Falls

My Top differentials in this patient:

Cognitive impairment
Poor home environment
Polypharmcacy

Assess pt
- Gait - ?ataxia, ?Parkinsonian (festination, slowing),
- Cognitive Ax – MMSE, AMTS
- Frailty – grip strength, timed up and go, BMI, self-reported exhaustion
- Functional Ax
- Visual assessment - cataracts

Biochemical
- Check for reversible causes of this person’s cognitive impairment Vit D, thyroid, hypercalcaemia
- Rule out diseases, esp. infection (raised inflamm markers, urinanalysis for UTI)
- Consider CT brain (stroke, haemorrhage)

Home environment
- OT home assessment = ? environmental assessment, loose rugs, long cords
- installation of rails as necessary
- Pre-emptive Community ACAT assessment – in case patient may continue on downward trajectory
in terms of cognitive impairment, and may need to go into respite or RACF. ACAT nurse will do an
indepth assessment, and provide funding for services

Cognitive Impairment

55M HIV -? unsure if well controlled

Glioblastoma resection
Mental slowing

Top differentials in this patient:

Opportunistic infections in c/o HIV
Neurosyphilis
HIV associated neurocognitive disorder
Radiotherapy for glioblastoma

Mx:
Obtain collateral history from family – get an idea of any longitudinal decline in cog impairment

Rule out pseudodementia (depression) – DASS or K10 questionaire

Rule out reversible causes of cognitive impairment – Ca, Vit D, TFTs, ?CT brain (vascular or embolic
phenomena)
Obtain CD4 count and viral load – assess if HIV is underlying cause

Assess cognitive assessment further

- MMSE
- AMTS
- Clock drawing test
?Can follow-up with formal neuropsych assessment
?Can do functional imaging of brain - functional MRI, FDG-PET

Mx
- Promote increased physical activity
- ?Donepezil – may benefit a small proportion of patients by slowing cog decline, hard to predict who
Must do ECG for bradycardia prior

Smoking cessation
Identify reasons for this person’s relapse
- Psychosocial stressors – e.g. family conflict
- Low mood in c/o of transplant care

Identify
(i) level of dependence
(ii) stage of change – pre-contemplative, contemplative, preparation, maintenance

As such, my goal of management with this patient is:

- Quitting smoking
OR
- Harm minimisation
+/- Addressing associated vascular risk factors

Mx:
Attempt to forge a therapeutic relationship with patient through regular OP review
At the outset, set up a follow-up date within a week of the patient’s proposed date of
quitting/cutting down
- this should be done irrespective of how successful the patient is in achieving their goal

I would like to explain to the pt the benefits of quitting smoking

- improved mortality
- decreased risk of CVD, COPD, cancer, T2DM, bone mineral density loss, serious infections, poor
wound healing
- saving money

I would recommend a combination of behaviourial and pharmacological treatments to help this

patient quit, as studies show that this is most beneficial

Behaviourial therapies:
- Counselling
- Cognitive Behaviourial Therapy
- Improve physical activity (30 mins mild-moderate intensity per day)
- Ask pt to avoid known triggers -e.g. alcohol or visintg certain social venues
- Enlist the help of family or friends to keep them accountable
- Install quitting apps on his phone (e.g. Quit Now!)

Pharmacological therapties
- Best evidence is with combination Nicotine Replacement Therapy (if pt can tolerate it). Incldes a
nicotine patch (long-acting form of NRT) and short-acting NRT of patient’s choice (gum, lozenges,
inhaler, mouth spray).
- benefit is that pt can titrate the dose of NRT to suit their needs until their cravings abate
CONTRAINDICATE – unstable angina, coronary vasospasm, recent MI, stroke

Other options
- Buproprion – for target groups of patients with CVD or COPD
S/E: insomnia, nightmares, headaches, dry mouth, nausea
-Varencicline. S/Es: nausea, sleep disorders.

Non-adherence
Why I’m concerned about non-adherence in this patient
…

I believe the reasons for this patient’s

Mx
1. Financial costs
- Help this person apply for concession card (e.g. Pensioner’s card, Disability Support Benefit) to
obtain medicines at a discount
- Explore any allowances that they are entitled to from the Government – e.g. Youth Start, Family
Allowance

2. Health beliefs
- Formally assess capacity
- Sit down and explore their concerns, including side-effects or adverse reactions
- Educate them on the benefits of taking the medications
- Involve family/carers/friends/GP in discussion, if they have a therapeutic relationship with them

3. Difficult formulation
- Engage a pharmacist to see if there are alternative formulations (be it liquid, or smaller
tablets/capsules)
- Do a comprehensive pharmacy review -> rationalize medications, choose single tablets, opt daily
dosing where possible, organize a Blister Pack

4. Busy lifestyle
- Seek to tie medication taking with regular day-to-day activities -> e.g. brushing teeth
- Set up alarms on mobile phone
Social Isolation
Why I’m concerned about this patient:
Impact on overall health
QoL
Mortality
Mental wellbeing in c/o of bilat lung Tx
Impacting on his usual activities, including surfing with friends
Impeding his ability to interact with friends
Impact on his ability to follow-up with outpatient clinics

Mx:

First rule out any associated disorders that might be exacerbating his social isolation
- Depression – DASS, K10
- Cognitive impairment – MMSE, AMTS, Clock drawing test. Rule out secondary, reversible causes:
Vit D, TFTs, Ca.

Refer him to community support groups, could provide him with a safe, friendly and healing
environment of like-minded individuals to help improve his mood and improve his social
integration
- e.g. Men’s Shed, Community Day Centres, RSL clubs

To help with him attend his outpatient specialist appointments, I would seek to:
- Improve his access to these appointments by facilitating community transport, and
- (where possible) Coordinating specialist appointments to occur on same day, so he has less chance
of missing them