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
194
https://t.me/med1917
194
CHAPTER8 Chronic disease and elderlycare
Prescribing forolderpeople
Use of medicines i as people get older; 1 in 3 NHS prescriptions are for
patients >65y and 90% of these prescriptions are for repeat medication.
Adverse drug events are common reasons for hospital admission in the
>75 age group; many are avoidable. Regular review is essential. Problems
commonly encountered:
Polypharmacy Elderly people often have multiple problems. It is easy to
keep adding drugs for each new problem resulting in polypharmacy. This
iconfusion about drug regimens, and results in poor concordance and multiple interactions/ side eects.
• Before prescribing a new drug consider whether it is necessary— avoid
treating normal changes of ageing; use non- pharmacological therapies
wherever possible; avoid ‘a pill for every ill’ approach and try to treat
the underlying condition not the symptoms
• Balance the potential risks of the drug against the benets. Drug trials of
ecacy of medication often exclude older participants— the applicability
of evidence to elderly patients cannot be assumed. For prophylactic
medication (e.g. warfarin, statins), consider the likelihood of
concordance and benets in the context of the whole person (including
other co- morbidities)
• Review medication regularly. Stop ineective/ redundant drugs and
consider if the overall drug regimen can be simplied
Form of the medicine Swallowing tablets can be dicult for elderly
people. Consider using liquid preparations/ giving explicit advice to take
medication with plenty of water and sitting upright.
Confusion after discharge Up to ½ all patients are inadvertently pre-
scribed the wrong medication after hospital discharge.
Drug hoarding/ self- medication Especially if recent changes in medi-
cation it is common for elderly people to have a back stock of drugs and
continue taking their old drugs alongside new ones. Awritten list may be
helpful. Many elderly people also self- medicate extensively with OTC preparations. If necessary, do a home visit to sort out the drugs.
i susceptibility to side eects Common due to altered:
• Pharmacodynamics i susceptibility to GI side eects (e.g. constipation
with opioids; gastric irritation with NSAIDs) and i sensitivity to eects
of CNS drugs, e.g. benzodiazepines, opioids— use with care
• Pharmacokinetics d renal function is particularly important— always
assume any elderly person has moderate renal impairment
Social and personal factors Low level of home support; physical fac-
tors, e.g. poor vision, poor hearing, or poor manual dexterity; and mental
state, e.g. confusion/ disorientation, depression— can all aect ability of an
older person to take medication.
Specic medicines The Beer’s list is a list of agents to be avoided/ used
with extreme caution in elderly patients. It can be accessed via M www.dcri.
duke.edu/ ccge/ curtis/ beers.html
https://t.me/med1917
PRESCRIBING FOROLDERPEOPLE
Guidelines forprescribing fortheelderly
Think beforeprescribing
• Is the drug needed?
• Is there another non- pharmacological way of managing the problem?
• Are you treating the underlying condition or the symptoms of it?
• What are the pros and cons of the patient taking this drug?
• What is the evidence base for its use in this age group?
• Will the patient be able to take the drug (formulation; packaging)?
• Will the patient be concordant?
• Will the patient comply with any necessary monitoring?
Limit therange ofdrugs youuse
Prescribe from a limited array of drugs that you know well.
Repeats anddisposal
• Tell patients how to get more tablets and monitor frequency of repeat
prescriptions; review repeat prescriptions regularly (E p. 118)
• Tell patients what to do with any left- overs if a drug is stopped
d thedose
• Start with 50% of the adult dose
• Avoid drugs likely to cause problems e.g. hypnotics
Review regularly
• Consider on each occasion whether each drug could be stopped or
the regimen simplied
• Consider lowering dosage of drugs if renal function is deteriorating
• Involve carers, community pharmacists, and other PHCT members
Simplifyregimens
Use od or bd regimens wherever possible; avoid polypharmacy.
Explainclearly
• Decision aids can be helpful, e.g. M www.anticoagulation- dst.co.uk/
• Put precise instructions on the drug bottle— avoid ‘use as directed’
• Give written instructions about how the drug should be taken
• Ensure explanations are given to carers as well, if appropriate
Consider method ofadministration
• Bottles with child- proof tops are often impossible for arthritic hands
to open. Suggest the patient asks the chemist for a standard screw cap
• Drug administration boxes in which the correct tablets are stored in
slots marked with the day and time of administration can be helpful.
Available from pharmacists and can be lled by the patient, a carer,
friend, or relative, or the pharmacist
• Medication reminder charts can also help
195
Further information
Gallagher P, etal. (2008) STOPP (Screening Tool of Older Persons
Prescriptions) and START (Screening Tool to Alert doctors to Right
Treatment). Consensus validation. Int J Clin Pharmacol Ther 46:72– 83.
Lavan AH, etal. (2017) STOPPFrail (Screening Tool of Older Persons
Prescriptions in Frail adults with limited life expectancy):consensus
validation. Age Ageing 1;46:600– 7.
ALGRAWANY
196
https://t.me/med1917
196
CHAPTER8 Chronic disease and elderlycare
Elderly care and disabilitymanagement
‘Use strengthens, disuse debilitates’
13– 14% of the population has some disability. This is i as populations age
and people survive longer with disability. Many more are just elderly and
frail. 35% of people aged >80y cannot live an independent life. Most patients
are best managed by a MDT in their home environment (if practicable) with
a problem- oriented approach. Good interdisciplinary communication and
coordination is essential and many patients benet from specialist rehabilitation services. Psychological and sociocultural aspects are as important as
medical aspects of care.
Hippocrates (460– 357 BC)
Role of the GP within the MDT Maintain an open door policy and
encourage patients and carers to seek help for problems early. Try to become familiar with patients’ diseases, even if rare. Information alone can
improve outcome.
Consider
• Can physical symptoms be improved?
• Can psychological symptoms be improved (including self- esteem)?
• Can functioning within the home be improved (aids and adaptations
within the home, extra help)?
• Can functioning in the community be improved (mobility outside the
home, work, social activities)?
• Can the patient’s or carer’s nancial state be improved?
• Does the carer need more support?
0 If progress is slower than expected, or stalls, consider other medical
problems (e.g. anaemia, hypothyroidism, dementia), a neurological event,
depression, or communication problems (e.g. poor vision/ hearing).
Principles ofcare
• Use of assessments/ measures Central to the management of disability.
Use validated measures accepted by all team members (e.g. Barthel
index; PHQ- 9— E p. 979). Reassess regularly
• Multidisciplinary teamwork Good outcomes are associated with
clinicians and other involved health and social care professionals working
as a team towards a common goal with patients and their families (or
carers) included as team members
• Goal- setting Goals must be meaningful and challenging— but achievable.
Use short- and long- term goals. Involve the patient ± carer(s). Regularly
renew, review, and adapt
• Underlying approach to therapy All approaches focus on modication
of impairment and improvement in function in everyday activities. May
include drugs, physical or psychological therapies, ± social support
• Referral for specialist support Consider specialist medical or
rehabilitation services; social services (if not already part of the MDT);
voluntary organizations and self- help groups; Citizen’s Advice
Maintaining independence E p. 198 Carers E p. 200
https://t.me/med1917
ELDERLY CARE AND DISABILITYMANAGEMENT
Common neurological rehabilitation problems E p. 554
Learning disability health checks People with a learning disability
have poorer physical/ mental health and die younger. Annual health checks
can be oered as a Directed Enhanced Service to patients aged >14y on the
practice learning disability register. Standard templates are available within
practice software systems. Health checks aim to:
• Ensure all available health prevention measures are oered, e.g.
screening, routine vaccinations, contraception
• Identify health conditions that might otherwise go undetected
• Optimize management of ongoing conditions
• Identify patients/ carers who may need more support
Adult safeguarding Means to protect a person’s right to live in safety,
free from abuse, harm, and neglect. Includes proactive and reactive measures and recognizes that adults may choose to make unwise decisions. An
adult at risk is any person who is ≥18y and at risk of abuse, harm, or neglect
because of their needs for care and/ or support.
Types of abuse Include:
• Physical e.g. hitting, misuse of medication or restraint
• Sexual e.g. rape, sexual acts to which the adult has not consented
• Psychological e.g. threats of harm/ abandonment, humiliation, blaming
• Financial e.g. theft, exploitation, fraud
• Neglect e.g. ignoring health/ care needs, inadequate nutrition
Six safeguarding principles Underpin adult safeguarding:
• Empowerment • Proportionality • Partnership
• Prevention • Protection • Accountability
The role of the GP GPs must undergo regular adult safeguarding training. This
is assessed as part of their annual appraisal. They must:
• Be able to recognize potential signs of abuse
• Work as part of the MDT (including local adult safeguarding services) to
take all necessary action to safeguard their patients
• Reect on safeguarding events and take any necessary actions to
improve adult safeguarding within their own organizations
Deprivation of Liberty Safeguards (DoLS) E p. 1106
Elder abuse E p. 87 Domestic violence E p. 86
Modern slavery E p. 88 Female genital mutilation E p. 710
‘Prevent’ strategy E p. 89
Organizational abuse Usually aects people in residential care settings
(e.g. hospitals, care homes) but can occur in relation to paid care in people’s
own homes. Individuals’ wishes and needs are sacriced for the smooth
running of the service/ organization, e.g. no choice of food, shared clothing,
forced early bed times. If suspected, raise with the service provider in the
rst instance (with the patient’s/ carer’s permission if possible). If no action
is taken, refer to local social services adult safeguarding lead.
Further information
RCGP Safeguarding adults at risk of harm toolkit. M www.rcgp.org.uk/
clinical- and- research/ resources/ toolkits/ safeguarding- adults- at- risk- ofharm- toolkit.aspx
197
ALGRAWANY
198
https://t.me/med1917
198
CHAPTER8 Chronic disease and elderlycare
Maintainingindependence
Maintaining independence is important. It gives individuals autonomy, a
sense of purpose and achievement, and allows them to make their own
choices. Lack of independence can result in a feeling of ‘being a burden’,
boredom, frustration, loneliness, and social isolation.
Equipment and adaptations If diculty coping at home due to dis-
ability or age, anyone can request a needs assessment by an occupational
therapist via their local social services department. This enables provision of
equipment/ adaptations necessary to maintain independence.
Benets E p. 104
Help to use the telephone Many people have diculty using the tele-
phone either because of physical impairments or communication problems.
British Telecom can provide suggestions about how to address many of
these issues— M www.bt.com/ includingyou/ index.html
Alarm systems Enable anyone who is alone at times to call for help, even
when they cannot reach a telephone. Suitable for anyone capable of using
an alarm system. Arrange via local social services or housing departments.
Alternatively charities for the elderly have schemes (e.g. Age UK Personal
Alarm F 0800 030 4385).
Walking aids Wide variety— from simple walking sticks and crutches, to
a range of wheeled and unwheeled walking frames. Physiotherapists can
advise on the best mobility aid for each individual patient. Can be obtained
on loan from the NHS or purchased by the individual.
Wheelchairs If needed short term, available on loan from local Red
Cross branches. The NHS can provide a wheelchair for anyone requiring
one for >3mo. Referral must be made by an authorized healthcare practitioner (e.g. GP) to the local NHS Wheelchair Service. After assessment individuals can opt to have an NHS wheelchair or be provided with a voucher
to put towards the cost of their own. Directory of NHS wheelchair service
centres:M www.wheelchairmanagers.nhs.uk
Community transport services Available in many areas for people
who have diculty using public transport. Include door- to- door transport
to attend appointments, trips to shopping centres, and other outings. Local
arrangements vary.
Free bus passes 0 May be restrictions on time of travel.
Disabled people are entitled to free bus passes in England through the
English National Concessionary Travel Scheme if they meet eligibility criteria (Box8.1). Similar schemes operate in Scotland, Wales, and Northern
Ireland. Acarer may also be issued with a free pass if the individual cannot
travel alone. Applications are made via local authorities, but the bus pass
can be used anywhere within the country it was issued. AGP letter to conrm eligibility may be required.
Elderly people can also apply for free bus passes from 60y in London (also
valid for Underground), Scotland, Northern Ireland, and Wales, and from
the women’s state retirement age elsewhere in England.
Disability and driving E p. 99
https://t.me/med1917
MAINTAININGINDEPENDENCE
Box 8.1 Criteria forapplication fora free bus pass
inEngland
A disabled person is likely to get a concessionary bus pass if he or she:
• Is blind or partially sighted
• Is deaf or unable to speak
• Is unable to walk very far because of a disability, illness, or injury
• Is unable to use his/ her arms (or does not have arms)
• Has severe learning disability
• Has been refused a driving licence for a health reason (but not
because of problems with drugs or alcohol)
Blue Badge Scheme Entitles the holder to park:
• In specied disabled spaces
• Free of charge or time limit at parking meters or other public places
where waiting is limited
• On single yellow lines for up to 3h (no time limit in Scotland)
The disabled person does not have to be the driver but the badge should
not be used if the disabled person is not in the car. Applications are made
via the local authority. Automatically eligible if >2y old and one of the following criteria apply:
• Registered as blind
• Receiving higher rate mobility component of DLA, or receiving PIP and
scored ≥8 points in the ‘moving around’ area of the PIP assessment
• Getting War Pensioners’ Mobility Supplement or received a lump sum
payment as part of the Armed Forces Compensation Scheme (taris
1– 8), and certied as having a permanent and substantial disability
People with permanent problems walking, or who cannot use their arms
may be eligible and should apply— each application is judged on its merits.
Motability (M www.motability.co.uk) Qualifying benets (must have
≥12mo award length remaining):
• Higher rate mobility component of DLA
• Enhanced rate mobility component of PIP
• War Pensioners’ Mobility Supplement, or
• Armed Forces Independence Payment
Mobility payments associated with state benets can be used to lease a
car, wheelchair- accessible vehicle, scooter, or powered wheelchair. Includes
many special adaptations, insurance, breakdown assistance, servicing, and
maintenance. Grants may also be available for additional adaptations or
driving lessons. 0 The driver does not have to be the claimant.
Road Tax Exemption Should be received automatically by anyone re-
ceiving any of the eligibility benets listed for the Motability scheme.
Patient information and support
Age UK Wide range of information and factsheets. F 0800 055 6112 M
www.ageuk.org.uk
Citizens Advice M www.adviceguide.org.uk
Disabled Living Foundation Advice about equipment and appliances.
F0300 999 0004 M www.dlf.org.uk
Scope. Disability information line. F 0808 800 3333 M www.scope.org.uk
199
ALGRAWANY
200
https://t.me/med1917
200
CHAPTER8 Chronic disease and elderlycare
Carers
Who is a carer? Acarer is someone of any age who provides unpaid
support to family or friends who could not manage without this help. This
could be caring for a relative, partner, or friend who is ill, frail, disabled, or
has mental health or substance misuse problems. Anyone can become a
carer. ~2million people/ y move in/ out of caring roles.
Young carers Children and young people who assume inappropriate responsibilities to look after someone who has an illness, a disability, or is aected
by mental ill health or substance misuse. Young carers often take on practical and/ or emotional caring responsibilities that would normally be expected of an adult.
0 Some carers do not regard themselves as carers, or may dislike the
label ‘carer’, believing that it can detract from their identity as a parent,
child, partner, or sibling to the person that they care for. It is also important not to confuse carers with paid care workers.
How many carers are there? 12% of adults in the UK are carers.
1.2million provide care for >50h/ wk; those aged >65y account for 1 in 3
of those providing >50h care each week and many have their own health
problems too. There are also around 1million young carers.
Carers as partners in care Carers know the people that they care
for better than anyone else. Involving carers is important in order to identify problems that may require intervention; plan patient care; and improve
concordance with care plans.
What problems do carers have as a result of their roles? Many
carers gain great personal satisfaction from their caring role and want to
continue caring, but they suer adverse consequences too:
• Psychological i stress and depression/ anxiety; abuse from the person
being cared for; young carers have i risk of bullying/ self- harm
• Physical health i mortality; i morbidity from CVD; i risk of back and
other musculoskeletal injury
• Social activity restriction Deterioration of relationships with other
family members, social isolation
• Employment/ schooling d ability to work, d promotion prospects, poor
performance, and i absenteeism at school
• Financial The more care provided, the more likely a carer is to be in
nancial diculty; 55% are in debt but <50% claim all the benets they
are eligible for
Supporting carers in general practice See Figure 8.6
Benets For sickness/ disability/ carers— E p. 108; low income— E
p. 104
Social services assessment Every carer has a right to ask for a full
assessment of their needs by the social services. Emergency planning to
provide substitute care in the event of a crisis is part of that assessment.
https://t.me/med1917
CARERS
201
Figure8.6 Practice action plan for supporting carers
Further information
RCGP (2011) Supporting carers:an action guide for GP and their teams.
M www.rcgp.org.uk
Carer support
Carers Trust M www.carers.org
Carers UK M www.carersuk.org
ALGRAWANY
202
https://t.me/med1917
https://t.me/med1917
Chapter9
Cardiology and vascular
disease
Symptoms and signs of CVD 204
Examining the heart 206
Examination of the arterial system 208
Cardiac investigations 210
Brief guide to common ECG changes 212
Prevention of cardiovascular disease 214
Blood pressure measurement 216
Hypertension 218
Hyperlipidaemia 222
Angina 226
Drug treatment of angina 228
After myocardial infarction 230
Chronic heart failure 232
Management of chronic heart failure 234
Pulmonary hypertension and cor pulmonale 236
Tachycardia 238
Atrial brillation (AF) 240
Bradycardia 242
Infective endocarditis 244
Rheumatic fever, myocarditis, and pericarditis 246
Cardiomyopathy and heart transplant 248
Valve disease 250
Other structural abnormalities of the heart 252
Aneurysms 254
Chronic peripheral ischaemia 256
Varicose veins 258
Deep vein thrombosis 260
203
ALGRAWANY
Соседние файлы в папке Библиотека им академика М.И. Перельмана