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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2720_Библиотеки_им_академика_М_И_Перельмана
.pdf
154
Physical exercise
and/or cycling (h/wk)
0
Some but <1
1–2.9
≥
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154
CHAPTER7 Healthyliving
Exercise
In the UK, 60% of adults are not active enough to benet their health.
Recommended amounts ofactivity
• Adults:≥30min/ d moderate intensity exercise on ≥5d/ wk
• Children:≥1h/ d moderate intensity exercise every day
Assessing levels ofphysicalactivity See Figure 7.3. Use a validated
tool to assess levels of physical activity, e.g. General Practitioner Physical
Activity Questionnaire (GPPAQ).
Health benets ofexercise Regular physical activity:
d riskof
• DM— through i insulin sensitivity
• Obesity— E p. 152
• Cardiovascular disease— physically inactive people have ~2× i risk of
CHD and ~3× i risk of stroke
• Osteoporosis— exercise d risk of hip fractures by ½
• Cancer— exercise d risk of colon cancer by ~40%. There is also evidence
of a link between exercise and d risk of breast and prostate cancers
Is a useful treatmentfor
• i BP— can delay onset of hypertension, and result in 10mmHg drop of
systolic and diastolic BP in people with established hypertension
• Hypercholesterolaemia— exercise results in i high- density lipoprotein
(HDL), and d low- density lipoprotein (LDL)
• Cardiac rehabilitation (E p. 230) and COPD (E p. 286)
• DM— exercise improves insulin sensitivity and favourably aects other
risk factors for DM, including obesity, HDL/ LDL ratio, and i BP
• Arthritis and back pain— exercise maintains function
• Mental illness— exercise d intensity of depression and d anxiety
Benets fortheelderly
• Maintains functional capacity • d levels of disability
• d risk of falls and hip fracture • Improves quality of sleep
Occupation
Sedentary Standing Physical Heavy
Inactive Moderately
Moderately
inactive
Moderately
3 Active Active Active Active
Figure7.3 Physical activity index (PAI) derived from the GPPAQ
Reproduced from Department of Health and Social Care. The General Practice Physical Activity
Questionnaire (GPPAQ). © Crown copyright. Available at https:// assets.publishing.service.gov.uk/
government/ uploads/ system/ uploads/ attachment_ data/ le/ 192453/ GPPAQ_ - _ guidance.pdf.
Contains public sector information licensed under the Open Government Licence v3.0.
active
inactive
Moderately
active
Active Active Active
Moderately
active
Active Active
manual
Active
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Figure7.4 Management plan for increasing activity levels
Eectiveinterventions
• Healthcare counselling Is as eective as more structured exercise
sessions (see Figure 7.4). Specialist rehabilitation schemes are available
for patients with specic conditions (e.g. post- MI, COPD); exercise
schemes operate in some areas, oering low cost, supervised exercise
for patients who might otherwise nd it unacceptable to visit a gym and
are accessed via GP ‘prescription’; many sports facilities oer special
sessions for pregnant women, the over- 50s, and people with disability
• Workplace interventions To i rates of walking to work are eective
• Schools Appropriately designed and delivered physical education
curricula can enhance physical activity levels. Awhole- school approach
to physical activity promotion is eective
• Transport Well- designed interventions i walking/ cycling to work
• Communities Community- wide approaches i activity
Further information
DH (2011) UK physical activity guidelines M www.gov.uk/ government/
publications/ uk- physical- activity- guidelines
NICE (2013) Physical activity:brief advice for adults in primary care. M
www.nice.org.uk/ guidance/ ph44
EXERCISE
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CHAPTER7 Healthyliving
Smoking
Facts andgures In England, 21% of adults (♂ 21%; ♀ 20%) smoke.
Prevalence is highest amongst those aged 20– 24y (32%) and lowest aged
>60y (12%). 6% of school children aged 11– 15y are regular smokers
(♀10%; ♂ 8%). Surveys of smokers show 73% want to stop and 30% intend to give up in <1y— but only ~2%/ y successfully give up permanently.
Risks of smoking Smoking is the greatest single cause of illness and
premature death in the UK. Half of all regular smokers will die as a result of
smoking— 106,000 people/ y. Smoking is associated with i risk of:
• Cancers ~29% of all cancer deaths. Common cancers include:lung
(>90% are smokers); lip; mouth; stomach; colon; bladder
• Cardiovascular disease CHD, CVA, peripheral vascular disease
• Chronic lung disease COPD, recurrent chest infection, exacerbation of
asthma (29% of respiratory deaths result from smoking)
• Problems in pregnancy PET, IUGR, preterm delivery, neonatal and late
fetal death
• DM • Thrombosis
• Osteoporosis • Dyspepsia ± gastric ulcer
Passive smoking is associatedwith
• i risk of coronary heart disease and lung cancer (i by 25%)
• i risk of cot death, bronchitis, and otitis media in children
Helping people tostopsmoking Advice from a GP results in 2% of
smokers stopping— 5% if advice is repeated. See Figure 7.5.
Aids tosmoking cessation
Nicotine replacement therapy (NRT) i the chance of stopping ~1½×. All pre-
parations are equally eective. Start with higher doses for patients highly dependent. Continue treatment for 3mo, tailing o dose gradually over 2wk
before stopping (except gum which can be stopped abruptly). Contraindicated
immediately post- MI, stroke, or TIA, and for patients with arrhythmia.
Bupropion Smokers (>18y) start taking the tablets 1– 2wk before intended
quit day (150mg od for 3d, then 150mg bd for 7– 9wk). i cessation rate>2×.
Contraindications:epilepsy or i risk of seizures, eating disorder, bipolar disorder.
Varenicline Smokers (>18y) start taking the tablets 1wk before intended
quit day (0.5mg od for 3d, 0.5mg bd for 4d, then 1mg bd for 11wk). d dose
to 1mg od if renal impairment/ elderly. i cessation rate >2×. If the patient
has stopped smoking after 12wk, consider prescribing a further 12wk treatment to d chance of relapse. Contraindications:caution in psychiatric illness.
e- cigarettes Heat a liquid (usually comprising propylene glycol and glycerol ±
avours) into an aerosol for inhalation. Vary in nicotine content from none to
>20mg/ mL. Although good- quality evidence is currently lacking, the general
consensus is that e- cigarettes do i smoking cessation rates— both through nicotine replacement, and by addressing sensory/ behavioural aspects of smoking
addiction. e- cigarettes are not licensed as medicines currently and are not available on NHS prescription. Long- term eects of ‘vaping’ are as yet unclear.
Alternative therapies Hypnotherapy may be helpful in some cases.
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SMOKING
Remind smokers of the importance of stopping smoking
with leaets and posters around the surgery
Assess smoking status of all patients at least 1×/y if possible
If smoking
Advise smokers to stop
Assess willingness to change
If not
willing to stop
Record advice given to stop smoking
Give the patient an advice leaet to
take away
Repeat advice to stop smoking whenever
the patient is seen in the GP surgery
Nicotine withdrawal symptoms:
Urges to smoke (70%)
Increased appetite (70%—mean 3–4kg
weight
i)
Depression (60%)
Restlessness (60%)
If willing
to stop
Oer to refer to the smoking
cessation clinic
Help the patient to set a quit date
Advise the patient to stop smoking
completely on the quit date ‘not even one
pu’
Recommend nicotine replacement
therapy, buproprion, varenicline or
e-cigarettes
Consider oering a follow-up
appointment to check progress
Support the information given with an
advice sheet
Poor concentration (60%)
Irritability/aggression (50%)
Night-time wakening (25%)
Light-headedness (usually just the rst
few days after quitting) (10%)
Figure7.5 Suggested management plan for smoking cessation
Support In many areas, ‘stop smoking’ services are provided by PCOs.
These programmes consist of a combination of group education, counselling ± individual support in combination with nicotine replacement, bupropion, varenicline, or e- cigarettes.
Prescribing smoking cessation medication Prescribe only for
smokers who commit to a target stop date. Initially, prescribe only enough
to last 2wk after the target stop date, i.e. 2wk nicotine replacement therapy,
3– 4wk bupropion, or 3wk varenicline. Only oer a second prescription if
the smoker demonstrates continuing commitment to stop smoking. 0 If
unsuccessful, the NHS will not fund another attempt for ≥6mo.
Smokeless tobacco Misri India tobacco, qimam, naswar, gul, khaini,
gutkha, zarda, mawa, Manipuri, or betel quid with tobacco. Particularly used
in South Asian communities. Carries risk of nicotine addiction, CVD, dental
disease, and mouth/ throat cancer. Provide brief advice to stop; consider NRT.
Further information
Hartmann- Boyce J, etal. (2018) Electronic cigarettes for smoking cessa-
tion. BMJ 360:j5543.
NICE (2012) Smokeless tobacco cessation:South Asian communities.
Mwww.nice.org.uk/ guidance/ ph39
NICE (2018) Stop smoking interventions and services. M www.nice.org.
uk/ guidance/ ng92
Useful contacts
Action on smoking and health (ASH) M www.ash.org.uk
NHS Smokefree M www.nhs.uk/ smokefree
Quit F 0800 00 22 00 M www.quit.org.uk
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CHAPTER7 Healthyliving
Alcohol
‘An alcoholic is someone you don’t like who drinks as much as you do’
Dylan Thomas (1914– 1953)
Alcohol misuse is a major public health and social concern. Alcohol- related
problems cost the NHS ~£1.7 billion/ y. Most harm is caused by nondependent drinkers. Screening (Figure 7.6) and brief interventions in primary care can identify drinkers in this group and d consumption and harm.
What is a unit ofalcohol? 1 unit=10mL (or 8g) of pure alcohol. It is
the amount of alcohol that an adult can process in ~1h— though speed of
elimination does vary. It can be calculated. The ‘alcohol by volume’ (ABV)
is stated on the packaging of all alcoholic drinks sold in the UK. Calculating
units from ABV:number of units=ABV × volume (mL) ÷ 1000. As a rough
guide, 1 unit 8 ½ pint of beer, a small glass of wine, or a single shot of spirit.
Recommendedlimits ≤14U/ wk for ♂ and ♀.
Prevalence ofalcoholmisuse
• Hazardous/ harmful drinking— excess drinking causing potential or
actual harm but without dependence— aects 32% ♂; 15% ♀
• Binge drinking (>8U for ♂ or >6U for ♀ in 1d)— aects 21% ♂; 9% ♀
• Alcohol dependence— aects 6% ♂; 2% ♀
Alcohol and health Moderate consumption (1– 3U/ d) may d risk
of non- haemorrhagic stroke, angina, and MI— but overall risks >> benets. Risk depends on other factors too (e.g. smoking, heart disease).
Potential harms:
Death 15,000– 22,000 deaths/ y in the UK are associated with alcohol
misuse— most related to stroke, cancer, liver disease, accidental injury/ suicide.
Physical health
• Obesity (high
caloriecontent)
• Fatty liver
• Hepatitis
• Cirrhosis
• Liver cancer
• Oesophageal varices
± haemorrhage
• Gastritis
• Pancreatitis
• i BP
• CVA
Mental health Anxiety, depression, and/ or suicidal ideas; dementia and/ or
Wernicke’s encephalopathy ± Korsako’s syndrome (E p. 553).
Social harms ofalcohol
• Marriage breakdown • Povert y • Social isolation
• Loss of work • Absence from work • Loss of shelter/ home
• DM
• Cancer of the mouth,
larynx, and oesophagus
• Breast cancer
• Haemopoietic toxicity
(i MCV)
• Nutritional deciencies
• Neuropathy
• Myopathy
• Cardiomyopathy
• Poor sleep
• Tiredness
• Brain damage
• Sexual dysfunction
• Infertility
• Fetal damage
• Back pain
• Interactions with
prescribed drugs
• Injuries due to
alcohol- related
activity (e.g. ghts)
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Questions
1) How often do you have a drink containing alcohol?
Scoring: 0
2) How many drinks containing alcohol do you have on a typical day
when you are drinking?
Scoring: 0
3) How often do you have 6 or more drinks on one occasion?
4) How often during the last year have you found that you were not able
to stop drinking once you started?
5) How often during the last year have you failed to do what was
normally expected of you because of drinking?
6) How often during the last year have you needed a rst drink in the
morning to get yourself going after a heavy drinking session?
7) How often during the last year have you had a feeling of guilt or
remorse after drinking?
8) How often during the last year have you been unable to remember
what happened the night before because of your drinking?
Scoring:
9) Have you or someone else been injured because of your drinking?
10) Has a relative, friend, doctor or other health care worker been
concerned about your drinking or suggested that you cut it down?
Scoring:
Questions assessing
hazardous alcohol use
Action*
Audit score 0–7
Audit score 8–15
Audit score 16–19
Audit score 20–40
* Provide the next highest level of intervention to patients who score ≥2 on
Questions 4, 5 and 6, or 4 on Questions 9 or 10.
Never
1×/mo
1
2–4×/mo
2
1 or 2 drinks
1
3 or 4 drinks
2
5 or 6 drinks
0
Never
1
<1×/mo
2
Monthly
0
No
2
Yes – but not in the last year
4
Yes – in the last year
Questions assessing
dependence symptoms
Alcohol education
Alcohol education + simple advice
Simple advice + brief counselling + continued monitoring
Referral to specialist alcohol services for evaluation and
treatment
2–3×/wk
3
≥4×/wk
4
347–9 drinks
≥10 drinks
34Weekly
Daily or almost daily
Questions assessing
harmful alcohol use
ALCOHOL
159
Figure7.6 The alcohol use disorders identication test (AUDIT)
Reproduced with permission from Babor, T.F.etal. The Alcohol Use Disorders Identication
Test:Guidelines for Use in Primary Care, second edition. Geneva, Switzerland:World Health
Organization. Copyright © World Health Organization 2001. https:// www.who.int/ substance_
abuse/ publications/ audit/ en/
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CHAPTER7 Healthyliving
Management ofalcoholmisuse
Assessing foralcoholmisuse
Screening Ask patients directly about their alcohol use. Use standardized
questionnaires to identify patients with harmful and hazardous patterns of
alcohol consumption, e.g. AUDIT (Figure 7.6, E p. 159).
Suspicious signs/ symptoms i or uncontrolled BP; obesity; recurrent injuries/
accidents; non- specic GI complaints; back pain; poor sleep; tiredness.
Riskfactors
• Previous personal history of
alcohol misuse
• Family history
• Poor social support
• Work absenteeism
Examination Smell of alcohol, tremor, sweating, slurring of speech, i BP,
signs of liver damage.
Investigations FBC (i MCV); LFTs (i GGT in ~25% of heavy drinkers;
iAST; i bilirubin). USS— fatty liver/ cirrhosis. Often incidental ndings.
Alcohol anddriving Advise patients who persistently misuse alcohol
that they must stop driving and notify the DVLA. Licence is revoked until
≥6mo of abstinence/ controlled drinking (≥1y if Group 2 licence) and
normalization of blood parameters.
Alcohol management strategies (Figure 7.7) For patients drinking
within acceptable limits, rearm the limits. If misusing alcohol:
Non- dependent drinkers Brief GP intervention d drinking in ~24%. Present
results of screening interventions, e.g. AUDIT (E p. 159), and identify risks.
Provide information about safe amounts of alcohol and harmful eects of
exceeding these. Assess whether the patient is receptive to change. If so,
agree targets to d consumption, encourage, and negotiate follow- up.
Alcohol- dependent drinkers Suer withdrawal symptoms if they d alcohol
consumption (e.g. anxiety, ts, delirium tremens— E p. 1103).
• If wanting to stop drinking— refer to the community alcohol team; suggest
self- help organizations, e.g. Alcoholics Anonymous; involve family/ friends
• Detoxication in the community usually uses a reducing regimen of
chlordiazepoxide over a 1wk period. Various regimens are used e.g. 20–
30mg qds on days 1 and 2; 15mg qds on days 3 and 4; 10mg qds on day
5; 10mg bd on day 6; 10mg od on day 7 then stop
If ambivalent/ unwilling to change Provide information; reassess and reinform on each subsequent meeting; support the family.
Vitamin Bsupplements People with chronic alcohol dependence are
frequently decient in vitamins, especially thiamine— give oral thiamine indenitely (if severe, 200– 300mg/ d; if mild, 10– 25mg/ d). During detoxication in the community— give thiamine 200mg od for 5– 7d.
Relapse Common. Warn patients; encourage to re- attend. Be sup-
portive. Maintain contact (d frequency and severity of relapses). Consider
drugs to prevent relapse, e.g. acamprosate, disulram (specialist initiation).
Deliriumtremens E p. 1103
• Emotional and/ or family problems
• Financial and legal problems
• Drug problems
• Alcohol associated with work,
e.g.publican
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MANAGEMENT OFALCOHOLMISUSE
Assess the amount of alcohol patients are drinking on a regular basis when they
Ask any patients presenting with symptoms/signs which could be associated with
excessive alcohol consumption about the amount of alcohol they drink
Drinking within acceptable limits
Rearm safe drinking limits
• Record advice given to
• Give the patient an advice leaet
• Record advice to cut down whenever
the patient is seen in the surgery
Suggest the patient keeps a diary of alcohol
are seen in the surgery for other reasons
(≤14U/wk)
d alcohol
Non-dependent drinker
Provide advice
consumption
Agree targets and follow-up
and
Drinking excessively
NO
Dependent drinker
Provide advice
Refer to the community
alcohol team
Consider detoxication
Figure7.7 Alcohol management strategy
• Community detoxication is contraindicated for patients with:
• Poor home environment
• Poor cooperation
• Previous failed detoxication at
home
• History of previously complicated
withdrawal (e.g. withdrawal
seizures or delirium tremens)
• i risk of suicide
• Uncontrollable withdrawal
symptoms
• Confusion or hallucinations
• Epilepsy or ts
• Malnourishment
• Severe vomiting/ diarrhoea
• Acute physical/ psychiatric illness
• Multiple substance misuse
Further information
DVLA Assessing tness to drive— a guide for medical professionals. M www.gov.uk/ government/ publications/
assessing- tness- to- drive- a- guide- for- medical- professionals
NICE (2010, updated 2017)Alcohol use disorders:diagnosis and management of physical complications. M www.nice.org.uk/ guidance/ cg100
NICE (2010) Alcohol use disorders:prevention. M www.nice.org.uk/
guidance/ ph24
NICE (2011) Alcohol use disorders:diagnosis, assessment and management. M www.nice.org.uk/ guidance/ cg115
WHO Alcohol Use Disorders Identication Test (AUDIT):guidelines for use
in primary care. M www.who.int/ substance_ abuse/ publications/ audit/ en/
WHO Brief Intervention for Hazardous and Harmful Drinking:a manual for use
in primary care. M www.who.int/ substance_ abuse/ publications/ audit_ sbi/ en/
Patient advice and support
ADFAM Support for families. M www.adfam.org.uk
Alcoholics Anonymous F 0800 9177 650 M www.alcoholics- anonymous.org.uk
Drinkline (government- sponsored helpline) F 0300 123 1110
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(≥14U/wk)
Willing to
change?
YES
161
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CHAPTER7 Healthyliving
Assessment ofdrugsmisuse
14% of ♂ and 8% of ♀ aged 16– 59y report taking illicit drugs in the past year.
The majority of patients on treatment programmes report opioid misuse
(heroin— 54%; methadone— 13%), but the most frequently abused drugs
are cannabis, amphetamine, ecstasy, and cocaine. Three factors appear important:availability of drugs; vulnerable personality; and social pressures—
particularly from peers. Commonly misused drugs— Table7.5, E p. 164.
Controlled drugsregulations E p. 124
Legal highs New psychoactive substances (NPS) (‘legal highs’, ‘illegal
legals’, or ‘illegal highs’) are substances designed to produce similar eects
to controlled drugs (e.g. cannabis, cocaine, and ecstasy), but structurally
dierent enough to avoid being subject to the Misuse of Drugs Act. The UK
Psychoactive Substances Act (2016) bans manufacture, import/ export, or
supply of NPS. Possession of NPS is not an oence.
Detection Warning signs suggesting drug misuse:
Use ofservices Suspicious requests for drugs of abuse (e.g. no clear medical
indication, prescription requests are too frequent).
Signs andsymptoms
• Inappropriate behaviour
• Lack of self- care
• Unexplained nasal discharge
• Unusually constricted/ dilated pupils
Social factors Family disruption, criminal history.
Assessment Assess on >1 occasion before deciding how to proceed.
Exceptions are severe withdrawal symptoms and/ or evidence of an established regimen requiring continuation. Points to cover:
Generalinformation
• Check identication (ask to see an ocial document)
• Contact with other agencies (including last GP)— check accuracy
• Current residence:family— partner, children
• Employment/ nances
• Legal problems/ criminal behaviour— past and present
History ofdrug use/ risk- takingbehaviour
• Reason for consulting now and willingness to change
• Current and past usage • Knowledge of risks
• Unsafe sexual practices
Medical and psychiatrichistory
• Complications of drug abuse, e.g. HIV, hepatitis, accidents
• General medical and psychiatric history and examination
• Alcohol abuse • Overdose— accidental/ deliberate
Investigations
• Consider urine toxicology to conrm drug misuse
• Consider blood for FBC, LFTs, hepatitis B/ C, and HIV serology (with
consent and counselling— E p. 720), and other tests according to
medical history/ examination
• Evidence of injecting (e.g.
marked veins)
• Hepatitis B/ C or HIV infection
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ASSESSMENT OFDRUGSMISUSE
• Specic drugs See Table7.5, E p. 164. 0 Gabapentin/ pregabalin are
increasingly being used as drugs of abuse, particularly in prisons
Preventing prescription drugdependence
• Benzodiazepines and z- drugs E p. 169
• Opioids E p. 167
Prescribing fordrugmisusers Approach with special caution. Some
controlled drugs can be dispensed to substance misusers in instalments
providing they are prescribed on special NHS prescription forms (FP10
MDA— England; WP10 MDA— Wales; GP10— Scotland; HS21— Northern
Ireland). The prescription species:number of instalments; intervals between instalments and, if necessary, instructions for supplies at weekends
or bank holidays; total quantity of controlled drug providing treatment for
a period ≤14d; and quantity to be supplied per instalment. As a general
principle, substitute opioid medicines are prescribed in daily instalments. 0
The prescription must be dispensed on the date on which it is due.
Other equipment for drug misusers Doctors, pharmacists, and
drug workers may provide supplies of alcohol swabs, sterile water (≤10
ampoules of 2mL or less), mixing utensils, lters, and citric acid to drug misusers for the purposes of harm reduction.
Notication ofdrugmisusers Patients who start treatment for drug
misuse in the UK in specialized drug treatment centres have their details
passed anonymously to national drug monitoring services. All types of
problem drug misuse are reported. Databases cannot be used as a check
on multiple prescribing as data are anonymized.
Driving and drugsmisuse E p. 99
Overdose E p. 1098
Travelling abroad withcontrolleddrugs E p. 125
0 The RCGP Substance Misuse Unit provides certicate courses in management of drug and alcohol misuse. M www.rcgp.org.uk
163
Further information
DH (2017) Drug misuse and dependence:UK guidelines on clinical
management. M https:// www.gov.uk/ government/ publications/
drug- misuse- and- dependence- uk- guidelines- on- clinical- management
Advice and support forpatients and their families
ADFAM Support for families M www.adfam.org.uk
Benzodiazepines M www.benzo.org.uk
Drugs- info M www.drugs- info.co.uk
Drugwise M www.drugwise.org.uk
Know the Score (Scotland) F 0800 587 5879 M www.knowthescore.info
Solvent abuse F 01785 810762 M www.re- solv.org
Talk to FRANK (England and Wales) Government- run information, ad-
vice, and referral service. F (24h) 0300 123 6600 M www.talktofrank.com
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