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Elderly Drivers with Cognitive Impairment


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81. Diabetes Care

if patient presents with depression, falls, cognitive impairment, perceptual difficulties, or urinary incontinence. Use sulfonylureas (especially glyburide) with caution as the risk of hypoglycemia increases with age. Generally, initial doses can be half of those for younger people and increased more slowly. Monitor postural blood pressure. Consider less strict glycemic targets (7.1 - 8.5% A1C) if the individual has limited life expectancy, high functional dependency, extensive disease or multiple co (...) -morbidities etc. Consider a cognitive assessment before initiating insulin. See the - Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care for assessment tests. Pregnancy Contraception and pre-pregnancy planning in all patients with diabetes is encouraged. Identify patients with previous gestational diabetes. These patients can develop type 2 diabetes and special attention prior to next pregnancy and in later life, is necessary. See the CDA guide on women of child-bearing age

2015 Clinical Practice Guidelines and Protocols in British Columbia

82. Guidance on the clinical management of depressive and bipolar disorders, specifically focusing on diagnosis and treatment strategies

assessment for (hypo)manic symptoms is essential. Cognitive impairment in mood disorders. The issue of cognitive impairment in mood disorders has been recognised for many years, particularly in the elderly in whom the phenomenon has been described as pseudodementia. However, while it has been clear for some time now that episodes of mood disturbance are associated with significant cognitive impairment, two issues are becoming increasingly clear. Firstly, it is clear that in recurrent mood disorders some (...) degree of cognitive impairment remains between episodes. This is the case in both unipolar depression (Bora et al., 2013) and bipolar disorder (Baune and Malhi, 2015; Bourne et al., 2013). Secondly, this impairment is clinically significant in terms of overall functioning, once again in both unipolar and bipolar disorders (Malhi et al., 2007; Porter et al., 2015; Withall et al., 2009). Therefore, this is an issue which is receiving increasing attention with research into both pharmacological

2015 Royal Australian and New Zealand College of Psychiatrists

83. Ocrelizumab (Ocrevus) - multiple sclerosis

a positive opinion for granting a marketing authorisation to Ocrevus on 9 November 2017. 2. Scientific discussion 2.1. Problem statement 2.1.1. Disease or condition Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating disease of the central nervous system (CNS) resulting in neurological impairment and severe disability. With the present application the applicant intended to seek approval of ocrelizumab for the following indications: “Ocrevus is indicated for the treatment of adult patients (...) as the age at which higher levels of disability are achieved are comparable between subtypes despite the later age of onset in PPMS. The actual rate of progression of disability seems not to differ between subtypes, once steady progression of disability has commenced. A higher proportion of PPMS patients present initially with motor impairment, cerebellar ataxia, and brainstem symptoms than relapsing-onset patients, and spastic paraparesis is a common early clinical presentation. The diagnosis of PPMS

2018 European Medicines Agency - EPARs

84. Clinical guidance for responding to suffering in adults with cancer

, it is not the focus of this guideline as the literature review on which it is based excluded literature that solely focused on physical suffering. The psychosocial and spiritual aspects of suffering are the focus of this guideline. Whilst there may be some commonality with depression (the person who is depressed is invariably suffering), it is not true that the person who is suffering is invariably depressed. Depression is considered to be an illness char- acterised by pervasively lowered mood, impaired capacity (...) has not been satisfying. 58 There is a risk that demoralisation as a clinical problem is overlooked because the symptoms may be considered normal for someone in such a situation. However, using similar strategies for both people who are demoralised and those who are experiencing other kinds of suffering may be of benefit. Although the systematic review 2 did not find a significant effect for spirituality domains for Cognitive Behavioural Therapy 58 or dignity therapy, 75 which is designed

2014 Cancer Australia

85. Palliative care - nausea and vomiting

the stage of the person’s illness, their prognosis, the severity of their symptoms, and the wishes of the person and their family. Simple measures may help relieve nausea and vomiting in palliative care. They include: Ensuring access to a large bowl, tissues, and water. Eating snacks consisting of a few mouthfuls rather than large meals. Drinking cool fizzy drinks rather than still or hot drinks. Relaxation techniques. Parenteral hydration, if appropriate. Cognitive behavioural therapy (for anticipatory (...) therapies; relaxation and acupressure bands may be useful to relieve symptoms. Consider cognitive behavioural therapy for anticipatory nausea or vomiting. In general, avoid nasogastric suction. It has no role in the management of most causes of nausea and vomiting. Basis for recommendation Basis for recommendation These recommendations are based on palliative care literature from textbooks [ ; ; ] and published journal articles [ ; ]. CKS could not find studies relating to acupuncture or relaxation

2017 NICE Clinical Knowledge Summaries

86. Palliative cancer care - pain

elderly or cognitively impaired people, and those who are dying [ ]. CKS has adopted the classifications of severity of pain given (on the basis of expert opinion) in the SIGN guideline [ ]. However, it is acknowledged that these definitions are subjective, and clinical judgement is therefore needed. Assessment of pain characteristics How should I assess the characteristics of the pain? Enquire about: Site and number of pains. Radiation. Quality. Timing (onset, duration, breakthrough or incident pain (...) with the person directly if possible. The person, if competent and able to communicate, is the most reliable source of information about their pain. If it is not possible to ask them (because of cognitive impairment or communication deficits, for example), the family or healthcare professionals may be able to help with the assessment, bearing in mind that family members may overestimate, and healthcare professionals underestimate, the person's pain. Assess each pain a person has with a view to establishing

2017 NICE Clinical Knowledge Summaries

87. Delirium

circumstances The recommendations on when management of delirium in primary care may be appropriate are based on expert opinion in review articles [ ; ; ]. Delirium is serious and is often best managed in hospital. However, admitting the person to hospital for care must be balanced against the potentially negative effects of a sudden change in environment on elderly people or those who have cognitive impairment [ ]. Management plans should be formulated with the person's and their family and/or carer's (...) cognitive impairment is suspected following an episode of delirium, follow local protocols for cognitive impairment assessment. For further information, see the CKS topic on . Specialist treatment What specialist treatment is available? Specialists such as elderly care psychiatrists, the challenging behaviour team, or elderly care physicians may suggest pharmacological measures as a last resort for severe agitation or psychosis if [ ; ]: Verbal and non-verbal de-escalation techniques are inappropriate

2017 NICE Clinical Knowledge Summaries

88. Palliative care - secretions

the bronchiolar surfaces and cause inflammation of the mucosa, which triggers copious mucus production [ ]. Gastric reflux may also cause pooling of fluid in the hypopharynx [ ]. Oropharyngeal or gastric contents may be aspirated into the larynx and lower respiratory tract. Factors predisposing to aspiration include impaired consciousness, old age, impaired cough or gag reflex, and structural diseases of the airway and upper gastrointestinal tract. People who aspirate may have recurrent episodes of choking (...) that they are dying. Have reduced cognition, and are drowsy or comatose. Are bed-bound. Take little food or fluid, and have difficulty taking oral medication. Are peripherally cyanosed and cold. Have an altered breathing pattern Basis for recommendation Basis for recommendation These recommendations are based on guidance from the National Institute for Health and Care Excellence [ ; ] and expert opinion [ ]. Pooling of saliva is the most common cause of rattling breathing in a person who is terminally ill

2017 NICE Clinical Knowledge Summaries

89. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia

(catheter and radiofrequency; fast and slow pathway), accessory pathway (manifest and concealed), antiarrhythmic drugs, atrial fibrillation, atrial tachycardia, atrioventricular nodal reentrant (reentry, reciprocating) tachycardia, atrioventricular reentrant (reentry, reciprocating) tachycardia, beta blockers, calcium channel blockers, cardiac imaging, cardioversion, cost effectiveness, cryotherapy, echocardiography, elderly (aged and older), focal atrial tachycardia, Holter monitor, inappropriate sinus (...) and elevated levels of atrial natriuretic protein in patients with AVNRT compared with patients who have AVRT or atrial flutter. True syncope is infrequent with SVT, but complaints of light-headedness are common. In patients with WPW syndrome, syncope should be taken seriously but is not necessarily associated with increased risk of SCD. The rate of AVRT is faster when AVRT is induced during exercise, yet the rate alone does not explain symptoms of near-syncope. Elderly patients with AVNRT are more prone

2015 American Heart Association

90. Heart Failure Management in Skilled Nursing Facilities

-term residents in SNFs, 1 317 200 (nearly 90%) were ≥65 years of age, representing nearly 5% of the population aged ≥65 years. More than 70% of these were women, and nearly half were ≥85 years old. Close to 60% of long-term SNF residents are cognitively impaired. , An estimated 63 800, or 4.3% of long-term SNF residents, had a primary diagnosis of HF during admission, and ≈70 000 (4.7%) had a primary diagnosis of HF during this 2004 survey. Many postacute patients are admitted to SNFs with other (...) includes bathing, dressing, toileting, transferring, continence, and feeding, only 30% will return to their prior level of functioning. Gross motor coordination and manual dexterity, absence of cognitive impairment, and absence of significant weight loss are associated with a successful transition from SNF to home without disability. Frailty, defined as a compromised ability to cope with physiological stress, is common in SNF residents. Frailty is usually described by reduced function in multiple

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2015 American Heart Association

91. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence

of treatment ( ADA Level of Evidence C ).Less stringent A 1c goals (eg, <8.0% or even slightly higher) are appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced complications, cognitive impairment, and extensive comorbid conditions and those in whom the target is difficult to attain despite intensive self-management education, repeated counseling, and effective doses of multiple glucose-lowering agents, including insulin ( ADA Level of Evidence B ). Blood (...) , the A 1c threshold for increased diabetes mellitus risk is less clearly defined than that for a diagnosis of diabetes mellitus. There is a strong risk gradient between 5.7% and 6.4%, with no obvious threshold. Elevated A 1c , even below the threshold for diagnosis of diabetes mellitus, is also associated with cardiovascular outcomes after adjustment for traditional cardiovascular risk factors. , , , The evidence for an association of impaired fasting glucose (100–125 mg/dL) with cardiovascular outcomes

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2015 American Heart Association

92. Rapid literature review on motivating hesitant population groups in Europe to vaccinate

all types of vaccines and six focused on childhood vaccines. Study populations The literature review identified several study populations, in which determinants of vaccine refusals or hesitancy were ascertained: parents [2,3,1,4,5,6–9], mothers [10], religious communities [11,12,13], healthcare workers [14,15,1,16–18], immigrants [19], social media users [20], pregnant women [21], patients with chronic diseases [22,23], and the elderly [24]. Although no article focused entirely on ‘hesitant (...) [11,14,21,27,13,29,5,18,8]. The problem of access (timing or availability of vaccines) was encountered seven times [14,19,1,22,4,24,8]. Two of these articles were looking at healthcare workers [14] and patients with chronic diseases [4] in the UK, two were looking into immigrants [19] and the elderly [24] in the Netherlands, and one was looking at chronic disease patients [22] in France. Access issues were encountered regarding the influenza vaccine (seasonal or pandemic) and childhood vaccines. The issue of financial

2015 European Centre for Disease Prevention and Control - Literature Reviews

93. Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min)

Impairment (KHA-CARI) and the American Society of Nephrology (ASN), with the request to have the guideline evaluated by two of their members. In addition, all members of the ERA-EDTA received an online questionnaire in Survey Monkey format to evaluate the guideline using the AGREE-II framework. In addition, a free text field was provided to allow for additional comments (see Appendix 6). All comments and suggestions were discussed with the guideline development group by e-mail, as well as during a final (...) results in improved outcomes, QoL and patient satisfaction. Analyse outcomes on PD versus HD in different subgroups, such as elderly patients with diabetes, while taking into account differences in practices in different centres and countries (e.g. impact of assisted care). Development and validation of decision-making tools for the timely transfer to HD/PD after PD/HD start. Develop and validate statistical models that can take into account modality transfers and thus allow the exploration

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2015 European Renal Best Practice

94. Acute Pain Management: Scientific Evidence

Paediatric pain assessment 412 9.3.1 Pain assessment in neonates 413 9.3.2 Observational and behavioural measures in infants and children 414 9.3.3 Self-report in children and adolescents 415 9.3.4 Children with cognitive impairment or intellectual disability 416 9.4 Analgesic agents 421 9.4.1 Paracetamol 421 9.4.2 Nonselective NSAIDs 424 9.4.3 Coxibs 429xix CONTENTS 9.4.4 Opioids and tramadol 430 9.4.5 Ketamine 438 9.4.6 Alpha-2-delta ligands (gabapentin/pregabalin) 440 9.4.7 Alpha-2 adrenergic agonists (...) Cognitive-behavioural interventions 262xvii CONTENTS 7.2 Transcutaneous electrical nerve stimulation 265 7.3 Acupuncture and acupressure 265 7.3.1 Postoperative pain 265 7.3.2 Other acute pain states 267 7.4 Physical therapies 269 7.4.1 Manual and massage therapies 269 7.4.2 Warming and cooling intervention 270 7.4.3 Other therapies 271 References 271 8. SPECIFIC CLINICAL SITUATIONS 279 8.1 Postoperative pain 279 8.1.1 Multimodal postoperative pain management 279 8.1.2 Procedure-specific postoperative

2015 Clinical Practice Guidelines Portal

95. Strategies for discontinuing benzodiazepines

deterioration, accidents and falls, deterioration of complex skills such as driving, and paradoxical behaviour. 2 benzodiazepine-induced severe cognitive deterioration in elderly patients can be mistaken for the onset of dementia. For this reason ben- zodiazepines should be avoided in the elderly, but other sedating drugs can also cause the same problems. 2 Adverse effects occur more frequently when long half- life drugs (over 24 h) are used, when the dose is higher than the recommended, when treatment (...) Psycotherapy This consists of supporting a withdrawal strategy through cognitive behavioural therapy. It requires identification and correction of behaviour problems and learning sleep hygiene habits (Appendix 2), control of stimuli or relaxation techniques. 22 Various studies support the efficacy of cognitive behavioural therapy in addition to a benzodiazepine tapering schedule. In two studies, 23-24 this intervention proved adequate for elderly patients with chronic insomnia, although benefits may

2015 Drug and Therapeutics Bulletin of Navarre (Spain)

96. Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention

such as CVD, T2DM, and depression, which, either individually or collectively, represent the leading causes of morbidity and mortality in the United States. More than 35% of US adults >20 years are obese, and >1 in 4 Americans have multimorbidity, which is associated with high healthcare use and costs, functional impairment, poor quality of life, psychological distress, and premature death. Sustained weight loss of 3% to 5% can delay or possibly prevent T2DM , and significantly improve CVD risk factors (...) age (SD):Int1: 37.7 (11.8) yInt2: 39.6 (12.2) yWomen:Int1: 68%Int2: 81%White:Int1: 85%Int2: 78%BMI:Int1: 31.8 (3.2) kg/m 2 Int2: 31.4 (4.1) kg/m 2 Retention:Int1: 90%Int2: 92% Int1: Social cognitive theory–based wt loss podcastDiet: Increase fruit and vegetable intake, decrease fat intakePA: Increase from baselineBehavior: Encourage tracking wt, calories, and exerciseInt2: Non–theory-based wt loss podcastDiet: Avoid overeatingPA: NRBehavior: NR Podcast via MP3 player or computer for Int1 and Int2

2015 American Heart Association

97. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer

, high-resolution ultrasound (US) can detect thyroid nodules in 19%–68% of randomly selected individ- uals, with higher frequencies in women and the elderly (3,4). The clinical importance of thyroid nodules rests with the need to exclude thyroid cancer, which occurs in 7%–15% of cases depending on age, sex, radiation exposure history, family history, and other factors (5,6). Differentiated thyroid cancer (DTC), which includes papillary and follicular cancer, com- prises the vast majority (>90

2015 Pediatric Endocrine Society

98. Management of Constipation in Adult Patients Receiving Palliative Care

identified to have unmet needs, with more healthcare resource utilisation, increased inpatient days and emergency admissions as a result. Indicators of unmet clinical needs were associated with a €2,501.47 incremental annual healthcare cost compared to patients without these indicators. This cost difference was mainly driven by hospitalisation and pharmacy costs (26). Resource utilisation associated with the diagnosis and management of constipation is a significant driver of increased cost ( 22). Much

2015 National Clinical Guidelines (Ireland)

99. The Management of Upper Extremity Amputation Rehabilitation (UEAR)

facilities and VA healthcare since 2001, approximately 30 percent in DoD and 18 percent in VA have involved one or both upper limbs. [3] The successful rehabilitation of patients with upper limb amputations is influenced by a variety of factors that include, but are not limited to, level of amputation, cognitive impairment, physical conditioning, nutritional status, social support, psychological factors and motivation. To maximize successful outcomes and return patients to independent living in home (...) Pain Assessment 29 Behavioral and Cognitive Health Assessment 32 Assessment of Patient’s Personal, Social, and Cultural Contexts 34 VA/DoD Evidence-Based Clinical Practice Guideline for the Management of Upper Extremity Amputation Rehabilitation Page 4 of 149 Learning Assessment 35 Residual Limb Assessment 35 Contralateral limb and trunk 36 Prosthetic Assessment (if applicable) 37 Vocational Rehabilitation 38 Annual Assessments 39 Outcome Measures 39 Core 3: Patient-Centered Care 41 Shared Decision

2014 VA/DoD Clinical Practice Guidelines

100. General practice management of type 2 diabetes 2014-15

? Assess (inclusive within an annual cycle of care) Risk factors for modification GP/practice nurse/diabetes educator Weight, height GP/practice nurse Cardiovascular risk assessment GP/practice nurse Foot examination Podiatrist/GP/practice nurse Presence of other complications GP/practice nurse/diabetes educator Psychological status GP/practice nurse/psychologist Eye examination GP/optometrist/ophthalmologist Dental review Dentist Consider other assessments where appropriate, e.g. cognitive impairment (...) diabetes 3. Screening, risk assessment, case finding and diagnosis 3.1 Identifying risk of diabetes in asymptomatic patients Recommendations Reference Grade* Individuals should be screened for risk of diabetes every 3 years from age 40 years using AUSDRISK (25) NHMRC, 2009 B Individuals at high risk and those with impaired glucose tolerance or impaired fasting glucose (not limited by age) should be tested: • with fasting blood glucose (25) NHMRC, 2009 B • every 3 years (25) NHMRC, 2009 C Aboriginal

2014 Clinical Practice Guidelines Portal

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