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Delirium: the warning sign we don’t want to miss for our more frail patients

17 Sep 2020

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! And it is both common and serious.

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Delirium: the warning sign we don’t want to miss for our more frail patients

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! And it is both common and serious.

Delirium is an important presenting feature or ‘barometer’ of acute illness in our elderly patients, but it can be a challenge to diagnose! It is common: prevalence in the community in the over-85s may be as high as 14%. And it is serious: patients diagnosed with delirium during a hospital admission are twice as likely to die in the next 12 months.

During this pandemic, more than ever, it is important that we are aware of the diagnosis and how not to miss it. Some studies have shown that 20–30% of COVID-19 infections will present with or develop signs of delirium during the course of the illness (Age and Ageing 2020 49;4:497). Older adults do not always mount the typical febrile response we might see in infection, and there is therefore a risk of missing potentially-reversible causes for our patients’ deteriorating condition. In addition, the unique circumstances of lockdown – isolation, heightened anxiety and a loss of control over normal life – will all increase the risk of delirium developing.

There are three subtypes of delirium:

  • Hyperactive delirium is most-commonly recognised and is associated with restlessness and agitation.
  • Hypoactive delirium accounts for up to 50% of delirium and is characterised by being withdrawn, quiet and sleepy. IT IS EASY TO MISS!
  • Mixed delirium exhibits features of both hyperactive and hypoactive delirium.

We should use a validated tool to check for delirium, then assess for all possible causative factors and reverse/treat these. The mnemonic HIDDEN CAUSE might help you remember the common causes of delirium (HIDDEN), and important predisposing factors (CAUSE). Those in italics are associated with hypoactive delirium.
 

Hypoxia Hypo/hyperthermia     

Infection             

Dehydration (or malnutrition)    

Drugs, drug withdrawal, polypharmacy  

Electrolyte or metabolic disturbance        

No poo (constipation!)  

 

Comorbidity including pre-existing cognitive impairment

Age (increasing) and Alcohol abuse

Urinary catheter

Sleep deprivation

Environmental issues (sensory deprivation, social isolation)
 

Our Pearl this week includes details on how to identify delirium using tools like the Confusion Assessment method and the 4AT; how to spot the hidden causes of delirium; and up-to-date guidance on the management of delirium in line with NICE guideline CG103. Click PDF to read article.

“Can I have an ambulance?” “Yes, if you give me the NEWS2.”

10 Sep 2020

Sepsis awareness day is 13 September and this week's Pearl includes content from our upcoming autumn GP Update courses.

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“Can I have an ambulance?” “Yes, if you give me the NEWS2.”

Sepsis awareness day is 13 September and this week's Pearl includes content from our upcoming autumn GP Update courses.

Ever been flummoxed by an answer like this? Or are you a convert and using NEWS2 regularly?

NEWS2 is a way of assessing patients based on 5 physiological parameters, whether they are on oxygen and whether any confusion/altered consciousness is present. It isn’t just for sepsis!

It has been around for a while as a hospital-based scoring tool, but now research has shown that when primary care uses NEWS2:

  • People are transported to hospital by ambulance more quickly and are seen more quickly.
  • It may identify people with suspected sepsis better and may improve prognosis.

Our Autumn 2020 GP Update online courses will contain all the detail on how to use this scoring tool, but, in the meantime, this week’s Pearl is a reminder of the NICE guidelines on sepsis, including a handy colour chart to help you stratify the clinical indicators in your sick patient. Feel free to print this out and share it with your wider team!

But NEVER let clinical judgement be trumped by a score. If you are worried, act. Clinical instinct, experience, gut feeling – whatever you want to call it – should never be ignored!

Cough in the returning traveller - but, what if it’s NOT COVID?!

03 Sep 2020

In this week’s Pearl, we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

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Cough in the returning traveller - but, what if it’s NOT COVID?!

In this week’s Pearl, we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

My patient had just returned from a trip to visit her family in India. She had a cough, fever and malaise. I confidently sent her off for a COVID-19 test, and advised self-isolation, and not to return to her role in a local care home until her test results were back. But her COVID test was negative, and three weeks later she was still coughing. A CXR revealed signs suggestive of pulmonary TB, which prompted further testing and a referral to my local respiratory team, as well as a variation on my usual referrals to PHE!

The filter of a global pandemic can affect our diagnostic lens, but not all that coughs is COVID, and this case was a timely reminder to me to remain alert to the other infectious causes of chronic cough.

TB is not something we will be managing without specialist input, but we need to be aware of the possibility of the diagnosis, and the relevant tests and treatment regimens. In this week’s Pearl we have summarised the 2019 NICE guidance on tuberculosis, picking out the aspects relevant to us in primary care.

Click PDF to read our article.

When that 'Back to School' feeling isn’t so great: anxiety in children and young people

27 Aug 2020

September is around the corner and for most of us working in primary care, whatever our role, the summer may not have been quite as rejuvenating as usual.

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When that 'Back to School' feeling isn’t so great: anxiety in children and young people

September is around the corner and for most of us working in primary care, whatever our role, the summer may not have been quite as rejuvenating as usual.

This is also true for many of our children and the children of our patients. The 'Back to School' feelings may be tinged with more than the usual amount of anxiety. Anxiety is incredibly common in children and young people and, for many, it is transient and self-limiting.

 

So, how do we spot when anxiety in children is part of 'normal' and when does it start to become a problem, and something that needs support and intervention? What simple low level strategies might work and when should we refer? How can we explain anxiety to different age groups?

 

This week we offer you an article from the Child and Adolescent section of our mental health course 'Anxiety in children and young people'. Click PDF to read the article.

Diagnosing cancer: ‘soft markers’ and how they can help us

20 Aug 2020

One tool we have at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!). 

More info PDF

Diagnosing cancer: ‘soft markers’ and how they can help us

One tool we have at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!). 

The long-term plan for cancer is ambitious. It was ambitious before COVID-19. It is really ambitious now. It aims to ensure that by 2028, 55,000 more people (nationally) will survive cancer for 5 years or more each year, and that 75% of people will be diagnosed at stage one.

During lockdown, the rate of referrals via urgent two-week-wait pathways dropped by up to 75% per week. Turning this tap back on will need committed shared effort across all healthcare settings. Despite direct funding for cancer care seen in both QoF and the PCN DES, primary care needs support if there is any hope of implementing this in the context of our current workload.

This autumn, we will have a big focus on early cancer diagnosis as part of our GP Update and Primary Care Cancer Update courses. We will offer a really pragmatic pitfalls-based approach and lots of support to make implementing the DES and QOF effective and as easy as possible.

One tool at our disposal is spotting ‘softer markers’ of possible cancers, and thrombocytosis has been a big story over the past few years. This week’s PEARL shares an approach to tackling raised platelets (whether they are caused by cancer or not!); we hope the flowchart is useful – do feel free to print it out, share it with colleagues and laminate it!

Click PDF to read our article.

Why are gabapentinoids our new problem child?

13 Aug 2020

In this week’s PEARL, we would like to share some background which explains exactly why gabapentinoids have become our latest prescribing challenge. 

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Why are gabapentinoids our new problem child?

In this week’s PEARL, we would like to share some background which explains exactly why gabapentinoids have become our latest prescribing challenge. 

Last week, we shared a summary of the new NICE DRAFT guidance on chronic pain that stated that many of our conventional therapeutic options are now out. NICE also issued DRAFT guidance in July on Low Back Pain and Sciatica that stated we should not prescribe gabapentinoids or benzodiazepines for acute or chronic sciatica; we will be covering this, and a simple effective approach to back pain consultations, in our autumn courses with a great new GEMS (Guidelines and Evidence Made Simple).

In this week’s PEARL, we would like to share some background which explains exactly why gabapentinoids have become our latest prescribing challenge.

The bottom line?

  • They are ineffective for low back pain, sciatica, spinal stenosis and migraine – we should not use them for these conditions.
  • They may offer some benefits for post-herpetic neuralgia and diabetic peripheral neuropathy – but probably no more so than amitriptyline.
  • They should not be co-prescribed with opiates.
  • Side-effects are significant.

Want to know more? Click PDF to read our article on gabapentinoids which includes a useful resource to start a conversation with our patients about stopping.

Insomnia: Can you just give me something to help me sleep?

30 Jul 2020

Insomnia has been a really common presentation in patients during the COVID pandemic, affecting many of us as well. Read this week's article on assessment of insomnia, how to give a really good explanation and strategies that can help including CBT-I.

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Insomnia: Can you just give me something to help me sleep?

Insomnia has been a really common presentation in patients during the COVID pandemic, affecting many of us as well. Read this week's article on assessment of insomnia, how to give a really good explanation and strategies that can help including CBT-I.

It is an important and popular topic in our NEW Mental Health Course and can be a gateway presentation for other mental health conditions including depression and anxiety. Rates of prescribing vary widely between GPs. It is tempting to reach for a medication solution but the benefits of drug treatments are minimal and harms potentially significant. So, what can we do instead?

In this week’s Pearl, the first in a series of sleep and tiredness we unpack an approach to the assessment of insomnia, how to give a really good explanation and strategies that can help, including CBT-I.

And remember, if you are finding sleep difficult at the moment, all NHS staff members can access a range of wellbeing Apps for free including Sleepio which offers CBT-I.

Click PDF to read full article.

Coping with Uncertainty

16 Jul 2020

Covid has brought a huge amount of uncertainty into our lives so this is feeling difficult for you personally or as a team, you might find this Microskill article from our Mental Health course on Coping with Uncertainty helpful.

More info PDF

Coping with Uncertainty

Covid has brought a huge amount of uncertainty into our lives so this is feeling difficult for you personally or as a team, you might find this Microskill article from our Mental Health course on Coping with Uncertainty helpful.

You may also find this microskill useful to support people with anxiety. Remember that sometimes, holding that uncertainty and not making any decisions right now can also be a valid strategy! Click PDF to red full article.

MSK Remote Consultation Survival Guide

09 Jul 2020

We have teamed up with Versus Arthritis to produce this MSK Remote Consultation Survival Guide which covers: how to spot red flag MSK conditions and what to do, evidence and hints and tips for MSK remote consulting and useful tips & tools to support and sign-post patients towards self-management.

More info PDF

MSK Remote Consultation Survival Guide

We have teamed up with Versus Arthritis to produce this MSK Remote Consultation Survival Guide which covers: how to spot red flag MSK conditions and what to do, evidence and hints and tips for MSK remote consulting and useful tips & tools to support and sign-post patients towards self-management.

After a very atypical few months, we are starting to see a much more typical range of primary care consultations, though many of us are still handling these remotely, at least in the first instance! MSK problems make up about 30% of primary care consultations. We need to be able to spot the serious and urgent things that need assessment and referral, and separate them from the self-limiting or long-term conditions for which patients need high-quality education and support to self-manage. This is particularly important with longer-than-usual wait times for secondary care appointments, and reduced physiotherapy and pain clinic services.

Click PDF to read our article.
 

Burnout: is this more than COVID fatigue?

25 Jun 2020

2020 has been quite year, and the Covid crisis did not come at a time of peace, harmony and abundance in primary care. At the end of 2019, we were acknowledging a crisis in the medical profession and particular general practice of stress, overload and burnout.

More info PDF

Burnout: is this more than COVID fatigue?

2020 has been quite year, and the Covid crisis did not come at a time of peace, harmony and abundance in primary care. At the end of 2019, we were acknowledging a crisis in the medical profession and particular general practice of stress, overload and burnout.

So, if you are suffering right now, it may be in response to the fall-out from the Covid situation, but think carefully, could this be something more for you or a colleague?

  • Stress is a high energy state where everything is go,go,go – you do not have the resources to meet the demands upon you.
  • Burnout is a low energy state: you have run out of energy to do anything and feel demotivated. You may feel like your work is meaningless.

If you are struggling, you are not alone, help is out there, but please do get help, you matter. There are links to sources of support in the article. If you are OK right now, reading this article may help you to spot a colleague who isn’t.

Burnout and how to avoid it is an important topic on our Mental Health Course and in this article taken from the Mental Health handbook we cover:

  • How to spot burnout in yourself and others?
  • Why it matters
  • The role of the workplace
  • What we can do about it

Click 'PDF' to read the full article.

Change: choosing our new normal

18 Jun 2020

Primary care did the most incredible pivot over the early phases of the Covid crisis, moving from face to face consultations to virtual consultations in the space of about a week! For many of our practices, this bypassed all our usual decision making and change management processes, and to paraphrase Nike, we “Just Did It”.

More info PDF

Change: choosing our new normal

Primary care did the most incredible pivot over the early phases of the Covid crisis, moving from face to face consultations to virtual consultations in the space of about a week! For many of our practices, this bypassed all our usual decision making and change management processes, and to paraphrase Nike, we “Just Did It”.

And now, we are starting to unpick this. Of the changes we made, what will we keep, what will we go back to? Will our patients agree with us? Will our team?

Some may be hankering to go back to the way things were, others feel that that would be a disaster. The best solution will probably be different for different teams and different practices.

Last week we covered conflict and we may find referring back to this helpful as we support our teams through this decision making and change process. We hope that this article from our LMT course will be helpful. Click 'PDF' to read it.

COVID-19: Conflict in a time of COVID

Read the latest version of our COVID-19 Update: Conflict in a time of COVID FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 emotional and psychological survival: where are YOU and your TEAM now?

Read the latest version of our COVID-19 emotional and psychological survival: where are YOU and your TEAM now?  FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Supporting our rheumatology patients

Read the latest version of our COVID-19 Update: Supporting our rheumatology patients FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Remote Consulting Domestic Abuse

Read the latest version of our COVID-19 Update: Remote Consulting Domestic Abuse FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: The Role of Primary Care in Care Homes

Read the latest version of our COVID-19 Update: The Role of Primary Care in Care Homes FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Supporting our patients during Ramandan

Read the latest version of our COVID-19 Update: Supporting our patients during Ramandan FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: COPD and Asthma during the COVID-19 pandemic

Read the latest version of our COVID-19 Update: COPD and Asthma during the COVID-19 pandemic FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Coronavirus COVID-19

Read the latest version of our COVID-19 Update: Coronavirus COVID-19 FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19: symptom control (including end-of-life care)

Read the latest version of our COVID-19: symptom control (including end-of-life care) FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19: End of Life Care Discussions

Read the latest version of our COVID-19: End of Life Care Discussions FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Standard Operating Procedures

Read the latest version of our COVID-19: Standard Operating Procedures FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Death in the community

Read the latest version of our COVID-19 Update: Death in the community FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

COVID-19 Update: Clinical assessment and management in the community

Read the latest version of our COVID-19 Update: Clinical assessment and management in the community FREE on GPCPD.com.

COVID-19 Pearls have moved to GPCPD.com so that with the ever shifting landscape of the COVID-19 crisis, you will be guaranteed to always have access to the latest and most up to date version of our Pearls. GPCPD.com does have some paid for content but please rest assured that we will keep access to the COVID-19 Pearls free for all users at all times. 

For instructions on how to access our Pearls on GPCPD click here to watch a short instruction video. Alternatively, you can read full instructions by clicking the PDF button. 

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