Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2720_Библиотеки_им_академика_М_И_Перельмана
.pdf
174
https://t.me/med1917
174
CHAPTER8 Chronic disease and elderlycare
Multimorbidity
Denition and statistics Multimorbidity refers to the presence of ≥2
long- term health conditions in a single individual. It is common:1 in 6 patients in the UK has >1 QOF condition; 65% of people >65y and 82% of
those aged >85y have ≥2 conditions (♀ > ♂). However, although prevalence of multimorbidity i with age, multimorbidity can aect all age groups.
It is much more common in socially deprived populations and complexity
tends to increase the more conditions a patient has.
Challenges ofmultimorbidity
Single disease guidelines Since the early 1990s, a plethora of guidelines have
been produced synthesizing research around single disease entities into
‘best practice’ that we have learned to follow rigidly. However, most research is carried out on populations without co- morbidities, so may not
be applicable to patients with multimorbidity. Rigid adherence to guidelines
for patients with multimorbidity can lead to polypharmacy with subsequent
adverse eects, and conicting treatment targets/ advice.
Condition overlap Some conditions have similar symptoms and signs, resulting in diagnostic overlap. For example, breathlessness may be due to
heart failure or COPD. One condition may also have an impact on another.
For example, chronic pain can result in worsening of depression. This
makes unravelling a patient’s medical problems very dicult.
Polypharmacy It is easy to keep adding medication as new guidelines are
released, to reach performance targets or as patients present with symptoms. It is much harder to stop medication. The more medication a patient
is taking, the greater the risk of interactions between medications and adverse eects— E p. 194.
Medical complexity In a traditional GP appointment, the GP works alone
and has 10min to assess the patient and formulate a management plan.
That is simply not enough time for highly complex patients with multiple
interacting and interdependent problems, requiring a holistic multidisciplinary approach. Time pressure can result in inadequate assessment and/ or
disengagement of the patient/ carers.
High use of services Patients with multimorbidity use more GP appointments, take more medication, have more outpatient hospital appointments,
and are likely to be admitted to hospital both for routine and emergency
reasons.
Disorganization/ fragmentation of care The medical model of care uses a
systems- based approach. Early specialization of doctors has resulted in silo
working. Patients with multimorbidity are frequently under review by several dierent specialist medical teams resulting in mixed messages and prioritization of some of their problems over others, regardless of whether
these are priorities for the patient. Even in primary care, it is common for
patients with multimorbidity to be asked to attend multiple chronic disease
reviews in the same practice.
Patient burden Multimorbidity is a huge burden for patients and carers. They
may have to attend multiple appointments and manage complicated drug
https://t.me/med1917
MULTIMORBIDITY
regimens as well as dealing with the eects of their illnesses and side eects
of treatment. Multimorbidity is associated with poorer quality of life and i
risk of anxiety and depression.
Identifying patients at risk of adverse events
with ≥2 conditions need additional support. As multimorbidity is common,
it is important to focus resources on those who are most at risk of adverse
events. Consider:
• Patients at high risk of unplanned/ care home admission Computer
algorithms aid identication e.g. Electronic Frailty Index (eFI), QAdmissions,
Predicting Emergency Admissions Over the Next Year (PEONY)
• Number of regular prescribed medications In general, patients taking
>15 regular prescribed medications are at high risk; those taking 10– 14
medications are at moderate risk
• Frailty (E p. 190) Assess using:gait speed (>5sec to walk 4m), self-
reported health status on a 0– 10 scale (<6 suggests frailty), or formally
validated tools, e.g. PRISMA- 7 questionnaire (a score of ≥3 suggests i
risk of frailty and the need for further review)
N
Not all patients
Holistic approach tomanagement ofmultimorbidity
• For patients at high risk of adverse events, consider longer review
appointments and try to ensure continuity, e.g. with a named GP
• Coordinate care in the practice, e.g. routine blood tests all done at
the same time; all routine chronic disease reviews during the same
appointment; quantities of repeat medicines and review dates aligned
• List conditions and problems from the patient’s/ carer’s perspective
• Explore how the person’s health conditions and treatments interact and
how this aects quality of life
• Discuss the patient’s goals, health priorities, and treatment preferences—
this may also include advance care planning decisions (E p. 97)
• Discuss benets and risks of following recommendations from guidance
on single health conditions; review medications/ treatments weighing
risks vs benets of each with the patient
• Explore ways to i quality of life by d treatment burden, adverse events,
and unplanned care; focus on solving problems and symptom control;
be alert for depression— consider screening (E p. 173)
• Create a care plan and share this across the multidisciplinary team
highlighting the person responsible for coordination of care; ensure
that the patient and carers understand the plan and know what to do if
anything changes and in emergency situations
• Review the patient and care plan regularly
Further information
Cassell A, etal. (2018) The epidemiology of multimorbidity in primary
care:a retrospective cohort study. BJGP 68:e245– 51.
NICE (2016) Multimorbidity:clinical assessment and management. M
www.nice.org.uk/ guidance/ ng56
PRISMA- 7 questionnaire M www.cgakit.com/ fr- 1- prisma- 7
Wallace E, etal. (2015) Managing patients with multimorbidity in primary
care. BMJ 350:h176.
175
ALGRAWANY
176
https://t.me/med1917
176
CHAPTER8 Chronic disease and elderlycare
Genetics andgenomics
There are 46 chromosomes— 22 matching pairs with matching genes (autosomes) and 1 pair of sex chromosomes which may match (XX— ♀) or
dier (XY— ♂). Genetics refers to the study of individual genes. Genomics
refers to a person’s entire genetic code— their genome. There are many
ways in which variations in our genetic make- up result in disease.
Changes inchromosomenumber
• Alteration in number of chromosomes e.g. Down’s syndrome (extra
chromosome 21)
• Sex chromosome abnormalities— a sex chromosome is duplicated or
deleted, e.g. Turner’s syndrome (XO); Klinefelter’s syndrome (XXY
or XXYY)
Gross structural changes inchromosomes
• Translocation Part of one chromosome is transposed or translocated
onto another. If no genetic information is lost there is no clinical eect
(balanced translocation), although ospring often have problems. 6% of
children with Down’s syndrome have a translocation
• Deletion Loss of a portion of chromosome, e.g. cri- du- chat syndrome
(deletion of the short arm of chromosome 5)
Single geneabnormalities
Autosomal dominant inheritance (Figure 8.1) >1000 diseases all individually
rare. Heterozygotes have the disease; 1 in 2 pregnancies of an aected individual are aected— usually ♂=♀. Expression of the gene may vary, e.g.
tuberous sclerosis (E p. 840); Marfan’s syndrome (E p. 253); myotonic
dystrophy (E p. 550); neurobromatosis (E p. 552). Occasionally genes
may be co- dominant and both the gene inherited from the mother and the
gene inherited from the father are expressed simultaneously, e.g. blood types.
Autosomal recessive inheritance (Figure 8.2) >700 diseases that only manifest in the homozygote. Heterozygotes may be asymptomatic or have
milder abnormalities. To develop severe disease, the aected gene must
be inherited from both parents. The risk of an aected pregnancy is 1 in
4— usually ♂ =♀. Aected individuals have unaected children unless
their partner is a heterozygote Examples: sickle cell disease (E p. 645);
thalassaemia (E p. 644); cystic brosis (E p. 300).
Sex- linked disorders (Figure 8.3) ~100 are recognized. Most are recessively inherited from the mother and aect only ♂ ospring. A ♂ child
of a heterozygote mother has a 1 in 2 chance of developing the disease; a
♀child has a 1 in 2 chance of being a carrier. Examples:fragile X syndrome
(E p. 840); haemophilia (E p. 646), red- green colour blindness (E p.
948), Duchenne’s muscular dystrophy (E p. 550).
Mitochondrial disorders There are many thousands of mitochondria
in each cell. Mitochondria have their own DNA (mtDNA). Mitochondrial
conditions aect ♂ and ♀ equally. They result from mutations in mtDNA
which can only be inherited from an aected ♀, and so are always passed
through the female family line. Example:Leber’s optic atrophy.
https://t.me/med1917
GENETICS ANDGENOMICS
Figure8.1 Autosomal dominant
inheritance
Figure8.3 Sex- linked recessive inheritance
Illustrations courtesy of National Librar y of Medicine (US). Genetics Home Reference. https:// ghr.
nlm.nih.gov/ gallery
Figure8.2 Autosomal recessive
inheritance
New mutations Not all who present with a genetic condition have a
family history. Often, a new genetic mutation will arise either when the egg/
sperm is formed, or at the embryonic stage.
Polygenic inheritance All diseases result from a combination of genetic
and environmental factors. Variations in dierent parts of an individual’s
genome might i or d the chances of developing many common diseases
such as cancer, diabetes, or heart disease.
Cancer genes (oncogenes) Alterations in the genetic make- up of
cancer cells. Usually control cell division/ multiplication. Not inherited.
Identication of faulty tumour genes can potentially facilitate choice of
cancer treatment and improve eectiveness/ prognosis.
Personalized medicine This is a move away from a ‘one- size- ts- all’
approach to management of disease. Recent advances in genomic medicine
(both in terms of testing and mapping of the human genome) now enable
us to integrate information from the individual’s genomic code together
with the patient’s history to help us better identify those at risk of disease,
and target management options to improve treatment outcomes.
177
ALGRAWANY
178
https://t.me/med1917
178
CHAPTER8 Chronic disease and elderlycare
Medically unexplainedsymptoms
Medically unexplained symptoms (MUS) are physical symptoms for which
no organic cause can be demonstrated. GPs deal with MUS in about 25% of
consultations and MUS cost the NHS £3.1 billion/ y. MUS cause disability as
severe as that caused by illness with medically explained causes.
Epidemiology MUS are common throughout the world in all ages. Risk
factors for development of MUS include:
• ♀ > ♂
• Stressful life events, e.g. illness or death of a close relative, domestic
violence, history of child abuse
• Media campaigns that highlight specic diseases
Classication MUS can be divided into 3 types of complaint:
• Pain of a specic location, e.g. back pain, headache, bromyalgia
• Functional disturbance in a particular organ, e.g. IBS, palpitations
• Fatigue/ exhaustion, e.g. chronic fatigue syndrome
Many patients have >1 MUS. There are also common overlaps of symptoms, e.g. patients with IBS often meet diagnostic criteria for chronic pelvic
pain and vice versa.
Concurrent psychological illness 30% of patients with MUS have an
underlying psychiatric problem— usually anxiety or depression.
Underlying mechanism MUS may be caused by a clear trigger, e.g. an
illness or chemical exposure, but 2 mechanisms seem to underpin MUS:
• Enhanced sense of bodily awareness Tendency to notice and amplify
normal physical sensations such as heartbeat. Over- awareness i anxiety
which, in turn, makes the bodily sensation more likely
• Misattribution of symptoms Rather than normalizing symptoms (e.g. I
have a headache because I’ve been working too hard), patients with MUS
tend to attribute somatic explanations (e.g. I have a headache because
Ihave a brain tumour)
Assessment Consider a diagnosis of MUS in any patient with physical
symptoms for >3mo that are aecting functioning but cannot be readily
explained. Even if the patient is known to present with MUS, perform your
assessment without prejudice. Patients with MUS have the same chance of
developing serious new illnesses as any other patient. Ask:
• What are the symptoms? Rule out ‘red ags’
• How much and what type of impairment do the symptoms cause?
• What are the patient’s concerns about the symptom? Has the patient
sought information from other sources e.g. Internet, friends?
• What made the patient come to the surgery today?
• What would the patient like you to do for him/ her?
• Are there any signs of disease on physical examination?
• Does the patient have low mood or any symptoms of anxiety? Consider
depression and/ or anxiety screening questionnaires
• Are there any other social/ psychological factors that may be triggering
symptoms? e.g. family member or close friend who is ill; domestic
violence; debt; work problems; past history of child abuse
• Physical illness/ trauma
https://t.me/med1917
MEDICALLY UNEXPLAINEDSYMPTOMS
Investigation Review patient notes carefully before requesting investi-
gations. Usually investigations are used to clarify diagnosis and reassure the
patient and GP. However, in patients with MUS:
• >50% of patients are not reassured following negative investigations
• False- positive results lead to i anxiety and further investigation
• Colluding with the patient i illness behaviour
0 Find a balance between appropriate investigation and risk of harm
through over- investigation. Prior to doing investigations, explain why they
are being done and the meaning of negative results.
Management
• Connecting Go back to the beginning, listen to the patient, acknowledge
suering, use existing knowledge of the individual (or recognize that you
have no knowledge of the individual)
• Summarizing Allow the patient to summarize problems, recap your
understanding of the problem to the patient, give an explanation, and
show your interest in the problem
• Hand over Develop a shared action plan or personal health plan with
realistic goals to improve functioning, and provide reassurance about
long- term outcome
• Safety netting Share uncertainty, inform patients about red ags
indicating serious disease, and oer access should symptoms change
Regular appointments may be helpful, as may a brief physical examination
at each visit to check for signs of disease. Oering suggestions for selfmanagement (e.g. doing voluntary work, increasing physical activity levels)
can be useful. Avoid referral unless there is a clear medical indication.
G
4 key areas:
General treatment options If self- help is ineective, try:
• Antidepressant medication e.g. amitriptyline 10mg at 5p.m. (may be
unlicensed). As response is often not dose dependent, start with a low
dose. Explain that the drug is not being used to treat depression
• CBT Allows patients to develop changes in thinking/ behaviour that will
help them cope more eectively with their problems
Management ofspecicMUS
• Fibromyalgia— E p. 504
• IBS— E p. 388
• Chronic fatigue— E p. 502
• Atypical facial pain— E p. 531
• Chronic pelvic pain— E p.690
• Interstitial cystitis— E p. 423
• Tension- type headache— E p. 530
• TMJ dysfunction— E p. 910–11
• Globus— E p. 356
• Somatization disorder— E p. 975
Work Encourage patients to work if possible— E p. 92
Prognosis 4– 10% of patients with MUS go on to have an alternative or-
ganic explanation; of those with true MUS, 25% will have ongoing symptoms after 12mo.
Somatization disorder E p. 975
Further information
RCGP/ Royal College of Psychiatrists/ Trailblazers/ National Mental Health
Development Unit (2011) Guidance for health professionals on MUS.
Mhttps:// www.rcpsych.ac.uk/ pdf/ CHECKED%20MUS%20Guidance_
A4_ 4pp_ 6.pdf
179
ALGRAWANY
180
https://t.me/med1917
180
CHAPTER8 Chronic disease and elderlycare
Assessment ofpain
Take a history to ascertain:
• What the patient means when he or she complains of pain
• The cause of the pain
• The severity of the pain
0 Do not jump to conclusions/ make assumptions about a patient’s pain.
Assessment questions There are many approaches to assessing
pain. The specics of each scheme are not crucial— but it is important the
scheme used has a logical outline which works for the individual clinician.
Asimple mnemonic approach is detailed in Figure 8.4. Always note any past
history of addiction to prescription or illicit drugs.
Elderly patients and patients with diculty communicating
High prevalence of pain in the elderly population is now well recognized. 40–
80% of elderly people in institutions are in pain. The reason for this lies in the
diculty in assessing those with communication diculties. Additionally, the
elderly often minimize their pain making it even more dicult to evaluate.
Methods of evaluation Unusual behaviour and its return to normal with adequate analgesia, may be the only conrmation of pain in patients with communication diculties. Examples include:
Verbal expression e.g.
• Crying when touched
• Shouting
• Becoming very quiet
• Swearing
• Grunting
• Talking without making sense
Behavioural expression e.g.
• Jumping on touch
• Hand pointing to body area
• Increasing confusion
• Rocking/ shaking
• Not eating
• Staying in bed/ chair
• Grumpy mood
Facial expression, e.g.
• Grimacing/ wincing
• Closing eyes
• Worried expression
• Withdrawn/ no expression
Physical expression, e.g.
• Cold
• Pale
• Clammy
• Change in colour
• Change in vital signs if acute pain
(e.g. BP, pulse)
Pain assessment tools Sometimes it is helpful to use pain scales to
assess the degree of pain that a patient is in— particularly if communication
is dicult. The most commonly used tool is a simple visual analogue pain
scale— this consists of a line marked in graduations from 0 to 10. Ask patients to point to the place on the line which represents how much pain they
are in, where 10 is the most possible pain and 0 is no pain.
Examine the patient The cause of the problem may be clear to you
from history alone but examine the patient to conrm/ refute your proposed diagnosis.
https://t.me/med1917
ASSESSMENT OFPAIN
Site of pain Where? Any radiation? Numbness where
S
pain felt? Pattern of involvement?
Onset
O
C
R
A
T
E
S
When did it start? How did it start? What started
it? Change over time?
Character of pain Type of pain—burning, shooting,
stabbing, dull, etc.; pattern of pain, e.g. colicky,
constant, etc.
Radiation Does the pain go anywhere else?
Associated features Are there any skin or joint changes,
e.g. bruising, redness, or swelling?
Timing/pattern Is it worse at any time of day? Is it
associated with any particular activities, e.g. movement,
urination, eating, passing stool, coughing?
Exacerbating and relieving factors
Record, especially if the pain is chronic and you
Severity
want to measure change over time. Consider a patient
Ask about:
diary.
• Pain intensity, e.g. none–mild–moderate–severe; rank on
a 1–10 scale
• Record interference with sleep or usual activities
• Pain relief, e.g. none–slight–moderate–good–complete
181
Figure8.4 Points to consider when taking a history of pain
• Beware of emergency requests for opioids from patients unknown to
you or your practice.
Further information
Livewell with Pain M https:// livewellwithpain.co.uk/
Schoeld P (2018) The assessment of pain in older people:UK national
guidelines. Age Ageing 47:1– i22.
Patient support
Action on Pain F 0345 603 1593 M www.action- on- pain.co.uk
Pain Association of Scotland F 0800 783 6059 M www.painassociation.com
Pain Concern F 0300 123 0789 M www.painconcern.org.uk
ALGRAWANY
182
https://t.me/med1917
182
CHAPTER8 Chronic disease and elderlycare
Principles ofpaincontrol
Acute pain Symptom of injured/ diseased tissue. Subsides as the injury
heals. Can be worsened by fear. Treat the underlying cause.
Chronic pain Dened as pain persisting for >3– 6mo. Aects ~7% of
adults in the UK. Cause is often multidimensional— with physical, social, and
psychological factors all contributing to the overall feeling of pain.
Goals ofchronic painmanagement
• Set realistic targets— abolition of pain may be impossible— 70% have
pain despite analgesia
• If analgesia is not helping— stop it
• The aim is often rehabilitation with d in distress/ disability
Strategies for pain management Amultidisciplinary approach is es-
sential. Consider:
• Prevention e.g. wrist splints for carpal tunnel syndrome; analgesia prior
to minor surgery
• Removal of cause Treat medical causes of pain e.g. infection, d blood
sugar (diabetic neuropathy). Refer surgical causes for surgery if surgery
is appropriate, e.g. hip OA— joint replacement
• Pain- relieving drugs Start with a single drug at low dose and step up
dose or add another drug as needed. Especially in situations of acute
pain, step down if pain diminishes
• Physical therapies Acupuncture, physiotherapy, or TENS
• Nerve blocks Consider referral for epidural (low back pain), local nerve
block, or sympathectomy (e.g. vascular rest pain)
• Modication of emotional response Psychotropic drugs, e.g. anxiolytics,
antidepressants
• Modication of behavioural response e.g. back pain— consider referral
to a back rehabilitation scheme
WHO analgesic ladder Use a step- by- step approach (Figure 8.5).
Figure8.5 World Health Organization (WHO) analgesic ladder
Source:World Health Organization (WHO). Cancer Pain Relief. Geneva, Switzerland: World Health
Organization. Copyright © WHO 1986. https:// www.who.int/ cancer/ palliative/ painladder/ en/
https://t.me/med1917
PRINCIPLES OFPAINCONTROL
Step 1:non- opioid Start treatment with paracetamol. Stress the need for
regular dosage. Adult dose is 1g every 4– 6h (maximum daily dose 4g). If this
is not adequate in 24h, either try a NSAID, e.g. ibuprofen 400mg tds (if appropriate), alone or in combination with paracetamol, or proceed to step 2.
Step 2:weak opioid + non- opioid Start treatment with a combined preparation of paracetamol + codeine/ dihydrocodeine. Combining 2 analgesics
with dierent mechanisms of action enables better pain control than using
either alone. Combinations have d dose- related side eects but the range
of side eects is i (additive eects of 2 drugs). Combinations using 30mg
of codeine are more eective than paracetamol alone but it is cheaper and
more exible if constituents are prescribed separately, e.g. ‘paracetamol
500mg/ codeine 30mg’. Advise patients to take tablets regularly and not to
assess ecacy after only a couple of doses.
0 There is no proven additional analgesic benet for preparations containing paracetamol + 8mg of codeine, compared to paracetamol alone.
Step 3:strong opioid + non- opioid
• Use immediate- release morphine tablets or morphine solution. 2 tablets
of co- codamol 500/30 contain 60mg of codeine which is equi- analgesic
to ~6mg of oral morphine. If changing to morphine, use a minimum
dose of 5mg (6mg is hard to prescribe)
• Chronic pain may not be opioid sensitive. Give for a 1– 2wk trial and only
continue if of proven benet. If the pain seems responsive to opioids
and there are no undue side eects, i the dose upwards by 30– 50%
every 24h until pain is controlled to a maximum of 120mg/ d morphine
equivalent— E p. 186
• Take care if the patient is elderly or in renal failure— consider starting
with a d dose of morphine.
Addition of co- analgesics and adjuvant drugs In combination with
analgesics, can enhance pain control. Examples include:
• Antidepressants— in low dose for nerve pain and sleep disturbance
associated with pain; in larger doses for secondary depression
• Anticonvulsants— neuropathic pain
• Corticosteroids— pain due to oedema
• Muscle relaxants— muscle cramp pain
• Antispasmodics— bowel colic
• Antibiotics— infection pain
• Night sedatives— when lack of sleep is lowering pain threshold
• Anxiolytics— when anxiety is making pain worse (relaxation exercises
may also help in these circumstances)
Referral If unable to remove cause and unable to achieve adequate pain
relief, consider referral to a specialist pain control clinic or palliative care
(depending on the context of the pain).
183
• Be aware of secondary gain from pain if symptoms seem out of proportion (outstanding compensation claims are a signicant negative factor
in success of pain management).
ALGRAWANY
Соседние файлы в папке Библиотека им академика М.И. Перельмана