The National Medicine for Old Age Psychiatrists conference is an annual event that is now in its ninth year. Its aim is to provide old age psychiatrists with a comprehensive review of the common medical conditions that affect older patients. Topics reviewed at the conference included stroke, respiratory disease, cardiology, Parkinson’s disease and palliative care.
Stroke is common. It accounts for 11% of deaths in England and Wales (five million deaths annually). Every five minutes someone in England has a stroke. One in four people can expect to have a stroke if they live to 85 years and one quarter of strokes occur in people aged under 65 years.1 Around half of stroke survivors are left dependent on others for activities of daily living.
The World Health Organization describes stroke as “rapidly developing clinical signs or symptoms of focal cerebral dysfunction, lasting more than 24 hours, or that lead to death with no apparent cause other than vascular.”
Stroke is not always easy to diagnose but the right tests help. The role of imaging is to confirm clinical suspicion.
Atrial fibrillation (AF) is very common and it increases as you get older. AF causes a lot of strokes. The annual risk of stroke is 6% and if you are in AF and then have a stroke, the risk of another stroke goes up to 12%.2 In the next four hours, 10 people with AF will have suffered a stroke so it is very important to manage this. If a patient stops warfarin it takes only a few minutes for clots to form and for people to have strokes. The evidence is that drugs such as aspirin and clopidogrel only reduce risk by a fraction. So we use warfarin or the new oral anticoagulants such as rivaroxaban, dabigatran and apixaban. They are more expensive but NICE recommends that new patients go onto these medications.3
The take home messages are that stroke is a sudden local neurological loss of function—this is a neurological emergency and an ambulance needs to be called. Transient ischaemic attacks (TIA) are exactly the same as strokes (just less severe) and so patients with TIAs need to be referred urgently to the TIA clinic. Look for the cause (tailored prevention) of the TIA/stroke such as carotid stenosis and atrial fibrillation.
High blood pressure is the largest modifiable risk factor—monitor and treat to prevent all strokes. This is especially important in cerebral small vessel disease and primary intracerebral haemorrhage. Atherosclerosis may be less important here. Patients with ischaemic stroke should be on clopidogrel and a statin.
Report based on a talk by Dr Usman Khan, Consultant Stroke Specialist, St George’s Hospital NHS Trust
COPD: an update
Chronic obstructive pulmonary disease (COPD) didn’t exist when I was in medical school. Now it is an over arching term used to describe a number of conditions including chronic bronchitis, emphysema, chronic obstructive airways disease and chronic overflow limitation. There are some variations within this, but nearly all are caused by smoking and nearly all present in the same way.
What is it? Well it is a chronic disorder characterised by persistent airflow obstruction. It is associated with persistent and progressive breathlessness, chronic productive cough and limited exercise capacity. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. Unlike asthma where with good treatment you can get airflow back to 100%.
It is common. There are over 900,000 people in the UK with a diagnosis but prevalence will be much higher. Prevalence increases with age. It remains the fifth most common cause of death in England and Wales and it is the second largest cause of emergency admissions.
Diagnosis is based on the right history and confirmed by spirometry with FEV1/FVC less than 0.7.
Treatment of COPD is smoking cessation. According to the NICE guidance effective inhaled therapy should be offered.4 In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:
If forced expiratory volume in one second (FEV1) ≥50% predicted: either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)
If FEV1 <50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA
Offer LAMA in addition to LABA and ICS to people with COPD who remain breathless or have exacerbations despite taking LABA and ICS, irrespective of their FEV1.
Maintenance use of oral corticosteroid therapy in COPD is not normally recommended, according to NICE. Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. Keep the dose as low as possible, monitor for osteoporosis and offer prophylaxis.
Theophylline should only be offered after trials of short- and long-acting bronchodilators or to people who cannot use inhaled therapy. Theophylline can be used in combination with beta2 agonists and muscarinic antagonists. Mucolytic therapy can be considered in people with a chronic productive cough and continue use if symptoms improve.
Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations.
Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation.4
The impact of exacerbations should be minimised by: giving self-management advice on responding promptly to the symptoms of an exacerbation; starting appropriate treatment with oral steroids and/or antibiotics; use of non-invasive ventilation when indicated; use of hospital-at-home or assisted-discharge schemes.
The take home message for COPD is self-management and more aggressive use of oxygen and NIV.
Report based on a talk by Dr Mark Cottee, Consultant in Geriatric Medicine, St George’s Hospital and Medical School. Dr Cottee also spoke about the diagnosis and management of pneumonia
Parkinson’s disease: a neuropsychiatric problem?
Is Parkinson’s disease (PD) a movement disorder with neuropsychiatric problems or a neuropsychiatric disorder with a few movement problems? It all depends on where you are coming from.
Both NICE and SIGN guidance emphasise the importance of specialist review both to establish and review the diagnosis of PD and to manage treatment. This is important because some of the ideas in PD have changed considerably. The management of non-motor symptoms are also covered such as depression, dementia and sleep disturbance.5,6
Early diagnosis can be important and might make a difference to knowing what the future is going to hold. At the moment we don’t have a neuro-protective strategy.
Non-motor symptoms often give us clues to diagnosis but we mostly use the Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria.7 Step one is diagnosis of a Parkinsonian syndrome. Step two is exclusion criteria such as repeated strokes and repeated head injury. Step three is inclusion criteria such as rest tremor and unilateral onset.
There is a four stage paradigm of PD care, which includes diagnosis, maintenance, complex and palliative. Non-motor symptoms dominate the clinical picture of advanced PD and correlate with advancing age and disease severity.
The PDS survey8 found that non-motor symptoms have a major impact on quality of life such as balance, sleep, memory failure, confusion and drooling. These type of symptoms have more impact on quality of life than motor symptoms, and they are likely to lead to nursing home placement and are therefore costly. Non-motor symptoms though are often under-recognised and inadequately treated.
The non-motor symptom complex of PD includes neuropsychiatric symptoms (such as depression, apathy, and hallucinations), sleep disorders (such as restless legs, periodic limb movements and REM behaviour disorder), autonomic symptoms (such as bladder disturbances and sweating) and gastrointestinal (such as constipation). Many non-motor symptoms are treatable.
A large study looked at the prevalence of non-motor symptoms. Of the 149 people recruited 15 to 18 years ago in the Sydney Multicenter Study of Parkinson’s disease, one third survived. The original study compared low-dose levodopa with low-dose bromocriptine. Problems experienced by people who survived 15 years from diagnosis included falls, which occurred in 81% of patients, and 23% sustained fractures. Cognitive decline was present in 84%, and 48% fulfilled the criteria for dementia. Hallucinations and depression were experienced by 50%. A quarter of patients had been admitted to nursing homes by 10 years.9
The frequency of depression is also high in PD patients at 40%, which is twice the rate of severe depression seen in other equivalently disabled patients. Psychosis is also a big problem as is dopamine dysregulation syndrome, REM behavioural sleep disorder and impulse control disorders.
Neuropsychiatric symptoms are common, often unrecognised and are major predictors of care home admissions. The evidence base for management of any of these symptoms is lacking. The take home message is take care with diagnosis and use caution with drugs.
Report based on a talk by Dr Doug MacMahon, Consultant Physician, Coventry
There is an increasing ageing population, which has led to an increase in chronic disease, community care requirements and total number of patients with dementia.
There is also an increase in the age of carers, which leads to challenges in end of life care and financial implications of complex care packages.
According to the World Health Organization the definition of palliative care is: “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
In older people, they are more commonly affected by multiple medical problems of varying severity and the cumulative effect of these may be much greater than an individual disease and typically lead to greater impairment and need for care. Problems of acute care may also be superimposed on economic hardship and that is only going to get worse.
If you look at the literature about where people want to die, 75% of respondents would prefer to die at home whereas those recently bereaved are slightly more likely to prefer inpatient hospice care. A key question is can people with dementia make such choices? Advance planning needs to be made at an early stage even if it is a difficult conversation.
What are the special issues in dementia? There is under assessment of pain (one in five older people limit their daily activities due to pain), lack of information and involvement in decision making (family member involvement is essential), lack of home care, lack of access to specialist services and lack of palliative care within nursing and residential homes.
What do healthcare professionals need to do? Ensure that they are adequately trained in the palliative care of older people, including pain and symptom management, communication skills and care coordination. They also need to ensure that older people with palliative care needs are regarded as individuals and that their right to make decisions about their health and care is respected. Palliative care can be divided into symptom control, psychosocial care and disease management.
It is also important that organisations work in a co-ordinated fashion with other statutory private or voluntary organisations that may help older people needing palliative care.
An important question is: can we predict death? It is important to have goal planning as it helps patients develop insight. It is difficult to say to a family that this patient is dying, but it assists with decision making.
What are the most important prognostic indications? These include reduced performance status, impaired nutrition and low albumin. Specific predictors are unable to swallow, hold a meaningful conversation and increased frequency of medical complications.
Pain management is important in end of life care. We need to assess for the presence of pain, take a relevant history from patient/family and use a categorical numerical rating scale
The take home message is that pain is an almost inevitable consequence of ageing, but being in pain is not. Communication is key in end of life care and dementia makes diagnosis of pain very difficult. Ethics plays a large role so avoid paternalism at all costs.
Report based on a talk by Professor Margot Gosney, Director Clinical Health Sciences, Reading
9. Hely MA et al. Mov Disord 2005; 20(2): 190–99