Chouliaras L, Topiwala A, Cristescu T
… +1 more, Ebmeier KP
Practitioner
· 2015 Jan · PMID 25726616
Common causes of memory loss in older people are mild cognitive impairment, the various types of dementia, and psychiatric illness, mainly depression. Around 10% of patients with mild cognitive impairment progress to dem...Common causes of memory loss in older people are mild cognitive impairment, the various types of dementia, and psychiatric illness, mainly depression. Around 10% of patients with mild cognitive impairment progress to dementia each year. Alzheimer's disease accounts for 60-80% of cases. Other common types of dementia are vascular, fronto-temporal, Lewy body, Parkinson's, and mixed type dementia. There is evidence to suggest that dementia pathology is established before the onset of symptoms, and thus mild cognitive impairment can be considered as a predementia stage. NICE guidance suggests examination of: attention, concentration, short- and long-term memory, praxis, language and executive function. Particular attention should be paid to any signs of neglect, state of dress, agitation or poor attention. Dysphasia and difficulty in naming objects is often present. Mood symptoms (including suicidal ideation) may be primary or comorbid. Abnormal thoughts and perceptions should be probed for, as psychotic symptoms are common. Primary care options for cognitive testing include the General Practitioner Assessment of Cognition or the Abbreviated Mental Test Score. Physical examination should include observation of gait, inspection for tremor; examination for rigidity, bradykinesia, frontal release signs, upper motor neurone lesions, pulse and BP. Structural brain imaging can improve diagnostic accuracy, exclude other pathologies and act as a prognostic marker of dementia progression but the overlap in structural changes between the dementias makes imaging alone insufficient for diagnostic purposes. NICE guidelines recommend referral to a memory clinic for patients with mild cognitive impairment, those at high risk of dementia, such as patients with learning disabilities, Parkinson's disease, or patients who have had several strokes.
Psoriatic arthritis (PsA) is a chronic, autoimmune disease, affecting up to 1% of the adult population and up to 40% of those with psoriasis. There is no universally accepted definition or diagnostic criteria for the dis...Psoriatic arthritis (PsA) is a chronic, autoimmune disease, affecting up to 1% of the adult population and up to 40% of those with psoriasis. There is no universally accepted definition or diagnostic criteria for the disease although the CASPAR classification of PsA is now the most widely used. PsA has a peak age of onset between 35 and 55 years with an equal gender distribution. Around 20% of patients develop PsA before psoriasis, often many years before skin or nail changes. Enthesitis, pain and tenderness at the insertion of any tendon onto the bone, is characteristic and screening for enthesitis should include palpation of the lateral epicondyle of the humerus, the medial condyle of the femur and the achilles tendon insertion. Diagnosis of PsA relies on a detailed history, particularly as many of the manifestations may be mild or transient, and therefore not reported by the patient. There may be a previous, current, or family history of psoriasis. There are no diagnostic blood tests for PsA. The presence of rheumatoid factor or anti-CCP antibodies does not preclude a diagnosis of PsA, but should prompt careful scrutiny of the diagnosis. X-rays of the hands and feet should be performed at baseline for all those with suspected inflammatory arthritis. Features of back pain that suggest an inflammatory cause, rather than a mechanical problem, include the presence of early morning stiffness and pain that is relieved by exercise and exacerbated by rest. Any patient with suspected inflammatory arthritis and a six-week history of painful, swollen joints should be referred for specialist assessment. Patients with PsA have a higher self-rated disease severity than those with psoriasis only and a 60% higher risk of premature mortality than the general population, their life expectancy is estimated to be approximately three years shorter. Aggressive treatment of early stage progressive PsA can substantially improve the long-term prognosis.
Gout affects 2.5% of the total UK population and is four times more common in men than women. The peak prevalence and incidence in the UK is in those aged 80-84 years. Gout is associated with comorbidities such as nephro...Gout affects 2.5% of the total UK population and is four times more common in men than women. The peak prevalence and incidence in the UK is in those aged 80-84 years. Gout is associated with comorbidities such as nephrolithiasis, chronic renal impairment, metabolic syndrome, depression and heart disease. It is also associated with increased mortality. Untreated gout can result in disabling irreversible peripheral joint damage and chronic usage-related pain. However, gout is curable. The pathogenic agents that cause gout i.e.urate crystals can be eliminated through a combination of effective patient education and evidence-based, targeted urate-lowering therapy. Gout is caused by the precipitation of monosodium urate crystals in and around a joint. The crystals preferentially form in peripheral, cooler joints and especially in those with osteoarthritis. It is thought that some of these preformed crystals within articular cartilage spill over into the joint space and trigger an acute attack of inflammation. Uric acid is predominantly renally excreted and the common heritable component of gout results from relative inefficiency of urate excretion. Chronic kidney disease, metabolic syndrome and drugs that reduce renal function (e.g. thiazide diuretics, beta-blockers and ACE inhibitors) will all lead to reduced elimination. Patients with chronic gout can present with monoarthritis but more commonly present with asymmetrical polyarthritis or tophi. Joints affected by osteoarthritis are preferentially targeted, the most common sites of involvement are feet, knees, hands and elbows. Diagnosis can be confirmed in primary care by taking a good history and clinical examination. An acute peripheral monoarthritis which reaches its peak within 24 hours and causes 'the worst pain ever experienced' is characteristic of an acute attack. A patient may have co-existing risk factors for gout such as osteoarthritis, obesity, hypertension, renal impairment, diuretic and antihypertensive drug use or increased beer or spirit consumption. A raised serum uric acid can confirm the diagnosis, however, this can be normal in the acute phase. Radiographs are rarely helpful but joint ultrasound may demonstrate deposits in cartilage, the synovium and peri-articular sites.
The number of men living with prostate cancer in the UK is predicted to rise from 255,000 to 416,000 in 2020 and 620,000 by 2030. More than 80% of men diagnosed with prostate cancer can expect to survive for at least fiv...The number of men living with prostate cancer in the UK is predicted to rise from 255,000 to 416,000 in 2020 and 620,000 by 2030. More than 80% of men diagnosed with prostate cancer can expect to survive for at least five years. Up to 87% of men with prostate cancer may have unmet supportive care needs. Patients regularly cite psychological and sexual issues as the most significant. Poor functional outcomes after treatment such as incontinence and erectile dysfunction have a major impact on quality of life. The traditional model of hospital follow-up fails to deliver optimum patient-centred cancer care. Holistic aspects of care such as psychological needs and factors which may facilitate full rehabilitation of patients back into society may be missed. The key elements of a survivorship programme are: education, intervention, surveillance and co-ordination of care. Interventions which may improve immediate care include: structured holistic needs assessment and care planning, treatment summaries and cancer care reviews, patient education and support events and advice about, and access to, physical activity schemes. Urologists and GPs need to collaborate to establish shared care pathways for prostate cancer patients. Elements of these innovative pathways will include clear follow-up protocols for prostate cancer survivors discharged into the community and rapid access arrangements for patients about whom GPs are concerned.
The UK has been highlighted, by the International Cancer Benchmarking Project and the EUROCARE groups, as a country with one of the lowest lung cancer survival rates. It has been postulated that this is due to an excess...The UK has been highlighted, by the International Cancer Benchmarking Project and the EUROCARE groups, as a country with one of the lowest lung cancer survival rates. It has been postulated that this is due to an excess of early deaths, delays in diagnosis are thought to contribute to this problem. A recent study showed that 30% of patients with lung cancer die within the first 90 days and they have seen their GP on average five times in the four months before diagnosis, suggesting there may be opportunities to diagnose these patients earlier in the disease process. The challenge GPs face is to identify and refer those at risk as early as possible and to maintain a high index of suspicion if symptoms persist. The SIGN guideline reiterates the importance of performing a chest X-ray in those in whom the suspicion of lung cancer has been raised and not to be falsely reassured by a normal chest X-ray in a high-risk patient. The initial investigation of choice in secondary care remains a CT scan of the chest and abdomen, followed by PET-CT scanning in those deemed suitable for potentially curative treatment. Smoking cessation reduces the risk of post-operative and systemic treatment-related complications and also reduces the chance of cancer recurrence. Surgery remains the initial treatment of choice for those with early stage disease in NSCLC who are deemed fit enough. Those who have early stage NSCLC (stage I or stage II) who are either medically inoperable or decline surgery should be offered radical radiotherapy. Hospital follow-up should be continued while patients are receiving treatment, complemented by clinical nurse specialist input alongside community support. All patients should have access to specialist palliative care teams. Those with palliative care input have improved quality of life and symptom control and fewer hospitalisations.
Studies in adult patients have suggested that 30% of those diagnosed with asthma do not have the condition and it is likely that the diagnosis is missed in many others. Initial clinical assessment should explore symptoms...Studies in adult patients have suggested that 30% of those diagnosed with asthma do not have the condition and it is likely that the diagnosis is missed in many others. Initial clinical assessment should explore symptoms of wheeze, breathlessness, chest tightness and cough. The probability of asthma is increased if more than one of these symptoms is present and particularly if symptoms are worse at night and in the early morning or are exacerbated by triggers such as exercise, allergen exposure, cold air or drugs. The BTS/SIGN guideline advocates spirometry after taking the history. If airflow obstruction is present, a trial of treatment can commence, but a firm diagnosis also requires a symptomatic response and an improvement in the measured airflow obstruction. The FeNO level correlates well with airway inflammation, and is therefore a good indicator of asthma and in particular of the likely response to inhaled corticosteroids. The test is especially useful for patients with suggestive symptoms but normal spirometry. The cornerstone of asthma monitoring is a structured clinical review conducted in primary care on at least an annual basis. Health outcomes are improved by education in self-management, incorporating written personalised asthma action plans. Checking concordance with existing therapies and inhaler technique before escalating treatment is an important part of improving the pharmacological management of asthma. Any patient prescribed more than one short-acting bronchodilator device a month should be identified and have their asthma assessed urgently and measures taken to improve overall control.