute trust providers to support smaller outbreak responses

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32
Q

Primary Care/Community Provider Trusts role in communicable disease control

A

Support outbreak investigation and management, through taking samples and organising treatment and prophylaxis

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33
Q

Acute Hospital trusts role in communicable disease control

A

Provide microbiological advice regarding single cases of communicable disease/outbreaks.

In a hospital incident the Director of Infection Prevention and Control (often a microbiologist) leads the outbreak management.

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34
Q

Local Authorities role in communicable disease control

A

Environmental HEalth Officers support the investigation of certain communicable disease cases/outbreaks which may have an environmental source, e.g. GI infections, Legionella.

They organise food questionnaires and stool samples in an outbreak of GI disease, as well as inspection of food premises/kitchens which may be implicated. They can prosecute where necessary.

The Director of Public Health (and teams) in the Local Authority has the statutory responsibility to ensure there are plans in place to protect the health of the population and will support the outbreak response.

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35
Q

State the organisations involved in communicable disease control

A 
PHE
NHS England
CCG
Primary Care/Community Provider Trusts
Acute Hospital Trust
Local Authorities
- Environmental Health Officer
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36
Q

State and give examples of direct modes of transmission

A

Touching (Scabies)

Kissing (oral infection)

Sexual (Chlamydia, Gonorrhoea, syphilis, HIV, HepB)

Droplet Spread (measles, mumps, flu, meningococcal)

Vertical Transmission - Transplacental/during childbirth (toxoplasmosis, rubella, CMV, HSV, HIV, Hep B, HepC)

Faeco-Oral (campylobacter, salmonella, E.coli, Hep A)

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37
Q

State and give examples of indirect modes of transmission

A

Vehicle Borne (flu) - inanimate objects, food/water, biological products e.g blood, tissues

Vector Borne (malaria) - an insect or living carrier which carries disease from an infected individual to a susceptible individual

Airborne - aerosols e.g TB and dust, fungi and respiratory viruses.

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38
Q

Define the Natural History of disease

A

The progress of a disease process in an individual over time without intervention

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39
Q

Outline the stages involved in the natural history of disease

A 
Exposure
Subclinical (unapparent pathological) changes
Onset of symptoms
Clinical illness (or not)
Recovery or Death
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40
Q

Define incubation period

A

The time interval between initial contact with an infectious agent and the appearance of the first sign or symptom of the diseases.

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41
Q

Incubation period of influenza?

A

1-5 days

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42
Q

Incubation period of measles

A

10 days

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43
Q

Incubation period of Typhoid

A

1-21 days

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44
Q

Define Latent Period

A

Time between becoming infected and becoming infectious

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45
Q

Define Infectious period (period of communicability)

A

The time during which an infectious agent may be transferred directly or indirectly from an infected person to another person, from an infected animal to man or from an infected person to an animal.

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46
Q

Define ‘sporadic’ in terms of disease

A

Irregular pattern of disease, occasional cases at irregular intervals (Bat to human)

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47
Q

Define Endemic

A

Persistent, low or moderate level of disease (Wuhan province)

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48
Q

Define Hyperendemic

A

A higher persistent level of disease (3 Provinces)

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49
Q

Define Cluster in terms of disease

A

Occurrence exceeds the expected level for a given population and/or in a given geographical area and/or in a given time period (cases have a possible but unconfirmed link)

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50
Q

Define Epidemic

A

Occurrence exceeds expected level for a given population and/or in a given geographical area and/or in a given time period.

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51
Q

Define Outbreak

A

A localised epidemic, and is also practically defined as two or more linked cases, or a single case or serious disease e.g rabies, diphtheria, botulism, polio

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52
Q

Define Pandemic

A

Epidemic occurring worldwide or over a very wide area, crossing international boundaries, and usually affecting a large number of people.

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53
Q

List the ways of breaking the chain of transmission

A

Control the Source (Mink Culling)
Interrupt transmission (Close borders, Wash hands)
Protect susceptible by immunisation of chemoprophylaxis

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54
Q

List the stages in managing an outbreak and epidemic curves

A

Confirm (verify diagnosis)
Immediate control
Convene an Outbreak Control Team
Review epidemiological (time, place and person) and microbiological information
Case Finding
Definitive control measures
Descriptive epidemiology (epidemic curves)
Analytical study (case control or cohort)
Declare outbreak over (lessons learnt, prevention measures in place, ongoing monitoring)
Communication throughout

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55
Q

Define a ‘Point’ cause of an outbreak

A

A dodgy burger van

All cases appear to occur within one incubation period, suggesting that cases did not arise from person-to-person spread.

The fact the outbreak was short in duration suggests a single, brief exposure that didn’t persist over time

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56
Q

Define a ‘Propagated’ cause of an outbreak

A

COVID-19

Begins like an infection form a single case but then develops into a full-blown epidemic with secondary cases infecting new people who, in turn, serve as sources for other cases.

Produces successively taller peaks on an epidemic curve, initially separated by one incubation period, but peaks tend to merge into waves with increasing numbers.

The epidemic continues until the remaining numbers of susceptible individuals decline or until intervention measures take place.

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57
Q

Define a ‘continuous’ cause of an outbreak

A

The London Cholera Outbreak

As with the point source outbreak, a group of people are exposed to a single noxious influence. But the exposure continues over a longer time (e.g a contaminated water supply that doesn’t get fixed, so the outbreak persists for longer.

The relatively abrupt beginning of the outbreak suggests that many people were exposed simultaneously rather than case to case transmission.

The lack of cases following an incubation period after termination to exposure suggests this.

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58
Q

Define a ‘Mixed’ cause of an outbreak

A

COVID-19 Traveller from China to Italy

A single case (returning traveller) infects other people, and cases arise after an incubation period (point source with secondary transmission)

Outbreak waves when the infected people no longer transmit the infection to other susceptible people, perhaps because of control measures (isolation or quarantine)

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59
Q

List the epidemiological definitions of causes of an outbreak

A

Point
Propagated
Continuous
Mixed

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60
Q

List examples of conflict between autonomy of an individual vs protection of the population in relation to infectious disease

A

Vaccination (Individual protection vs Herd immunity)
Post-exposure chemoprophylaxis (individual protection < Elimination of transmission
Exclusion from school/work (not allow to return until clear samples or 48 hours after N+V)
Use of Part 2A order legislation (Require investigation and detention of an individual who poses a risk to the public)

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61
Q

Define the term Migrant

A

Any person who is moving or has moved across an international border or within a state away from their habitual place of residence, regardless of: legal status, whether the movement is voluntary, what the causes are, or the length of stay.

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62
Q

Define the term Refugee

A

Persons who are outside their country of origin for reasons of feared persecution, conflict, generalised violence, or other circumstances that have seriously disturbed public order and, as a result, require international protection.

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63
Q

Define the term Asylum Seeker

A

A person who has fled their country but whose claim has not yet been finally decided on by the country in which they have submitted it.

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64
Q

Define the term Migrant Worker

A

A person who is to be engages, is engaged or has been engaged in a remunerated activity in a state which they are not a citizen.

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65
Q

Outline the NHS entitlements in England in relation to immigration

A

Everyone in England is entitled to free pharmacy care, regardless of immigration status

Asylum seekers and refugees are entitled to free secondary care, others are charged.

Understanding these terms can help HCPs advocate for their patients.

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66
Q

Outline the factors affecting migrants’ use of health systems

A 
Leadership/Governance
Healthcare Financing
Health Workforce
Medical products and technologies
Information and Research
Service Delivery
Healthcare Seeking Behaviour
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67
Q

What is the Leadership/Governance factor of migrant healthcare

A

Conflicting policy goals between ministries responsible for health, immigration, and human resources.

Legislation is not migrant inclusive

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68
Q

What is the Healthcare financing factor of migrant healthcare

A

Eligibility and enrolment in health insurance schemes

Cross border health and social insurance schemes

Migrant ability to pay when not enrolled in heath insurance schemes

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69
Q

What is the Health workforce factor of migrant healthcare

A

Profession norms involving discriminatory treatment and perceived “deservingness” and cultural competence of staff treating migrant patients (training)

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70
Q

What is the Medical products and technologies factor of migrant healthcare

A

Availability of essential medicines and technologies for migrant patients

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71
Q

What is the information and research factor of migrant healthcare

A

Data collection systems disaggregated by migrant status

Availability of databases on migrant health

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72
Q

What is the service delivery factor of migrant healthcare

A

Language skills or interpreter availability

Essential health packages for migrants regardless of documentation status

Proximity and accessibility of services (mobile units)

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73
Q

What determines migrants’ healthcare seeking behaviour?

A

Age, gender, culture, education, or language
Perceived health needs
Existing health knowledge and practices including self treatment
Perceived “deservingness” for services
Knowledge, information and accessing care
Legal status and possession of documents
Fear of arrest or deportation
Freedom of movement

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74
Q

List some common health issues associated with migration

A

Perinatal health (worse outcomes)
Child health (disrupted immunisation schedule)
Adolescent health (stigma, exclusion, bullying)
Mental Health (1st gen worst)
Communicable diseases (Hep B,C, HIV, Syphilis, TB, leprosy)
Non-communicable disease (interruption of care worsens chronic conditions)
Tobacco and alcohol use
Occupational health due to employment type (injury, weather, pesticide, depression.
Malnutrition
Anaemia
Parasitic infection
Effects of conflict exposure
Trafficking and modern slavery
FGM
Effects of detention and torture

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75
Q

How are migrant health issues related to country of origin?

A

Blood feuds and police corruption make living in country of origin too dangerous

Extreme poverty means living in unsafe environments and lack of access to healthcare

Forced prostitution, kidnapping, trafficking and rape.

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76
Q

How are migrant health issues related to travel to the UK?

A

Unsanitary conditions on travel

A lot of young women are assaulted and raped (and become pregnant) on their way to the UK.

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77
Q

How is migrant health care related to life in the UK?

A

Some areas do not have a specialised service for asylum seekers which leads to difficulties in accessing health care (language barriers)

Some practices refuse to register asylum seekers.

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78
Q

Which infectious disease is not screened for during a refugee and asylum seeker health screen?

A

Leprosy

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79
Q

What occurs during a nursing assessment of a refugee and asylum seeker?

A 
Current and PMH
TB
Mental health screen
Sexual health screen
Women asked about FGM and safeguarding
Asked for an outline of why they are seeking asylum
Refer to GP if any significant issues
Blood tests for infectious disease, sickle cell, thalassaemia + FBC
Chlamydia Test
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80
Q

What questions are asked in a TB screen?

A

Persistent Cough? Blood?
Significant weight loss?
Night sweats?
Contact of infected person?

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81
Q

What follow up occurs after a positive HIV screen?

A

GP discusses positive result with patient in a breaking bad news consultation.
Refer to sexual Health
Annual cervical smear for female HIV positive
Annual flu and pneumococcal vaccination.

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82
Q

Where is hepatitis B most common?

A

Asia and Africa

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83
Q

How is Hepatitis B transmitted?

A

Spread by body fluids e.g sex, vertical transmission

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84
Q

What occurs following a positive Hepatitis B result?

A

Refer to hepatology specialist
Check levels of virus : if high and liver damaged then may need antivirals
Spouse and children need screening and immunisation.

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85
Q

What occurs following a positive Hepatitis C result?

A

Refer to hepatologist

Needs antiviral treatment as it will progress to cause liver damage

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86
Q

What is the treatment for syphilis?

A

Penicillin

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87
Q

How are haemoglobinopathies managed?

A

Refer to sickle cell and thalassaemia service
If pregnant, screen partner
Require annual flu vaccine, pneumococcal vaccine and hepatitis A and B vaccine
Manage with regular penicillin and folic acid + pain relief.

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88
Q

Describe the management of TB

A

Active TB identified by screening questions
Positive quantiferon gamma assay blood test indicates active or latent TB
Call patient in for GP appointment and explain
Arrange CXR and basic blood tests to exclude active TB
Refer to hospital TB team
For latent TB, they will arrange 3 month TB chemoprophylaxis in community.

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89
Q

Which Mental health conditions are most associated with migrants?

A

Anxiety and/or depression
PTSD
Paranoid Schizophrenia
Bipolar

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90
Q

Outline the holistic approach to migrant health care

A

Applicable to all vulnerable populations with complex needs
Understand individual situations as fully as possible
Referrals to social services, housing.
Signpost to Refugee Centre and organisations that can provide social/financial/legal advice
Keep up to date with new agencies (modern slavery unit, black country women’s centre)

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91
Q

What should we do to make migrant healthcare more inclusive?

A

Confront urgently, vigorously, and persistently, divisive myths and discriminatory rhetoric about migrants

Foster cross-sector, complementary decision making that integrates health considerations across policies and services that determine the health of migrants

Advocate for and improve the rights of migrants to ensure safe and healthy educational and working conditions that includes freedom of movement with no arbitrary arrest.

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92
Q

What steps should we take to stand up against migrant healthcare exclusivity?

A
  1. Make sure patients know they don’t need to give a personal address
  2. Display a poster declaring your surgery a safe space
  3. Never ask to see a passport, visa or identity document.
  4. Don’t ask for proof of address documents
  5. Make sure frontline staff know the rules
  6. Check your registration policy.
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93
Q

Define Equal Access

A

Providing the same level or kind of service to everyone

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94
Q

Define Equitable Access

A

Providing services according to need.

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95
Q

Define Horizontal Inequality in healthcare

A

When people with the same needs do not have access to the same resources, unequal treatment of equals.

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96
Q

What is meant by the term ‘post-code lottery’ in terms of healthcare?

A

Different geographical areas get access to better healthcare or more opportunities for treatment than others.

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97
Q

Define Vertical Inequality in healthcare

A

When people with greater needs are not provided with greater resources to meet those needs

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98
Q

Give some reasons why inequity in health care should be addressed

A

“The right thing to do” - fairness and social justice

Equitable access to medical and health care can contribute to reduction in health inequalities

Not addressing inequity could widen health inequalities

Duty under the equality act 2010.

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99
Q

What impacts have increased equity had on patient care?

A
  1. recent fall in CHD attributed to improved treatment uptake across all social groups
  2. Increase in proportion of resources allocated to deprived areas led to a reduction in absolute health inequality
  3. 15-20% of life expectancy gap can be influenced by health care interventions.
  4. Vital to quality of life
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100
Q

Name some groups who experience inequitable health care in primary settings

A

Asylum seekers (access)
Homeless people (access)
Travellers (access)
LGBTQ+ report less satisfaction with GP care
Uptake of colorectal cancer screening is lower in most social disadvantaged groups.
Low income households less likely to take up immunisation and child health screening.

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101
Q

Name some groups who experience inequitable health care in secondary settings

A

Limited use of total hip arthroplasty among patients from deprived area and inappropriate high use in affluent areas
Inequities in treatment provision at the weekend
Bowel cancer patients from disadvantages areas have more emergency admissions
Most disadvantaged less likely to survive lung cancer
Young women (<70) more likely to receive breast reconstruction than old women after breast cancer
Disadvantaged patients more likely to die in hospital
Ethnic inequalities in the access to cardiac care and secondary diabetes care
Significant levels of untreated ill-health and high number of avoidable deaths.

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102
Q

What are the elements necessary for good access to GP services?

A

Improving access for all and reducing inequalities in access to GP services.

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103
Q

Give examples of supply (provider) barriers to equitable health care

A 
Lack of funding
Services at wrong time/place
Costs attached
Culturally inappropriate
Variable Quality
Clinician Biases
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104
Q

Give examples of demand (user) barriers to equitable health care

A

Health literacy
Can’t use services due to geographical or physical barriers
Community and cultural attitudes and norms

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105
Q

Outline the 4 underpinning ways that barriers to health care access must follow to be overcome.

A

MDT approach
Driven by information from health impacts assessments
Complex and multi-faceted
Action at organisational level

106
Q

How can barriers to health care access be overcome (examples)

A

Reduce physical and geographical barriers
Address attitudinal or knowledge biases of clinicians
Reduce variations in quality of services offered to patients with identical needs (between areas, age, gender, ethnicity, disability)
Reduce costs to individual
Take account of affordability and indirect costs (day of work, childcare)
Ensure health service info on availability and type of service is known with equal clarity
Preferences for services in particular locations/times
Community and cultural attitudes and norms

107
Q

Define rough sleeper

A

People sleeping, about to bed down or actually bedded down in the open air

People in buildings or other places not designed for habitation

Doesn’t include people in hostels or shelters, campsites or other sites used for recreational purposes or organised protest, squatters or travellers

108
Q

Define sofa surfer

A

Staying for short periods with different friends or family because you have nowhere settled to stay

109
Q

Define Hidden homeless

A

People who are homeless but found temporary solutions by staying with family members or friends (sofa surfing), living in squats or other insecure accommodation, cars or night shelters.

110
Q

Outline the statutory homelessness duty

A

Main homelessness duty is owned by a council where the authority is satisfied that the applicant is eligible for assistance unintentionally homeless and falls within a specified priority need group.

111
Q

List those in priority need of statutory homelessness duty

A

Households with dependent children or a pregnant woman

Those who are vulnerable in some way (mental illness or physical disability)

Those aged 16/17 or aged 18-20 who were previously in care

Those who are vulnerable as a result of time spent in care, custody or HM forces

Those who are vulnerable as a result of having to flee their home because of violence or threat of violence.

112
Q

List the structural causes of homelessness

A 
Poverty
Inequality
Housing supply and affordability
Unemployment
Access to social security
113
Q

List the individual causes of homelessness

A 
Poor physical health
Mental health 
Childhood trauma
Refugees
Time in care or prison
Relationship breakdown
Bereavement 
Substance Abuse
Experience of violence
Abuse
Neglect
Harassment
Hate Crime
114
Q

What are the two causes of homelessness

A

Structural

Individual

115
Q

Which demographic is most likely to experience homelessness by the age of 30?

A

Mixed ethnicity females

116
Q

List some health needs of homeless people

A

Attend A&E 6 times as often as housed people
Admitted to hospital 4 times as often
Stay twice as long because they are 2 to 3 times sicker when they arrive.
More likely to have long term physical health problems
More likely to have mental health problems
Much higher use of drugs or to be in recovery

117
Q

List some common health problems of homeless people

A 
2.5x more likely to have asthma
6x more likely to have heart disease
TB rates are 34x higher
Hep C rates 50x higher
Leg ulcers
Dental Problems 
Sepsis
Severe malnutrition
118
Q

Which drugs are used the most illicitly by homeless people

A 
Cannabis (64%)
Prescription Drugs (29%)
Heroin (27%)
Benzodiazepines (18%)
Amphetamines (17%)
119
Q

List some wellbeing factors for homeless people

A

Regular smokers (77%)
Do not eat at least two meals a day (35%)
Only 1-2 Pieces of fruit and veg per day

120
Q

Outline the rules around registering with a GP in England

A

Everyone has the right to register with a GP in England

Do not need a fixed address, ID and your immigration status doesn’t matter

This is often unknown or misunderstood by patients and receptionists

121
Q

List the barriers to health care for homeless people

A 
Prejudice from HCPs
Fear and embarrassment
No phone so unable to book
Inflexible appointment times
No consistent GP
Blacklisted from local GPs
Appointments too short to address all problems
Lack of self-worth
Lack of trust in authority
Lack of trust in medical professionals
Chaotic lives
122
Q

What is the role of HCPs when working with homeless people?

A

Identify risk of homelessness among people who have poor health, and prevent this

Minimise the impact on health from homelessness among people who are already experiencing it.

Enable improved health outcomes for people experiencing homelessness so that their poor health is not a barrier to moving on to a home of their own

123
Q

Outline the Homeless Reduction Act (2017)

A

Some authorities in England have a duty to notify local housing authorities of users they think may be homeless or at risk of homelessness

Duty to Refer

  • Prisons
  • Youth offending teams
  • Probation services
  • Secure training centres
  • Colleges
  • Jobcentre Plus
  • Social service authorities
  • Emergency departments
  • Urgent treatment centres
  • Hospitals in their function of providing inpatient care

If threatened with becoming homeless within 56 days, or a service discloses this, the authority is required to ask customer if they would like to be referred to a local housing authority of their choice.

Public authority is required to make the referral if its agreed on, to the LHA of the reason for referral.

124
Q

How can we alleviate the burden on homeless people?

A 
Listen 
Allow time to discuss issues
Ask about housing when clerking
Refer to local housing authorities
Understand 'drug' slang
Timely methadone prescription
Understand good pain relief prescribing
Promote vaccinations
Promote sexual health
Arrange for district nurse care in temporary accommodation
Be aware of local homelessness and addiction services
125
Q

Top 3 causes of death in Africa (WHO)

A

Infectious

LRTI
HIV/AIDS
Diarrhoeal Disease

126
Q

Top 3 causes of death in Europe (WHO)

A

Non-communicable

IHD
Stroke
Trachea, bronchus, lung cancer

127
Q

Define DALYs

A

Disability Adjusted Life Year

A single measure to quantify the burden of diseases, injuries and risk factors.

Based on years of life lost from premature death and years of life lived in less than full health.

DALYs account for the quantity and quality of life lost due to disease/disability.

Better measure of disease burden than deaths alone.

128
Q

List the global risk factors for infectious disease

A 
Poverty
War
Lack of clean water and food supply
Environment
Under resourced health care services
Lifestyle
Illiteracy
Political instability
International Travel
129
Q

List some zoonoses as a mode of disease transmission

A 
Avian flu 
Bats: COVID-19, Nipah Virus
Ebola
Marburg virus
Borrelia burgdorferi: Lymes Disease
Deer Tick
Mastomys Rodent: Lassa Fever
Hantavirus pulmonary syndrome
130
Q

Outline the source and spread of Ebola

A

Spread by direct contact with blood/bodily fluids of someone who has developed symptoms

Initial infection is spread by infected fruit bats, may also be monkeys, dogs, or pigs.

131
Q

Outline the size of problem, global distribution, and transmission of malaria

A

Transmission

  • caused by parasites of the plasmodium genus
  • most important protozoa infection in the world
  • 4 human species of malaria (P.falciparum, P.ovale, P.malaria, P.vivax)

Global Distribution

  • P. falciparum dominant in Africa and new guinea
  • P. vivax predominates in India, Pakistan, Bangladesh
  • P. ovale and malaria occur mainly in Africa and South America

Problem

  • 300m people contract malaria annually
  • 1 million die
  • mostly children <5 years in sub-saharan Africa
  • 2/3 of reported cases are in Africa, Indian subcontinent, Vietnam and Columbia and Brazil
  • 10,000 - 30,000 people contract in developed countries through foreign travel
  • 2,000 cases annually in UK with 10 deaths
132
Q

Outline the problem and global distribution of TB

A

Most common infectious disease in the world
1/3 of population infected
2.5 million deaths annually
8.7 million new cases
Bulk of infection in south asia (3m) and Africa (2m)
1/3 of patients infected in Africa are co-infected with HIV

133
Q

Outline the source and type of infection of Bilharziasis

A

Blood fluke - trematode infection where worms live in the host’s mesenteric veins for years
Caused by 3 major schistomiasis species
- S.mansoni (Africa, Middle East, South America)
- S.japanicum
- S.haematobium (Africa, Middle East, South America)

Chronic intestinal and hepatic schistomiasis caused by S.mansoni and S.japanicum
Chronic urinary schistomiasis caused by S.haematobium

134
Q

Outline the type of infection, problem, route of transmission and reservoir of Yellow Fever

A

Type of infection

  • Viral disease that is transmitted by several species of mosquito
  • Caused by the yellow fever virus, which belongs to genus flavivirus

Problem

  • Endemic in 10 countries in South America
  • Endemic in 30 countries in sub-saharan Africa
  • Great degree of underreporting
  • WHO estimates 200,000 cases per year
  • 30,000 deaths per year

Route of transmission is mosquito

  • Aedes aegypti
  • Haemogogus spp

Reservoir
- Humans and monkeys

135
Q

Define concordance

A

A negotiated, shared agreement between clinician and patient concerning treatment regimes, outcomes and behaviours.

A more cooperative relationship than those based on issues of compliance and non-compliance.

136
Q

Define Compliance

A

The fulfilment by the patient of the HCPs recommended course of treatment.

137
Q

Define Adherence

A

The extent to which a person’s behaviour (taking meds, following a diet, and/or executing lifestyle changes) corresponds with agreed recommendations from a healthcare provider

138
Q

List the categories of factors affecting concordance

A

Patient-centred/demographic
Psychological
Patient-Prescriber Relationship

139
Q

List the factors of patient-centred/demographic that affect concordance

A

Age

  • Better concordance as patient gets older until disabilities occur
  • Younger patients’ work commitments hamper concordance
  • Adolescents have poor concordance - rebellious behaviour, disagreement with parents and authorities, want to live normal life like friends

Ethnicity, Gender and Education
- Equivocal results, except in adolescents with diabetes

Marriage
- Increases concordance, support from spouse

140
Q

List the Psychological factors that affect concordance

A

Patient beliefs and motivations

  • improved concordance in patients that believe illness poses threat, motivated to take treatment they believe to be effective.
  • Decreased concordance in patients who believe disease is uncontrollable, fear dependence, fear ineffective, religious beliefs, cultural beliefs

Negative attitude towards therapy

  • depression, anxiety, anger towards illness
  • adolescents feel stigmatised and different to peers.
141
Q

List the patient-prescriber relationship factors that effect concordance

A

Communication
Patient trust in prescriber
Empathy of prescriber towards patient

142
Q

How can we improve concordance

A

Patient centres treatment plan
Detailed explanations
Understanding illness and therapy.

Therapy-related

  • Oral route of administration is best
  • Treatment complexity: dosing frequency not quantity
  • side effects
  • degree of behaviour change needed

Socioeconomic

  • Time commitment for appointments
  • 1:10 US seniors cannot afford medication
  • Social support: Friends and family
143
Q

What design does the healthcare system need to adopt to improve concordance?

A

Waiting times, problems accessing treatment and quality of consultation all affect availability and accessibility.

144
Q

How does the type of disease affect concordance?

A

Concordance reduces with

  • fluctuating/absent symptoms e.g HTN
  • severity: adolescents have better concordance with mild asthma

Concordance improves with

  • Marked improvement of symptoms
  • Perceived poor health status
145
Q

What is the importance of concordance in long-term condition management?

A

Concordance needs to be embraced in the healthcare system in order to improve care.

Financial burden from excess urgent care visits, hospitalisation and higher treatment costs.

146
Q

Define Adolescence

A

The period following the onset of puberty, during which a young person develops from a child into an adult.

147
Q

What are the current major global health issues in adolescents?

A

Expected that adolescence would be a period of good health, but higher rate of mortality during adolescence than in early childhood (1-9 years)

Adolescents are learning to manage onset of new conditions and are dealing with long term self-management of existing chronic conditions.

148
Q

Outline the basics of brain development in adolescence

A

Just before puberty, there is exuberant synaptogenesis
- The weaker connections are pruned in several areas of the brain including prefrontal cortex which is responsible for advanced reasoning, understanding cause and effect and impulse management.

149
Q

Define risk behaviours

A

Those that potentially expose people to harm, or significant risk of harm, which are associated with poor health or psychosocial outcomes.

150
Q

How is brain development linked to risk taking in adolescence?

A

Risk taking is a normal part of adolescence

Disparity between the limbic system (risk reward) and prefrontal cortex (impulse control) during early-mid adolescence.

Limbic system matures more quickly that the frontal love explaining why mid adolescents take more risks than older.

151
Q

Outline how self-management and adherence/concordance is associated with risk taking in chronic conditions during adolescence

A

Self-management partially laid down in adolescence
Adolescence is a period of transition to self-management with ups and downs along the way
Lack of concordance a problem
Learn to manage conditions and fit in rather than deliberately destructive behaviour.
Young people manage their condition depending on age, sex, family context and socio-economic position
Some barriers are similar across conditions, other are condition or treatment specific.

152
Q

Why might self-management be difficult in adolescents?

A

Management regimes are difficult and demanding
Self-monitoring is inconvenient and disruptive: social activities take priority
Feel like they are being ‘controlled’
Management regimes make it difficult to ‘fit in’

153
Q

What do young people with chronic conditions want from health services?

A

Treated like a person
Understanding, giving options and encouragement
Don’t force

154
Q

List some non-disease (or social) factors that can contribute to delays in getting a diagnosis in childhood

A

Whether you can access appointment
Parents not engaging with healthcare
Continuity of care
Doctor’s attitudes to family

155
Q

How are decisions to consult related to the way in which a disease presents in childhood?

A

Early diagnosis and prompt referral depends on:

  • Children and parent recognising symptoms as ‘not right’ and presenting
  • Doctors recognising symptoms as being suggestive of something serious.

Consulting behaviour depends on way in which disease presents and way symptoms are interpreted by parents and children.

First suspect something wrong because of range of medical signs/symptoms and/or feelings that child ‘not right’ (crankiness, tiredness, quiet, change in behaviour)

156
Q

State some symptoms with possible innocent explanations in children

A

‘It’s a virus’, ‘growing pains’, ‘wants to get out of school’

Adopt wait and see approach: temporalising of symptomology

Consult if symptoms persist or if feeling that child ‘not right’ doesn’t go away.

157
Q

State some unusual frightening symptoms or events in children

A

Fits, fainting, blood in urine, felt lump in tummy

Tend to interpret these as needing prompt attention

Seek attention promptly

158
Q

Define the term temporalising of symptomatology

A

Use of temporalising strategies
- Place a time limit on signs/symptoms before taking action or making a referral

Use of discrediting strategies
- seeing the parent as lacking credibility ‘mum too anxious’

159
Q

List strategies that parents may use to get a diagnosis

A

Returning repeatedly to see the GP
Using private healthcare
Visiting A&E

160
Q

List the key features of children’s accounts of having childhood cancer

A

Experiences linked to clinical management and social context of children’s lives

Key Features

  • Distressing symptoms
  • Disruption to identity and relationships
  • Uncertainty and fear
  • Strategic Management
161
Q

What are the threats to identity of childhood cancer?

A

Changes to appearance
Received to be different or treated differently
Forms of care associated with infancy
- Bathing
- Toileting
- Feeding
Difficulty maintaining a socially acceptable identity among peers.

162
Q

What evidence of normalisation exists amongst childhood cancer patients?

A

Keep pre-illness lifestyle

Re-designation of illness life as new ‘normal life’

163
Q

List some coping strategies that children with chronic illness adopt

A

Trying to gain self control
- Strategies for adults are not available for children

Older children have more strategies

  • Taking control (CF: pushed into adulthood)
  • Risk taking (CF: way of showing condition has not restricted them)
164
Q

Define a Health Needs Assessment

A

A systematic method of identifying unmet health and healthcare needs of a population and making changes to meet these unmet demands

165
Q

What is the aim of a Health Needs Assessment?

A

Provide information to plan, negotiate, and change services for the better and to improve health in other ways

166
Q

List the objectives of a health needs assessment

A

Change services/activities for the better (effectiveness)
Improve equity (equal resources for equal need)
Target Efficiency (allocate resources to those in need)
Set Priorities
Gather general intelligence on population health/need
Corporate involvement

167
Q

Define Need

A

What people benefit from

A need for medical care exists when an individual has an illness or disability for which there is effective and acceptable treatment or care.

168
Q

Define Supply

A

What is provided

169
Q

Define Demand

A

What people ask for/want

170
Q

Outline the Stevens and Raftery framework for a Health Needs Assessment

A

Epidemiological Approach

  • Epidemiology of health condition and risk factors
  • Evidence of effectiveness and cost-effectiveness
  • Description of current services.

Comparative
- compare service and care between different (but comparable) populations

Corporate (stakeholders and views)
- Ask experts, users, policy makers and any other stakeholders what the issues are and what changes are needed.

171
Q

Strengths and Weaknesses of an epidemiological approach to a health needs assessment

A

Strengths

  • Systematic and objective approach
  • size of problem, what works, current services

Weaknesses

  • Lack of existing local epidemiological data
  • Lack of evidence for certain interventions
  • Carrying out new epidemiological work is costly and time consuming
172
Q

Strengths and Weaknesses of a Comparative approach to a health needs assessment

A

Strengths

  • Usually quick to achieve
  • Inexpensive

Weakness
- Problems of finding a sufficiently similar locality for an accurate comparison

173
Q

Strengths and Weaknesses of a Corporate approach to a health needs assessment

A

Strengths

  • Making the needs assessment responsive to local concerns
  • Fostering “local ownership”

Weaknesses

  • Determines demands rather than needs
  • Stakeholders may be influenced by political agendas
174
Q

List people who would be considered to have a ‘corporate view’ in a health needs assessment

A 
Purchaser
Providers
Professionals
Patients/service users
Press
GP
Politicians
Opinion Leaders
175
Q

Outline the PDSA health needs planning cycle

A

Plan, Do, Study, Act

Plan

  1. Problem identification and desired outcome
  2. Identify most likely causes through data
  3. Identify potential solutions and date needed for evaluation

Do
4. Implement solution and collect data for evaluation

Study
5. Analyse data and develop conclusions

Act
6. Recommend further study and/or action

176
Q

Outline the brief intervention tool for smoking

A

Ask
- ask and record patients’ smoking status, smoker, ex-smoker or never-smoked
Advise
- advise patients on the best ways to stop, most effective way is with a combination of stop smoking meds and support
Act
- Offer all patients who smoke a referral to an effective stop smoking intervention and offering stop smoking meds if appropriate.

177
Q

Outline the brief intervention tool for alcohol

A

Identify
- identify and record alcohol risk using AUDIT-C
Advise
- advise patients who drink above the low-risk level, but are not dependent, about harms and benefits of cutting down
Refer
- those who are identified as possibly alcohol dependent for specialist assessment and support.

178
Q

Which tool is used to assess alcohol use?

A

AUDIT-C

179
Q

Briefly explain what a score on the AUDIT-C relates to and how to act in accordance

A

Low risk (0-4)

  • explain score: low risk of harm
  • Give advice on low risk levels
  • Congratulate patient

Increasing or higher risk (5-10)

  • Explain their alcohol use ay be increasing their risk of ill health
  • Provide brief advice to reduce
  • Give information leaflet

Possible Dependence (11-12)

  • Explain cause for concern
  • Offer a referral to specialist assessment and support and, if they agree, make an active referral.
180
Q

What is a clinical audit?

A

A quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes.

181
Q

Outline research evaluation

A

Designed to derive generalisable new knowledge
Designed to test a hypothesis
Addresses clearly defined questions, aims and objectives
Study design may involve allocation patients to intervention groups
Normally requires research ethics committee review

182
Q

Outline Clinical Audit evaluation

A

Designed and conducted to produce information to inform delivery of best care
Designed to answer ‘does this service reach a predetermined standard’?
Measures against a standard
No allocation to intervention
Does not typically require research ethics committee review

183
Q

Outline Service Evaluation

A

Designed and conducted solely to define or judge current care
Designed to answer ‘what standard does this service achieve’?
Measures without reference to a standards
No allocation to intervention
Doesn’t require research ethics committee review

184
Q

State the purposes of clinical audit

A

Health and Social Care Act 2008
CQC - essential standards of quality and safety
Revalidation for medical staff
Professional standards for individual disciplines
NHS standard contract
Local trusts quality accounts
Monitor compliance framework
Monitoring or current practice alongside guidance
High volume/High cost procedures
Response to serious incidence, risk issue or complaint
Trust/departmental/speciality/local priorities
Re-audits
Quality improvement

185
Q

Outline the elements and stages in a clinical audit cycle

A

Stage 1: Preparation and Planning

  • Select topic
  • identify standards
  • Create Audit Team
  • Agree methodology
  • Develop tool
  • Sample size and selection
  • Carry out pilot test
  • Follow local NHS procedures.

Stage 2: Measuring Performance

  • Information governance issues
  • Ensuring data quality
  • Recording - need for evidence trail
  • Analysing and presenting results

Stage 3: Implementing Change

  • Present and discuss results
  • Discuss issues and recommendations
  • Set realistic goals and timescales
  • Develop an action plan
  • SMART actions

Stage 4: Sustaining improvement including re-audit

  • Complete action plan and evaluate progress
  • Review and implement the actions
  • Discuss areas of concern following data collection/results/feedback
  • Re-audit
  • Is a full re-audit required
  • Targeted audit focusing on key aspects from audit
  • Spin-off audits on areas that have been highlighted as areas of concern
  • Can be a starting point for a service evaluation and research
186
Q

Outline the UK ‘Low Risk’ alcohol guidelines (2016) on Weekly drinking

A

Keep health risks from alcohol to a low level it is safest to not drink more than 14 units a week on a regular basis

If you regularly drink as much as 14 units per week, it is best to spread your drinking evenly over 3 or more days.

If you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days each week.

187
Q

Outline the UK ‘Low Risk’ alcohol guidelines (2016) on single episodes of drinking

A

Limiting the total amount of alcohol you drink on any single occasion

Drinking more slowly, with food, and alternating with water

Planning ahead to avoid problems such as transport home.

188
Q

Outline the UK ‘Low Risk alcohol guidelines (“016) on pregnancy and drinking

A

The safest approach is to not drink alcohol at all, to keep risks to baby to a minimum

Drinking in pregnancy can lead to long-term harm to the baby with the more you drink the greater the risk

189
Q

Outline the CMO Guidance for alcohol consumption in children

A

Children and their parents and carers are advised that an alcohol-free childhood is the healthiest and best option. However, if children drink alcohol it should not be until at least 15.

If young people aged 15 to 17 consume alcohol, it should always be with the guidance of a parent or carer or in a supervised environment.

190
Q

Define Stigma

A

The presence of an attribute that discredits its possessor

191
Q

Define social stigma

A

Attributes, behaviours or pathological states that set people apart from others, that mark them as less unacceptable or inferior beings in some way.

192
Q

What are the 4 forms of social stigma?

A

Enacted
Felt
Discreditable
Discrediting

193
Q

Define Enacted Stigma

A

Real experience of negative attitudes and discrimination

194
Q

Define Felt Stigma

A

Fear that prejudice or discrimination may occur

195
Q

Define Discreditable Stigma

A

Attribute, condition or impairment not immediately obvious or known by many e.g mastectomy

196
Q

Define Discrediting Stigma

A

Obvious and visible attribute, condition or impairment

197
Q

Identify some conditions/impairments with social stigma

A 
Epilepsy
Hearing and visual impairment
HIV and AIDS
Mental Illness
Psoriasis
Physical Impairment
Some cancers (lung)
Alcohol Dependence
Obesity
198
Q

Which forms of stigma would be experienced in lucid mental health periods?

A

Felt

Discreditable

199
Q

Which forms of stigma would be experienced in active periods of mental health?

A

Enacted

Discrediting

200
Q

List strategies used for coping with social stigma

A

Passive (Absorb or accept)
Normalisation (New normal)
Withdrawal (limit engagement)
Active (seek support, challenge stigma)

201
Q

Define the term Learning Disability

A

A condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence.

Cognitive, language, motor, and social abilities

202
Q

List some current terminology relating to learning disability

A

Learning Disability (UK health and social services)
Learning Difficulties (UK Education)
Mental Retardation (Worldwide, USA WHO)
Developmental Disability
Intellectual Disability (current RCPsych term)
Intellectual Development Disorder (DSM-5)

203
Q

List domains of learning disabilities

A

Ranges from mild to severe

  • Mild (IQ 69-50)
  • Moderate (IQ 49-35)
  • Severe (IQ 34-0)
Expressive Language
Comprehension
Non-Verbal Communication
Self-Care
Independent Living
Academic Work
Adult Work
Mobility
Social Development
Associated Deficits
204
Q

What is involved in psychometric assessment of intellectual functioning?

A

Assessment by Educational or Clinical Psychologist
Tests include Wechsler Adult Intelligence Scale IV
Performance on testing can be affected by various factors (motivation, mental illness, fatigue, drugs, alcohol)
Impacts of culture, language, ASD can skew the result

205
Q

What is involved in adaptive functioning and why is it assessed?

A 
Communication
Self-care
Home living
Social Skills
Community Use
Self-direction
Health and Safety
Functional Academics
Leisure
Work

Assesses individual needs to provide for self.

206
Q

Outline the IQ cut-offs of interllectual function

A 
Normal IQ: 100 +- 15
Borderline IQ: 70-84
Mild Learning Difficulty: 50-69 (developmental age 9-12)
Moderate LD: 35-49 (dev age 6-9)
Severe LD: 20-34 (dev age 3-6)
207
Q

Outline the prevalence of learning disabilities

A 
Mild LD 
- 2% general population
- 75% of people with a LD
Moderate LD
- 0.5% general population
- 20% people with a LD
Severe
- 5% people with a LD
Profound
- <0.05% population
- <1% people with a LD
208
Q

State the 3 general causes of learning disability

A

Genetic Factors
Antenatal Factors
Perinatal Factors

209
Q

State the genetic factors that can lead to a learning disability

A

Chromosomal abnormalities present at conception

  • Trisomy 21 (Down’s)
  • Fragile X Syndrome
  • 5p Syndrome
  • Sex chromosome disorders
  • Prader Willi Syndrome

Primary disorder with secondary neurological damage

  • Defective protein metabolism (PKU)
  • Endocrine disorders (congenital hypothyroidism)
  • Neurocutaneous disorders (tuberous sclerosis)
210
Q

State the antenatal factors that can lead to a learning disability

A 
Iodine deficiency
Neural tube defects
Autoimmune (rhesus)
Infectious diseases (TORCH, measles, HIV, Syphilis)
Drugs, alcohol and toxins
211
Q

State the perinatal factors that can lead to a learning disability

A 
Trauma (forceps)
Hypoxia
Hypoglycaemia
Cerebral Thrombosis
Premature/Low birth weight babies are particularly at risk
212
Q

What needs to be taken into account when assessing capacity in people with learning disabilities?

A

Assumption of capacity
LD is an impairment of the mind and as such can interfere with decision making abilities
Capacity is purpose and time specific
Capacity may fluctuate

213
Q

What is required to be considered as having capacity?

A

Understand information related to decision
Retain information for long enough to
- Use and weigh up information to make decision
- Communicate the decision by any means

214
Q

What needs to be considered in a patient that lacks capacity and when a best interest decision needs to be made?

A

Can the decision wait?
Not making assumptions based on disability or other factors
Consult family, carers, any substitute decision makers
Involve the person, consider what you know about them
Refer to IMCA for serious medical treatment
Actions proportionate to need
Decision maker is responsible

215
Q

What is a DoLS?

A

Deprivation of Liberty Safeguards

  • Introduced as an amendment to the 1983 MHS.
  • For those who lack mental capacity and are deprived of liberty in care or in hospital but not subject to mental health legislation.
216
Q

When can you treat a patient without consent?

A

When an emergency arises in a clinical setting and it is not possible to find out a patient’s wishes.

Can treat providing the treatment is immediately necessary to save their life or prevent serious deterioration of their condition.

Least restrictive of the patient’s future choices.

217
Q

How do mental health problems differ between people with learning disabilities and people without?

A

Higher rates of problems in PWLD

  • Dementia 10-25%
  • Psychosis 1-6%
  • Autism 30%

Presentation

  • Depression (less self harm)
  • Mania (flight of ideas)
  • Psychosis (-ve symptoms more than +ve)
  • Anxiety (baseline anxiety, ASD related, LD related)
  • Dementia (mood/personality issues prior to memory and skill decline)
218
Q

What is the multi axial formulation (WHO 1996)?

A

Different domains that are used when assessing patients with a learning disability

Axis I - Severity of learning disability
Axis II - Associated medical conditions
Axis III - Psychiatric disorders (inc ASD)
Axis IV - Assessment of psychosocial disability
Axis V - Abnormal psychosocial situations

219
Q

State some facts about physical health in people with learning difficulties

A

On Average 18 years lower life expectancy for females with LD (14 for males)

By 2021 PWLD aged over 60 expected to increase by 36%

2010-12 inquiry into deaths of PWLD

  • 22% died before 50
  • 42% felt to be premature
  • 43% unexpected
220
Q

Why were annual health checks introduced for people with learning disabilities?

A

Introduced in 2008-09 following formal investigation into health inequalities

Allow for reasonable adjustment of needs

Detection of unmet, unrecognised and potentially treatable health conditions.

221
Q

List some associated health issues related to people with a learning disability

A 
Epilepsy
- increased with level of LD
- 20x higher in PWLD
Sensory impairment
- Visual 20-30%
- Hearing 10-40%
Mental illness (20-40% higher)
Obesity (up to 68%)
Dysphagia
- 5% community
- 36% hospital
- 60% if cerebral palsy
Other eating disorders
- PICA
- Atypical anorexia
- Autistic food fads
GORD (60-90% H.Pylori)
Constipation (up to 69% of LD population)
Dental health (86%)
222
Q

Outline the Learning disability mortality review and its aims

A

Notifying the death and review into the circumstances leading to the death of PWLD aged 4-74

Stages roll-out of LeDeR

Help reduce premature mortality and health inequalities

Reviews of deaths lead to reflective learning

223
Q

How does mortality rate differ between learning disability patients and those without? Why?

A

PWLD have higher mortality rates and rates of preventable death

  • 58x more likely to die before 50
  • 3x higher mortality rate in those with moderate to severe LD
  • 4x more likely to die from preventable death
  • 26% hospitalised compared to 14% of general population
  • Suffer more Accidents
224
Q

List the reasons why patients with learning disabilities may get inferior or inappropriate medical care

A 
Clinician
- Educational needs
- Diagnostic overshadowing
- Personal communication skills
- Legislation awareness (MCA etc)
Service
- Accessibility
- Flexibility of appointments
- Clinical Environment
- User friendly information
Patient
- Cognitive ability
- Communication
- Poor 'Health Literacy'
- Phobia / anxiety (autism)
- Sensory impairment
- Late presentation
Carer
- Health awareness (training issue for paid carers)
- Own cognitive abilities
- Poor 'Health literacy'
225
Q

What is palliative care?

A

An approach that improves quality of life of patients and families facing the problems associated with life-threatening illness

  • Early identification
  • Impeccable assessment
  • Treatment of pain and other problems, physical, psychosocial and spiritual
226
Q

What does life-limiting/life-threatening mean?

A

A life-limiting illness is an illness that cannot be cured and that you are likely to die from

Also known as life-threatening, terminal, progressive or advanced

227
Q

What is involved in a holistic approach to palliative care?

A

Managing pain and other distressing symptoms

Psychological
Social
Physical
Spiritual

Support for patient and family

228
Q

Define End of Life Care

A

Involves treatment, care and support for people who are nearing the end of their life.

For people who are thought to be in the last year of life, but can be difficult to predict.

229
Q

What are the domains used for prevention and relief of suffering

A

Early Identification

  • Early recognition and appropriate discussion
  • Prognostication is difficult

Impeccable assessment
- Person centred approach (what matters, main concerns, what can’t you do, goals)

Treatment of pain and other problems, physical, psychosocial and spiritual

230
Q

What is meant the term total pain?

A

That the amount of pain a person is in is associated with physical, psychological, social and spiritual causes.

231
Q

List and give examples of total pain domains using the Saunder’s Model

A 
Physical Pain
- Physical causes
- Other symptoms
- Adverse effects of treatment
- Co-morbidities
Psychological Pain
- Anger
- Anxiety
- Depression
- Fear of suffering
- Past experience of illness
Spiritual Pain
- Hopelessness
- Finding meaning
- Loss of faith
- Fear of the unknown
- Anger at fate/anger at higher power
Social Pain
- Dependency
- Worry about future of family
- Financial concerns
- Job loss
- Loss of role and social status
232
Q

How many people die in England each year?

A

500,000

233
Q

How many people in the UK will die of cancer

A

1 in 4

234
Q

Why do we need to recognise when a patient is approaching the end of their life?

A

Allow for shared decision making
Prevent unnecessary interventions
Ensure dying persons expressed wished are considered
Avoid misunderstanding and unnecessary distress.

235
Q

How does good communication pf a dying persons prognosis affect their care?

A

Improves end of life care

Improves bereavement experience of those important to them

236
Q

What are the 6 ambitions for Palliative and End of Life care?

A
  1. Each person seen as an individual
  2. Each person gets fair access to care
  3. Maximising comfort and wellbeing
  4. Care is coordinated
  5. All staff are prepared to care
  6. Each community is prepared to help
237
Q

List some worries people have about death

A
  1. Dying in Pain (83%)
  2. Dying Alone (67%)
  3. Being told they are dying (62%)
  4. Dying in hospital (59%)
  5. Going bankrupt (41%)
  6. Divorce/end of relationship (39%)
  7. Losing their job (38%)
238
Q

Why is it hard to recognise that a person is reaching the end of their life?

A 
We want to save lives
Acceptance only when interventions fail
Pressure to provide medically futile treatment (patient/family/society)
Tendency to shy away from dying
Feeling of failure
Lack of experience
Lack of training
Inadequate communication skills
239
Q

What signs are there to help us recognise someone is entering the last days of life?

A 
Signs getting worse day by day or hour by hour
Reduced mobility/bedbound
Extreme tiredness and weakness
Little interest in food or drink
Difficulty swallowing oral meds
Sleepiness and drowsiness
Reduced urine output
Changes in breathing
New incontinence
Increased restlessness
Confusion +/- agitation
No reversible cause for deterioration.
240
Q

What tools can be used to monitor someone’s decline from a chronic disease?

A

Australian-modified Karnofsky Performance Scale (0-100)

  • 0 = death
  • 50 = Considerable assistance and frequent medical care
  • 100 = normal with no complaints or evidence of disease

ECOG Performance Status Scale (Grade 0-5)

  • 0 = fully active, able to carry on all pre-disease performance without restriction
  • 3 = Capable of limited self-care, confined to bed or chair more than 50% waking time
  • 5 = dead
241
Q

Outline the Palliative Care Phase of Illness

A 
Phase 1: Stable
Phase 2: Unstable
Phase 3: Deteriorating
Phase 4: Terminal
Phase 5: Bereavement
242
Q

What question can be asked to assess if a patients is close to the end of their life?

A

The ‘surprise’ question

Would you be surprised in the patient died in the next…

  • 12 months
  • 6 months
  • 1 month
  • Few Days
  • Few hours
243
Q

What needs to be considered when communicating about a patient dying?

A

The earlier the better
Ascertain patients level of involvement in decision and amount of information
Leads to advanced care planning and patients wishes
- Place of care and death
- what’s important
- ascertain and address concerns/questions
- Escalation of care and DNAR discussion.
Important to communicate whilst patient has capacity

244
Q

What needs to be considered when documenting that a patient is dying?

A

The earlier the better
Needs to be shared with all involved in patient care (discuss with patient)
Regular reviews
Made available to all HCPs - avoid repetition
Patient held documentation

245
Q

What is involved in end of life management?

A 
Symptom control
Appropriate medication only - correct dose and route
Stop inappropriate interventions
Rationalise medications
Consider anticipatory drugs
246
Q

Outline and list some examples of Anticipatory Prescribing

A

Prescribing jobs in case a situation arises

  • Pain = Morphine s/c
  • N+V = Levomepromazine s/c
  • Agitation = Midazolam s/c
  • Secretions = hyoscine butylbromide s/c

Requires an authorisation to administer form

247
Q

Define Risk

A

The probability that a hazard will give rise to harm

248
Q

Define Relative risk reduction

A

Reduction of risk in the intervention group relative to the risk in the control group

249
Q

Define Absolute risk Reduction

A

The difference between risk in the intervention and control group

250
Q

Define ‘number needed to treat’

A

The number of patients who need to be treated to prevent on additional adverse outcome

251
Q

How do you calculate relative risk reduction? (RRR)

A

(Control group event rate - Experimental group event rate) / control group event rate *100 for %

RRR=(CER-EER)/CER*100

252
Q

How do you calculate the Absolute Risk Reduction? (ARR)

A

ARR = control event rate - Experimental event rate

ARR = CER - EER

253
Q

How do you calculate the number needed to treat (NNT)

A

NNT = 1 / Absolute risk reduction

OR

NNT = 1 / (CER - EER)

254
Q

Define mismatched framing

A

Using relative risk to point out the benefits but absolute risk for the harms

255
Q

Define ratio bias

A

Use bigger denominators to make it look impressive (5/10 vs 500/1000)

256
Q

Define framing

A

Use the bigger percentage to make your point (chance of winning is 10%, chance of losing is 90%)

257
Q

Define emotional tactics

A

Using smiley faces on a decision aid, groups of faces, red for negatives, DNR vs Allow natural death

258
Q

How do you calculate an absolute risk?

A

AR = number of events in treated or control group / number of people in that group

AR = Events/n

259
Q

How do you calculate a risk ratio?

A

RR = incidence in exposed / incidence in control group

RR = Experimental / Control

260
Q

How do you calculate an odds ratio? (OR)

A

Use a 2x2 table of Treatment and control on the left vertical, Event vs No Event on the horizontal

Treatment + Event = A
Treatment + No Event = B
Control + Event = C
Control + No Event = D

          Event       No Event Treatment   A             B Control       C             D

OR = (AD)/(BC)

261
Q

How do you calculate relative risk?

A

Use a 2x2 table of Treatment and control on the left vertical, Event vs No Event on the horizontal

Treatment + Event = A
Treatment + No Event = B
Control + Event = C
Control + No Event = D

          Event       No Event Treatment   A             B Control       C             D

Relative Risk = [A/(A+B)] / [C/(C+D)]

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