Файловый архив студентов. Файловый архив студентов.
1330 вузов, 5508 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
15.09.2026
Размер:
12 Мб
Скачать
☆
•
•
•
•
•
•
•
•
Examination
LookforsignsofParkinsonism suggestiveofLewybodydementiaorfocal neurologicaldeficits suggestiveofvasculardementia Cognitivetesting(e.g.MontrealCognitiveAssessmentorAddenbrooke’sCognitiveExamination).
Investigations
Aimtoruleoutreversiblecausesofcognitiveimpairment.
Bedside
Urineculture(infection).
Bloods
FBC, U&E, LFT, calcium, magnesium, glucose, TFT (hypothyroidism), vitamin B12, folate, HbA1c.ConsiderHIVandsyphilisscreeningifhighclinicalsuspicion.
Imaging
BrainimagingwithCT/MRI(structuralabnormalities).
Other
Ifreversiblecausesanddrugcausesofcognitiveimpairmenthavebeenexcluded,referthepatient toadementiadiagnosticserviceforaformaldiagnosis If the diagnosis remains unclear, specialist memory clinics may perform fluorodeoxyglucose positronemissiontomography(FDG-PET),perfusionSPECT,oralumbarpuncture Forhospitalizedpatients,aCAMcanbeusedtohelpidentifydelirium(seeChapter10).
Management
The management ofdementiarequiresamultidisciplinaryteam,which may include old age psychiatrists, geriatricians, GPs, physiotherapists, occupational therapists, social services,specialistnurses,andcommunitysupportgroups.
Education
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Discusswiththepatientandfamilymembersorcarersaboutthediagnosisandprogressivenature ofthedisease Discusstheeffectthediagnosismayhaveontheir occupation (ifappropriate) andlifestyle,e.g. importanceofnotifyingtheDVLA(seeChapter115)ofanewdiagnosisofdementia Discussthepossibilityofparticipatinginresearchstudies.
Diseaseprogression
Unfortunately, there are no disease-modifying drugs for dementia. However, acetylcholinesterase inhibitors and N-methyl-D-aspartic acid (NMDA) receptor agonists canbeusedforsymptomatictreatmentofcognitiveandglobalfunctioning:
Acetylcholinesteraseinhibitors:
Donepezil,rivastigmine,andgalantaminecanbeusedasmonotherapiesformildtomoderate Alzheimer’sorLewybodydementia. Commonside effectsof acetylcholinesterase inhibitors includediarrhoeaandvomiting,and cramps.Hallucinations,pepticulcerdisease,andbradyarrhythmiascanalsooccur
NMDAreceptoragonist:
Memantine is recommended for patients with moderate Alzheimer’s disease who are intoleranttoacetylcholinesteraseinhibitors,orinestablishedAlzheimer’sdisease Common side effects of antiglutamatergic treatment include dizziness, hallucinations, and
confusion Stopanymedicationswith↑anticholinergicburdenasthiscanworsencognitiveimpairment Dosetteboxescanhelpaidmedicationcompliance.
Agitationandpsychosis
Addressanyunderlyingcausefortheirdistress(e.g.pain,infection) Utilizenon-pharmacologicaltherapies Considerantipsychotics(lorazepam/haloperidol)ifthepatientisatriskofharmingthemselvesor others,oriftheagitation orpsychosisiscausingthemdistress.Avoidlongertermuseduetothe riskofcerebrovascularsideeffects Antipsychotics may worsen motor symptoms in Lewy body dementia or Parkinson’s disease dementia. This should be discussed with the patient and family and if commenced should be monitoredclosely.
Depressionandanxiety
Considercognitivebehaviouraltherapy Consider antidepressants in moderate to severe depression (see Chapter 38) and anxiety (see
Chapter40).
Sleepproblems
https://t.me/med1917
•
•
•
•
•
•
•
•
Consider a personalized multicomponent sleep management approach including sleep hygiene education,exposuretodaylight,exercise,andpersonalizedactivities Donotroutinelyoffermelatoninorothersedatives.
Pain
Ifthepatientisunabletoreliablyreportpain,useanobjectivetooltomonitorforpain,e.g.Abbey painscale.
Advancedcareplanning
Offer opportunities for patients together with their family to discuss future plans including:
Lastingpowerofattorneyforhealthandwelfare Advancestatementabouttheirwishesandpreferencesregardinganyfutureceilingsofcare Advanced decisions to refuse treatment and cardiopulmonary resuscitation status (see Chapter
114)
Preferredplaceofcareanddeath Considerpalliativecareinputandprescribinganticipatorymedications.
Furtherreading
1.Alzheimer’sSocietywebsite.Availableat:https://www.alzheimers.org.uk
https://t.me/med1917
Chapter12
Falls
Guideline: NICE CG161 (Falls in older people: assessing risk and
prevention):https://www.nice.org.uk/guidance/cg161
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Fallsand fall-associatedinjuriesarecommonin older people(age>65years).Fallsmay beapresentingsymptomofacuteillness,especiallyiftheyareofrecentonset,ortheycan be a manifestation of underlying chronic disease. This chapter is also applicable to patientsaged50–64yearswhohave an underlyingcondition whichputs them ata high riskoffalls.
Diagnosis
Differentialdiagnosis
Thedifferentialdiagnosisforthecauseofafalliswideandolderpeopleoftenhavemore thanoneunderlyingdiagnosis(Table12.1).
Table12.1Differentialdiagnosisinapatientpresentingwithfalls
Historyof Differentialdiagnosis
Medications Recentchangeinmedicationor Polypharmacy
https://t.me/med1917
polypharmacy Psychotropicmedications,e.g.benzodiazepines,
antidepressants,antipsychotics Medicationsthatcauseorthostatichypotension,e.g. alpha-blockers,ACEinhibitors,amitriptyline Medicationsthatcauseperipheralneuropathy,e.g. chemotherapyagents Medicationsthatcausehypoglycaemia,e.g.insulin, sulphonylureas
Musculoskeletal Jointbucklingorinstability Arthritisorpreviousjointinjury
Lackofregularoradequateexercise Deconditioningduetoimmobility
Neurology Focalneurologicalsymptoms StrokeorTIA(seeChapter56)
Behaviouraldisturbances,cognitiveor moodimpairment
Dementia(seeChapter11) Delirium(seeChapter10) Depression(seeChapter38)
Witnessedhistorysuggestiveofseizure, prolongedpostictalstate
Seizuredisorder(seeChapter50)
Headtraumaorprevioustraumatic braininjury
Subduralhaematoma
Gaitdisorders Shufflinggait Parkinson’sdisease(seeChapter55)
Abnormalgait—broadbased,short stepping
Normalpressurehydrocephalus Cerebellarlesion
High-steppinggait Footdrop
PositiveRomberg’stest Peripheralneuropathy
Cardiovascular TLoCwithoutanywarningsymptoms Tachy-orbradyarrhythmias
Valvularheartdisease
(Pre-)Syncopeprecipitatedbyturning theheadorwearingtightcollars
Carotidsinushypersensitivity
(Pre-)Syncopeprecipitatedbystanding uporabriskchangeinposition
Orthostatichypotension
Genitourinary Urinaryurgencyordysuria Incontinence
Urinarytractinfection
Endocrine Historyofdiabetes Hypoglycaemia(seeChapter21)
Chronicsteroidusewithsudden cessationoftherapy
Adrenalinsufficiency
Ear,nose,and throat(ENT)
Dizziness,vertigo,orimbalance Benignparoxysmalpositionalvertigo(BPPV)
Vestibulardysfunction
Environmental Acollateralhistoryaboutthehome
environmentisvital
Poorlighting,looserugs,clutter,stairs,walkingaids, unsuitablefootwear
Otherfactors Visualimpairment
Alcoholconsumption Psychologicalfactors,e.g.thefearof
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
fallingitself
History
Ageneraloutlineofanacutefallhistoryshouldinclude:
Circumstancesofthefall:
Where,when,whowasthere,whatwasthepatientdoingatthetimeofthefall?
Beforethefall:
Anyprodromalsymptoms,e.g.light-headedness,palpitations,chestpain,nausea?
Duringthefall:
Didanyonewitnessthefall?Iftherewasawitness,takeacollateralhistory
Wasthereanylossofconsciousness(doesthepatientrecallthefallitself,orjustwakingup
after)?
Anysignsofseizureactivity(e.g.limbjerking/tonguebitingorincontinence)?
Didthepatient’sappearancechange(pale/flushed/blue)?
Wasthereanyheadinjury?
Didtheyfallonanoutstretchedhandorbackwards?
Afterthefall:
Wasthereclearrecollectionofthefallorweretheyconfused?
Howsoonweretheyabletoresumenormalactivities?
Wasthereanyspeechdifficultyorlimbweakness?
Severity:werethereanyinjuries? Chronicity: how many times have they fallen in the last 6 months? Explore each episode and
identifyifthereisapattern Coexistingmedicalconditionsandmedicationsthepatientistaking Alcoholconsumption.
Examination
ExamineusinganABCDEapproach(Table12.2).Seein Box12.1.
https://t.me/med1917
Table12.2ABCDEapproachtoanacutefallsreview
Findings
B Poorairwayexpansionandoxygensaturationduetoribfracturesorsignsofpneumonia
C Tachy-orbradyarrhythmias,orthostatichypotension,murmurstosuggestvalvularheartdisease
D Assesslevelofalertness,hypo/hyperthermia,hypoglycaemia
E Chest:ribtenderness/bruisingsuggestiveoffractures
Abdomen:abdominaltenderness/urinaryretentiontosuggesturinary/intra-abdominalinfection
Musculoskeletal:lookforsignsofinjuryandassessforanyevidenceoffractureswhichincludesC-spine
tenderness,limbdeformity,bruising
Neurological:abnormalitiesincranialnerves,e.g.visualimpairment,upperorlowerlimbweakness,or sensoryimpairment(stroke/TIA);glove-and-stockingsensoryimpairmentandRomberg’ssignpositive (peripheralneuropathy);ataxia(cerebellarpathology)
ENT:Dix–HallpikemanoeuvreifsymptomssuggestiveofBPPV
General:lookforevidenceoflongliesuchaspressuresoresandhypothermia
Gait,balance,andmobility:assessgait.TimedUpandGotest,Timed180°TurnTest
Box12.1Redflags
Thefollowingrequireurgentassessmentandconsiderationoffurtherimaging:
Acute change in level of consciousness, focal neurology, or head injury with concurrent anticoagulantorantiplatelettherapyuse(performCThead;seeChapter121) Limbpainorinabilitytoweightbearoranatomicalabnormalitythatsuggestsafracture(request X-raysandseekadvicefromorthopaedicteam)
Investigations
Notalloftheinvestigationslistedwillbeappropriateforallcircumstances(e.g.somemay only be relevant in acute falls or where a specific precipitant cause is suspected, or a specificinjuryissuspectedsecondarytothefall),soclinicaljudgementshouldbeapplied whendecidinghowtoinvestigate.
Bedside
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Cognitivescreening(4‘A’sTest(4AT)/AMTS) Lyingandstandingbloodpressure Bloodglucose Urinalysis ECG.
Bloods
FBC(anaemia,infection) U&E(dehydration) Creatinekinase(rhabdomyolysisinlonglie) LFT(chronicalcoholuse) BoneprofileincludingvitaminD(calciumabnormalities,electrolytedisturbance) CRP(infection) VitaminB12,TFT(peripheralneuropathy).
Imaging
ChestX-ray(ribfractures,signsofpneumonia,haemothorax) CThead(acuteorsubacuteintracranialbleedorinfarct)andC-spine Echocardiogram(valvularheartdisease)
Other
72-hourcardiactape(arrhythmia) Carotidsinusmassage Testsofautonomicfunction,e.g.tilttabletestingtoassessadrenergicresponse Electroencephalogram(EEG)ifseizuredisorderissuspected Dual-energyX-rayabsorptiometry(DXA)forassessmentofosteoporosisrisk(seeChapter24).
Acutemanagement
Treat any underlying medical illness leading to the fall or occurring concurrently, i.e. infections, dehydration, electrolyte abnormalities, abnormal blood glucose levels, pressure-relatedinjuries,andhypothermia.
Sometrustsmayhaveapost-fallsprotocol,whichmayincludeapost-fallsassessment tool and guidelines on management after a fall, i.e. if CT head is indicated after head injury,durationofGCSmonitoring,andreferraltospecialistfallsservices.
Chronicmanagement
https://t.me/med1917
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Patienteducation
Discuss individual risk factors for falling and provide information about measures to preventfurtherfallsinthecontextofafallspreventionprogramme,andhowtogethelp whentheyhavefallen,e.g.pendantalarms.Educatefamilymembersandcarers.
Lifestyleandsimpleinterventions
Strengthandbalancetraining Homehazardandsafetyassessmentandintervention,e.g.micro-environments,crashmatalarms Visionandhearingassessments.
Psychologicalinterventions
Screen for mood disorders using the Hospital Anxiety and Depression scale and treat appropriately.
Pharmacologicalmanagement
Reviewmedicationsthatmighthavecontributedtowardsthefallanddiscontinueifpossible Commenceboneprotectionifosteoporosisisdiagnosed.
Psychosocialconsiderations
Lossofmobilityleadingtosocialisolation,depression,increaseddependence,anddisability.
Specialistreferral
Cardiacpacingshouldbeconsideredincardioinhibitorycarotidsinushypersensitivity.
Offerreferraltoaspecialistfallsserviceinolder peoplefor a multifactorialfallsrisk assessment.Thiswillassessfactorsincluding:
Polypharmacy Cognitiveimpairment Continenceissues Previousfalls Inappropriatefootwear Comorbiditiesincludingsyncopesyndromeorconcurrentmedicationswhichmightaffectbalance Posturalinstabilityormobility/balanceissues Visualimpairment.
https://t.me/med1917
Furtherreading
1.WilcockG,RockwoodK(2011).Medicineinoldage.In:WarrellDA,CoxTM,FirthJD(eds)Oxford
Textbook of Medicine, 5th ed (Chapter 29.1). Oxford UK: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199204854.003.2901_update_001
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности