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Elderly Drivers with Cognitive Impairment

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161. Patient Modesty: Volume 88

with angina who insists that it is indigestion, may lead to unfavourable outcomes not only for the health care consumer, but also for the health care provider and the system. Then I wondered about other subcategories. What about the elderly, the infirm, the babies or the cognitively impaired? What about the 13-year-old who refuses treatment for severe pelvic inflammatory disease? The pregnant woman with a complicated pregnancy who insists on home delivery? Who is the client and who is the patient? Does (...) of grandeur used to justify paternalism and making the doctor work less. The reason for patient autonomy being legislated as a protected right and required by CMS is because societal expectations are is so technical, both cognitively and emotionally, based on published documentation (this blog, my blog) not readily understood by a physician that it becomes patently unfair to "dump" the final ensurement with regard to the specific activity (of shared decision making) onto the physician for an independent

2018 Bioethics Discussion Blog

162. Patient Modesty: Volume 91

for drugs requires that observers be of the same gender as the person being observed. No exceptions. This is the rule for the D.o.T for truck drivers and for SAMSHA for other federal agency required observed drug tests. The Feds gave men the same protections as women. However those protections do not extend to non-Federal jurisdictions. Private employer, State & Local police, court, and Halfway House mandated observed drug tests do not mandate same gender observers. Women more or less universally

2018 Bioethics Discussion Blog

163. Insulin therapy in type 1 diabetes

. However, the absolute blood glucose level at which signs and symptoms begin to occur can vary. The severity of hypoglycaemia is defined by the clinical manifestations: Mild hypoglycaemia presents with a wide variety of symptoms, including hunger, anxiety or irritability, palpitations, sweating, or tingling lips. As the blood glucose levels fall lower, the person may experience weakness and lethargy, impaired vision, and confusion or irrational behaviour. Cognitive function deteriorates when blood (...) % of the time and to calibrate it as needed. Children with one or more of the following: frequent hypoglycaemia; impaired awareness of hypoglycaemia associated with adverse consequences (for example seizures or anxiety); or inability to recognize, or communicate about, symptoms of hypoglycaemia (for example because of cognitive or neurological disabilties). Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence (NICE

2016 NICE Clinical Knowledge Summaries

164. Psychosis and schizophrenia

Psychosis and schizophrenia Psychosis and schizophrenia - NICE CKS Share Psychosis and schizophrenia: Summary Psychosis is a disordered mental state characterized principally by positive symptoms such as hallucinations, delusions, and thought disorder. Psychotic symptoms are cardinal features of psychotic disorders such as schizophrenia, but may be caused by medicines and substance misuse, and by medical conditions such as sepsis in the elderly. Psychotic disorders, including schizophrenia (...) drug should not be given to the person while awaiting specialist assessment unless it is done under advice from a consultant psychiatrist. For people who are at risk of developing a psychotic disorder, specialist mental health services will usually offer treatment with individual cognitive behavioural therapy (CBT) with or without family intervention. For people with a diagnosed psychotic disorder, specialist mental health services will usually offer a therapeutic trial of an oral antipsychotic

2016 NICE Clinical Knowledge Summaries

165. 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

2016 NICE Clinical Knowledge Summaries

166. Palliative care - nausea and vomiting

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 nausea (...) 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 for people experiencing nausea and vomiting

2016 NICE Clinical Knowledge Summaries

167. Palliative care - secretions

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, coughing, or pneumonia (...) . 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

2016 NICE Clinical Knowledge Summaries

168. Diabetes - type 1

does not cover the prescribing of insulin or the management of women with type 1 diabetes who are pregnant, planning a pregnancy, or breastfeeding. It also does not cover the diagnosis and management of impaired glucose regulation, or make detailed recommendations on the diagnosis and management of other types of diabetes. There are separate CKS topics on , , and . The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact (...) an informed discussion with the person about the risks and benefits of treatment, taking into account factors such as co-morbidities, potential benefits from lifestyle intervention, the person's preference, and life expectancy. December 2013 — minor update. Text has been removed from the section on antiplatelet treatment and links added to the updated CKS topic on Antiplatelet treatment . July 2013 — minor update. Links to the Driver and Vehicle Licensing Agency (DVLA) website have been updated. June 2013

2016 NICE Clinical Knowledge Summaries

169. Palliative cancer care - pain

, or verbal rating scales [ ]. This recommendation was based on expert opinion and non-analytic studies. There is no universally accepted tool for the assessment of cancer pain. Standardized pain assessment tools that have been recommended by the European Association of Palliative Care for use in research and clinical practice include visual analogue scales, numerical rating scales, and verbal rating scales [ ]. These are also valid tools for measuring pain in very elderly or cognitively impaired people (...) . 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 an underlying , bearing in mind

2016 NICE Clinical Knowledge Summaries

170. Insulin therapy in type 2 diabetes

, the absolute blood glucose level at which signs and symptoms begin to occur can vary. The severity of hypoglycaemia is defined by the clinical manifestations: Mild hypoglycaemia presents with a wide variety of symptoms, including hunger, anxiety or irritability, palpitations, sweating, or tingling lips. As the blood glucose levels fall, the person may experience weakness and lethargy, impaired vision, and confusion or irrational behaviour. Cognitive function deteriorates when blood glucose levels fall (...) , sweating, or tingling lips. Severe hypoglycaemia may result in convulsions, loss of consciousness, and coma. People with severe hypoglycaemia are unable to self-manage a hypoglycaemic episode and require help from another person to achieve normal blood glucose levels. Impaired awareness of hypoglycaemia occurs when a person with diabetes loses the ability to recognize the usual symptoms of hypoglycaemia, or when these symptoms are absent or blunted. Management of hypoglycaemia includes: Giving oral

2016 NICE Clinical Knowledge Summaries

171. Patient Modesty: Volume 91

for drugs requires that observers be of the same gender as the person being observed. No exceptions. This is the rule for the D.o.T for truck drivers and for SAMSHA for other federal agency required observed drug tests. The Feds gave men the same protections as women. However those protections do not extend to non-Federal jurisdictions. Private employer, State & Local police, court, and Halfway House mandated observed drug tests do not mandate same gender observers. Women more or less universally

2018 Bioethics Discussion Blog

172. Patient Modesty: Volume 88 Full Text available with Trip Pro

with angina who insists that it is indigestion, may lead to unfavourable outcomes not only for the health care consumer, but also for the health care provider and the system. Then I wondered about other subcategories. What about the elderly, the infirm, the babies or the cognitively impaired? What about the 13-year-old who refuses treatment for severe pelvic inflammatory disease? The pregnant woman with a complicated pregnancy who insists on home delivery? Who is the client and who is the patient? Does (...) of grandeur used to justify paternalism and making the doctor work less. The reason for patient autonomy being legislated as a protected right and required by CMS is because societal expectations are is so technical, both cognitively and emotionally, based on published documentation (this blog, my blog) not readily understood by a physician that it becomes patently unfair to "dump" the final ensurement with regard to the specific activity (of shared decision making) onto the physician for an independent

2018 Bioethics Discussion Blog

173. Depression

a first episode of depression, 70% after a second episode and 90% after a third episode. Increased in people under 20 years of age, and in elderly people. Depression is diagnosed according to the DSM-5 classification by the presence of at least five out of a possible nine defining symptoms, present for at least 2 weeks, of sufficient severity to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. People with depression should (...) Care. [ ] HTAs (Health Technology Assessments) No new HTAs since 1 July 2013. Economic Appraisals No new economic appraisals relevant to England since 1 July 2013. Systematic reviews and meta-analyses Barnard, K., Peveler, R.C. and Holt, R.I. (2013) Antidepressant medication as a risk factor for type 2 diabetes and impaired glucose regulation: systematic review. Diabetes Care 36 (10), 3337-3345. [ ]. Churchill, R., Moore, T.H.M., Furukawa, T.A., et al. (2013) ‘Third wave’ cognitive and behavioural

2015 NICE Clinical Knowledge Summaries

174. Insomnia

for elderly people). Lormetazepam 500 micrograms at night. Benzodiazepines are contraindicated in people with [ ]: Respiratory depression, marked neuromuscular respiratory weakness such as unstable myasthenia gravis, acute pulmonary insufficiency, and sleep apnoea syndrome. Adverse effects of benzodiazepines include : Cognitive and psychomotor impairment, depression, emotional blunting, and, less commonly, paradoxical excitement with increased anxiety, irritability, or hyperactive or aggressive behaviour (...) insomnia. The diary should be kept for at least 2 weeks. Good sleep hygiene should be established in all people with insomnia. This aims to make people more aware of behavioural, environmental, and temporal factors that may be detrimental or beneficial to sleep. For short-term insomnia, a short course (less than 2 weeks) of a hypnotic drug may be considered if daytime impairment is severe. For long-term insomnia, cognitive and behavioural interventions are recommended first line. A short course

2015 NICE Clinical Knowledge Summaries

175. Management of diabetes

Crescent Edinburgh EH12 9EB www.sign.ac.ukContents 1 Introduction 1 1.1 The need for a guideline 1 1.2 Remit of the guideline 1 1.3 Definitions 2 1.4 Statement of intent 3 2 Key recommendations 5 2.1 Lifestyle management 5 2.2 Psychosocial factors 5 2.3 Management of type 1 diabetes 6 2.4 Management of diabetes in pregnancy 7 2.5 Management of diabetic cardiovascular disease 7 2.6 Management of kidney disease in diabetes 7 2.7 Prevention of visual impairment 8 2.8 Management of diabetic foot disease 8 (...) and progression of kidney disease in diabetes 84 9.3 Screening for kidney disease in diabetes 85 9.4 Investigation of kidney disease in diabetes 87 9.5 Prevention and treatment of kidney disease in diabetes 87 9.6 Management of complications 93 9.7 Models of care 94 9.8 Checklist for provision of information 9510 Prevention of visual impairment 96 10.1 Risk identification and prevention 96 10.2 Screening 97 10.3 Treatment 100 10.4 Rehabilitation 102 10.5 Checklist for provision of information 102 11

2010 SIGN

176. Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning

addressed in this guideline, eg fever is covered by SIGN 108. 7 Table 1: Common impairments, limitations and complications after stroke Common impairments after a first ever stroke include: ? Aphasia ? Apraxia of speech ? Arm/hand/leg weakness ? Cognitive impairment ? Dysarthria ? Dysphagia ? Facial weakness ? Gait, balance and coordination problems ? Perceptual impairments, including visuospatial dysfunction ? Sensory loss ? Upper limb impairment ? Visual problems Common activity limitations include (...) General rehabilitation principles 12 4.2 Gait, balance and mobility 15 4.3 Upper limb function 19 4.4 Cognition 22 4.5 Visual problems 23 4.6 Communication 25 4.7 Nutrition and swallowing 26 4.8 Continence 29 4.9 Post-stroke spasticity 31 4.10 Prevention and treatment of shoulder subluxation 34 4.11 Pain 35 4.12 Prevention of post-stroke shoulder pain 36 4.13 Treatment of post-stroke shoulder pain 39 4.14 Post-stroke fatigue 42 4.15 Disturbances of mood and emotional behaviour 43 4.16 Sexuality 46

2010 SIGN

177. Management of obesity

and associated lost productivity. Treatment for affected individuals with elevated health risks, provided within clinical settings, represents only one part of a broader societal solution. The need for a comprehensive and multisectoral approach to obesity prevention is clear. Effective action requires addressing the commercial, environmental and social policy drivers of obesity. These are beyond the scope of this clinical guideline and approaches to broader determinants are discussed in other documents. 2,3 (...) or death. 46 2 + Mortality Obesity is associated with excess mortality. 47,48,49 BMI (above 22.5-25 kg/m 2 ) is a strong predictor of overall mortality with most of the excess mortality likely to be causal and due to vascular disease. In the elderly (age =65), a BMI in the moderately obese range is associated with a modest increase in mortality risk regardless of sex, disease state and smoking status. 50 Physical inactivity and adiposity have both independent and dependent effects on all-cause

2010 SIGN

178. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

in symptomatic patients, diabetes, diagnosis, dobutamine stress echocardiography, echocardiography, elderly, electrocardiogram (ECG) and chronic stable angina, emergency department, ethnic, exercise, exercise stress testing, follow-up testing, gender, glycemic control, hypertension, intravascular ultrasound, fractional flow reserve (FFR), invasive coronary angiography, kidney disease, low-density lipoprotein (LDL) lowering, magnetic resonance imaging (MRI), medication adherence, minority groups, mortality

2011 American Heart Association

179. Supportive care in multiple myeloma

be observed and some will become less anaemic as the myeloma is controlled with chemotherapy. ESA treatment is recommended for anaemic patients with myeloma with associated renal impairment ( ). ESA doses of <20 000 iu/week may be adequate in patients where renal disease is the main cause of the anaemia. In the UK, it may be necessary to refer the patient to a renal physician to access NHS funding for ESAs. Data from randomized trials, which have included patients with myeloma, suggest that ESAs increase (...) If no risk factors (RF) or only 1 RF consider aspirin If 2 or more RF present consider either: LMWH (high risk prophylactic dose e.g. enoxaparin 40 mg od) or Warfarin (target INR 2·5) Obesity (Body Mass Index ≥ 30) Co‐morbidities: cardiac, diabetes, renal impairment, chronic inflammatory disease Immobility (acute or chronic) Thrombophilias, myeloproliferative disorders, haemoglobinopathies Recent surgery (within 6 weeks): neuro‐, trauma, orthopaedic, general, other Medications: erythropoiesis stimulating

2011 British Committee for Standards in Haematology

180. CPG on sleep disorders in childhood and adolescence in primary care

practices and behavioral interventions that at least include stimulus control is recommended for treating insomnia. Another intervention that could be recommended is cognitive restructuring. B For adolescents, sleep education and management programmes are recommended, including guidelines on sleep hygiene practices, instructions on stimulus control and information about consuming substances and the impact that sleep problems can have on mood and academic performance. B To reduce cognitive activation (...) receive supervision when they perform potentially dangerous activities (such as swimming). Adolescents who are diagnosed with narcolepsy and who have driver’s licenses will be advised not to drive and to notify their status to the Department of Motor Vehicles. They will also be informed about legislation in force, which states that persons with narcolepsy may not obtain or extend a driver’s license, unless a favourable medical report is issued, in which case the validity period of the license can

2011 GuiaSalud

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