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Elderly Drivers with Cognitive Impairment

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61. Primary & Secondary Prevention of CVD

Glycemic Load Glycemic Index Glucagon-like peptide–1 Glucose Tolerance Test Impaired Glucose Tolerance High Density Lipoprotein Cholesterol Human Immunodeficiency Virus Impaired Fasting Glucose Generally Recognized As Safe Ischaemic Heart Disease Low Carbohydrate Diets Low-Fat Diet Low Density Lipoprotein Cholesterol Komuniti Sihat Perkasa Negara LV LVH MHT MI MOH MSSM MUFA NCCFN NHMS NCD NCVD-ACS NGO NOAC NRT Left Ventricular Hypertrophy Left Ventricular Menopausal Hormone Therapy Ministry of Health (...) . It however entails: • Education of the healthcare providers on: ? What constitutes a healthy diet ? How to teach simple practical exercises that even a busy/elderly person can perform. These simple exercises should be tailored to the physical capabilities of the individual. ? Where to go if individuals want help to quit smoking ? Practical tips on losing weight and where to refer overweight/obese invididuals with co morbidities Although there a number of strategies to prevent /reduce the burden of Non

2017 Ministry of Health, Malaysia

62. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society

tone, with rapid and spontaneous recovery. The presumed mechanism is cerebral hypoperfusion. , There should not be clinical features of other nonsyncope causes of loss of consciousness, such as seizure, antecedent head trauma, or apparent loss of consciousness (ie, pseudosyncope). , Loss of consciousness A cognitive state in which one lacks awareness of oneself and one’s situation, with an inability to respond to stimuli. Transient loss of consciousness Self-limited loss of consciousness can (...) %. Females reported a higher prevalence of syncope (22% versus 15%, P <0.001). The incidence follows a trimodal distribution in both sexes, with the first episode common around 20, 60, or 80 years of age and the third peak occurring 5 to 7 years earlier in males. Predictors of recurrent syncope in older adults are aortic stenosis, impaired renal function, atrioventricular or left bundle-branch block, male sex, chronic obstructive pulmonary disorder, heart failure, atrial fibrillation, advancing age

2017 American Heart Association

63. Recommendations for the Use of Mechanical Circulatory Support: Ambulatory and Community Patient Care: A Scientific Statement From the American Heart Association (Full text)

PVD Active substance abuse Impaired cognitive function Unmanaged psychiatric disorder Lack of social support CRT indicates cardiac resynchronization therapy; DT, destination therapy; NYHA, New York Heart Association; Vo 2 , oxygen consumption; and PVD, peripheral vascular disease. As of July 2014, 158 centers in the United States offer long-term MCS. Patients often live a substantial distance from the implanting center, necessitating active involvement of local first responders (emergency medical (...) to assist patients with MCS with device-related care on a daily basis. A multidisciplinary plan involving medical and psychosocial care, including psychopharmacology and counseling, may contribute to positive outcomes for both patients and caregivers. Cardiac-related cognitive dysfunction often resolves after MCS, which may significantly improve the quality of life for the patient and family. In elderly destination therapy patients, dementia can become an issue, and follow-up cognitive assessment

2017 American Heart Association PubMed abstract

64. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association (Full text)

not consistently occur. For example, different providers may have different methods of coding encounters, which can limit interprovider comparability. In addition, consistent biases in coding such as “up-coding” can significantly impair the veracity of claims data insights. Nonetheless, International Classification of Diseases codes have demonstrated accuracy in characterizing CVD conditions and care. Second, aspects of care that are important clinically (such as patient preferences) but not relevant from (...) Environmental Protection Agency air quality monitoring network to assess the relationship between coarse particular matter levels and cardiovascular hospitalizations among 110 large urban US counties. Researchers found that increased air pollution levels were associated with higher rates of hospitalizations in elderly patients, suggesting that actions such as counseling patients to remain indoors during high-pollution days may have an impact on overall cardiac health. Other environmental data sources

2017 American Heart Association PubMed abstract

65. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

and Obesity e28 5.2.2. Sodium Intake e29 5.2.3. Potassium e29 5.2.4. Physical Fitness e29 5.2.5. Alcohol e29 5.3. Childhood Risk Factors and BP Tracking e31 5.4. Secondary Forms of Hypertension e32 5.4.1. Drugs and Other Substances With Potential to Impair BP Control e32 5.4.2. Primary Aldosteronism e32 5.4.3. Renal Artery Stenosis e34 5.4.4. Obstructive Sleep Apnea e34 6. Nonpharmacological Interventions e35 6.1. Strategies e35 6.2. Nonpharmacological Interventions e35 7. Patient Evaluation e38 7.1 (...) . Racial and Ethnic Differences in Treatment e61 10.2. Sex-Related Issues e61 10.2.1. Women e62 10.2.2. Pregnancy e62 10.3. Age-Related Issues e63 10.3.1. Older Persons e63 10.3.2. Children and Adolescents e64 11. Other Considerations e64 11.1. Resistant Hypertension e64 11.2. Hypertensive Crises—Emergencies and Urgencies e65 11.3. Cognitive Decline and Dementia e68 11.4. Sexual Dysfunction and Hypertension e69 11.5. Patients Undergoing Surgical Procedures e69 12. Strategies to Improve Hypertension

2017 American Heart Association

66. Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association (Full text)

and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable (...) adult CHD (ACHD) admissions to an intensive care unit, abnormal thyroid, creatinine, and bilirubin tests were highly pre- dictive of both intensive care unit and hospital mortal- ity. 19 Furthermore, comorbidities can be costly. A recent study demonstrated renal insufficiency as a primary driver of high resource use for ACHD hospitalizations, which account for only 10% of the admissions but make up one third of the total hospital charges. 20 The impact of noncardiac comorbidities on both car- diac

2017 American Heart Association PubMed abstract

67. Benign Paroxysmal Positional Vertigo (BPPV)

of falls, depression, and impairments of their daily activities. Persistent untreated or undiagnosed vertigo in the elderly leads to increased caregiver burden with resultant societal costs including decreased family productivity and increased risk of nursing home placement. Among an estimated 7.0 million elderly individuals reporting dizziness in the prior 12 months, 2.0 million (30.1%) reported vertigo, and there were 230,000 office visits among the elderly with a diagnosis of BPPV (...) canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial

2017 American Academy of Otolaryngology - Head and Neck Surgery

68. Management of Opioid Therapy (OT) for Chronic Pain

beliefs and expectations about chronic pain and its treatment.[36] Patients with chronic pain may also experience worsened quality of life, mental health, immune system function, physical function, sleep, employment status, and impaired personal relationships.[3,42-44] Worsening of some of these factors (e.g., quality of life, change in employment status) seems to also be associated with pain severity and the presence of psychiatric comorbidities.[45,46] Patients with chronic pain report psychological (...) of controlled substances ? Intolerance, serious adverse effects, or a history of inadequate beneficial response to opioids ? Impaired bowel motility unresponsive to therapy ? Traumatic brain injury ? Pain conditions worsened by opioids (e.g., fibromyalgia, headache) ? True allergy to opioid agents (that cannot be resolved by switching agents) a. Significant Risk Factors • Duration and dose of OT: See Recommendation 2 for more guidance on duration of OT and Recommendations 10-12 for more guidance on dosing

2017 VA/DoD Clinical Practice Guidelines

69. Rehabilitation of Lower Limb Amputation

with LLA is influenced by a variety of factors that include, but are not limited to, level of amputation, cognitive impairment, physical conditioning, social support, comorbidities, and psychological factors.[20] Amputations caused by vascular disease generally occur in aging populations with numerous other comorbidities such as cardiovascular disease, hypertension, renal 3 See Veterans Health Administration Directive 1410, Prevention of Amputation in Veterans Everywhere. Available at: https (...) Care 23 VII. Discussion of Recommendations 24 A. All Phases of Amputation Rehabilitation 24 B. Perioperative Phase 31 C. Pre-Prosthetic Phase 39 D. Prosthetic Training Phase 40 VIII. Knowledge Gaps and Recommended Research 46 A. Training programs 46 B. Rehabilitation dosing 47 C. Patient factors and considerations 47 D. Cognitive assessment 47 E. Perioperative LLA interventions 47 VA/DoD Clinical Practice Guideline for Rehabilitation of Individuals with Lower Limb Amputation September 2017 Page 4

2017 VA/DoD Clinical Practice Guidelines

71. Obstructive Sleep Apnea in Adults: Screening

OSA include cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes. Detection Evidence on the use of validated screening questionnaires in asymptomatic adults (or adults with unrecognized symptoms) to accurately identify who will benefit from further testing for OSA is inadequate. The USPSTF identified this as a critical gap in the evidence. Benefits of Early Detection and Intervention or Treatment The USPSTF found (...) , but the applicability of this evidence to screen-detected populations is unknown. The USPSTF found inadequate evidence on whether treatment with CPAP or MADs improves other health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events). The USPSTF also found inadequate evidence on the effect of treatment with various surgical procedures in improving intermediate or health outcomes. Harms of Early Detection and Intervention or Treatment The USPSTF found

2017 U.S. Preventive Services Task Force

72. Diagnosis and Treatment of Low Back Pain

to remain active, and providing information about self-care options. Strong for Reviewed, Amended 7. For patients with chronic low back pain, we suggest adding a structured education component, including pain neurophysiology, as part of a multicomponent self-management intervention. Weak for Reviewed, New-added C. Non-pharmacologic and Non-invasive Therapy 8. For patients with chronic low back pain, we recommend cognitive behavioral therapy. Strong for Reviewed, New-replaced 9. For patients with chronic

2017 VA/DoD Clinical Practice Guidelines

73. Key policies for addressing the social determinants of health and health inequities

for improving population health, and especially important for more vulnerable children. Evidence indicates that actions to improve early child development have the most cost-effective impact on health equity (9,10,12,20). Children’s social, educational and health care needs are closely intertwined. Thus, inadequate socioeconomic conditions, care, health, nutrition and physical and emotional nurturing can reduce educational attainment by impairing cognitive and behavioural capacities, delaying motor (...) programmes should be considered (Case study 3). The most successful programmes place a strong focus on cognitive outcomes, which are more malleable earlier in life. More information on the importance of these approaches for SROI is provided in the linked report on investment for health and well-being (12). Such programmes provide disadvantaged children with an enriched out-of-family environment while also working to raise the quality of the home environment (22). Home visiting improves service uptake

2017 WHO Health Evidence Network

75. ABCD position statement on standards of care for management of adults with type 1 diabetes

of ageing leads to progressive losses which affect physical and cognitive performance and impact on diabetes management. Activity levels fall, muscle bulk reduces and appetite may decrease, leading to weight loss and frailty, with increased insulin sensitivity The risks of hypoglycaemia (particularly neurological damage and falls) are increased in this age group. Cognitive decline and visual impairment may make self- management decisions more difficult. Many people with type 1 diabetes will have decades (...) of experience in managing their condition – such knowledge cannot be passed on to carers and the loss of independence and the control of their diabetes can be very distressing. Factors affecting diabetes management in older people ? Comorbidities and geriatric syndromes including depression ? Impaired cognition leading to insulin errors, missed meals and reduced ability to identify and manage hypoglycaemia ? Visual, hearing and functional impairment ? Polypharmacy ? Falls and fractures ? Vulnerability

2017 Association of British Clinical Diabetologists

76. Interventions Targeting Sensory Challenges in Children with Autism Spectrum Disorder - An Update

parents. Augment Altern Commun. 2011 Dec;27(4):256-66. doi: 10.3109/07434618.2011.587830. PMID: 22136364.X-1 672. Hodgetts S, Magill-Evans J, Misiaszek J. Effects of weighted vests on classroom behavior for children with autism and cognitive impairments. Research in Autism Spectrum Disorders. 2011 2015-12- 09;5(1):495-505. doi: 10.1016/j.rasd.2006.08.006 http://dx.doi.org/10.1016/j.rasd.2010.06.015. PMID: 815571560; 2010-22960-053. X-1, X-3 673. Hodgetts S, Magill-Evans J, Misiaszek JE. Weighted vests (...) high risk of bias [ROB]). Populations, intervention approaches, and outcomes assessed varied across studies. Relative to usual care or other interventions, sensory integration–based approaches improved measures related to sensory and motor skills in the short term (3 RCTs with high, moderate, and low ROB and 1 high ROB retrospective cohort study). Environmental enrichment improved nonverbal cognitive skills in treated children compared with standard care in two small RCTs (low and moderate ROB

2017 Effective Health Care Program (AHRQ)

77. CRACKCast E102 – Seizures

damage Rhabdomyolysis Autonomic discharge & bulbar muscle involvement may result in Urinary or fecal incontinence Vomiting Tongue biting Potential airway impairment. Posterior shoulder dislocations or fractures [9] Describe the legal implications of diagnosis of new seizure According to the Government of British Columbia New onset seizure has a private driving restriction: With a seizure free period up to 6 months; Or Medical clearance to drive by a Neurologist Professional Drivers must be: Seizure (...) will see seizures! Bimodal age distribution with vast majority being in infants (febrile seizures) and the elderly over age 75 (structural brain abnormalities). For neurons to work properly, we need a balance milieu inside and out of the cell membrane. This includes the balance between excitatory neurotransmitters (think glutamate and acetylcholine) and inhibitory neurotransmitters (think GABA). So things like infection, infection, toxins, electrolyte imbalances, and other pathologic processes come

2017 CandiEM

78. BTS Clinical Statement on Pulmonary Arteriovenous Malformations

disease or symptoms, there is no evidence that patients with PAVMs require supplemental oxygen during air travel. 82 Supplementary oxygen may be helpful for rare patients describing cardiorespiratory symptoms (usually in the setting of concurrent cardiac, respiratory or bone marrow disease) or neurological symptoms such as ‘dizzy spells,’ impaired cognition or other indicators of reduced cerebral oxygen delivery. 80 iii) There is no indication for ‘prophylactic’ venesection for the asymptomatic PAVM (...) that provide a continuous right-to-left shunt between pulmonary arteries and veins. Their importance stems from the risks they pose (>1 in 4 patients will have a paradoxical embolic stroke, abscess or myocardial infarction while life-threatening haemorrhage affects 1 in 100 women in pregnancy), opportunities for risk prevention, surprisingly high prevalence and under- appreciation, thus representing a challenging condition for practising healthcare professionals. The driver for the current Clinical

2017 British Thoracic Society

79. Canadian stroke best practice recommendations: acute inpatient stroke care guidelines, update 2015

and strokerecoverygroupliaisons(EvidenceLevelB). iii. The interprofessional team should assess patients within48hofadmissiontohospitalandformulate a management plan (Evidence Level B). a. Clinicians should use standardized, valid assess- ment tools to evaluate the patient’s stroke- related impairments and functional status (Evidence Level B). b. Assessment components should include dyspha- gia, mood and cognition, mobility, functional assessment, temperature, nutrition, bowel and bladder function, skin breakdown, discharge (...) Level C). vi. Patients should undergo an initial screening for vascular cognitive impairment when indicated (Evidence Level C). 2.1. Cardiovascular investigations i. Incaseswheretheelectrocardiogramorinitialcar- diac rhythm monitoring (e.g. 24 or 48h ECG monitoring) does not show atrial ?brillation but a cardioembolic mechanism is suspected, International Journal of Stroke, 11(2) 244 International Journal of Stroke 11(2)prolonged ECG monitoring, up to 30 days dur- ation, is recommended in selected

2015 CPG Infobase

80. Care at the Scene: Research for ambulance services

and injuries. But the majority of 999 calls are not traffic accidents and heart attacks. More typical- ly, calls involve people with complex and ongoing health problems experiencing a crisis. This could be an elderly person with heart failure and diabetes having had a fall, someone with lung disease experiencing breathlessness or a person at risk of suicide ringing in distress. Patient needs have become more complex, there is an ageing population and the number of 999 calls has risen. At the same time (...) arrangements. It is sometimes difficult to know which option is best. And we need to understand what encourages people to choose one service over another. The question of where patients go is addressed in part of an NIHR review looking at published research on drivers for increased demand for emergency care (Turner 2015, NIHR published study one). The reasons were complex and difficult to synthesise from the 38 relevant papers, but included issues such as access to, and confidence in, primary care

2016 NIHR Dissemination Centre - Themed Reviews

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