Suspension level Adult (not of reproductive capacity) 50 g/dL 60 g/dL Young person 40 g/dL 50 g/dL Woman of reproductive capacity* 25 g/dL 30 g/dL A woman of reproductive capacity is a woman medically and physically capable of conceiving. This includes any woman on hormonal contraceptives. Background blood lead levels in the general population are usually <10 g/dL 2 Pregnant workers should be suspended from work involving signi \201 cant exposure to lead 3 Where a worker \200\231s blood lead level reaches the suspension level, the blood lead should be re-checked as a matter of urgency. Health records An entry documenting the individual \200\231s \201 tness for work with ino rganic lead should be made in his/her health record and be sent to his/her employer. The me dical surveillance records should be retained for 40yrs. Relevant legislation \200 HSE (2002). Control of Lead at Work Regulations 2002 , Approved Code of Practice and Guidance, L132. HSE Books, Sudbury. M http://www. hse.gov.uk/pubns/pr iced/l132.pdf HSE (2000). Management of Health and Safety at Work Regulations 1999 , Approved Code of Pra ctice and Guidance, 2nd edn, L21. HSE Books, Sudbury. 22_Smedley_Chap22.indd 435 1/2/2013 12:34:39 PM CHAPTER 22 Health surveillance 436 Organic lead Workers exposed to lead alkyls (e.g. tetraethyl lead, tetramethyl lead) should be subject to health surveillance where breathing zone sampling indicates that the 8h TWA is greater than half the lead in air standard of 0.10mg/m 3 or there is a risk of dermal ab sorption of lead alkyls. Most exposure to organolead occurs in the manufacture or use of le ad alkyls employed as anti-knock agents in leaded gasoline. 2 Only HSE EMAs/HSE appointed d octors should carry out such health surveillance. Frequency of health surveillance An initial medical assessment of \201 tness for lead wor k is required together with baseline urinary lead prior to work with lead commencing. Those with a recent history of psychiatric illness should not work with organic leads to avoid c onfusion between organic lead poisoning and a relapse of pre-existing mental illness. Consi deration should be given to factors that may increase lead absorption: \200 Nail biting \200 Smoking \200 Poor personal hygiene. Thereafter, the work activity and/or urine lead level dictates the frequency of workers \200\231 health surveillance. As a minimum this me ans an annual clinical review, including: \200 Physical examination \200 Review of medi cal records \200 Review of urinary lead \200 Annual blood lead. Samples A 25-mL urine sample should be collected at the end of the shift at the end of the working week. Analysis is by atomic absorption spectrophotometry to determine urinary lead levels. Results The results of lead monitoring should be fed back to the worker and a decision made on his/her continuing \201 tness for work with organic lead. Where the relevant suspensi on level is reached and is con \201 rmed by repeat testing, the appointed doctor will cert ify that the employee is no longer \201 t to work with organic lead. The Lead at Work Reg ulations 2002 indicate the following suspension levels (Box 22.3). \200 2 Pregnant worker s should be suspended from work involving signi \201 cant exposure to lead 3 Where a worker \200\231s urinary lead level reaches the suspension level, the urinary lead should be re-checked as a matter of urgency. Health records An entry documenting the individual \200\231s \201 tness for work with org anic lead should be made in his/her health record and be sent to his/her employer. The medi cal surveillance records should be retained for 40yrs. 22_Smedley_Chap22.indd 436 1/2/2013 12:34:39 PM ORGANIC LEAD 437 Box 22.3 Suspension levels for urinary lead Suspension level Adult (not of reproductive capacity) 110 g Pb/g creatinine Young person (aged 16 or 17) 110 g Pb/g creatinine Woman of reproductive capacity * 25 g Pb/g creatinine A woman of reproductive capacity is a woman medically and physically capable of conceiving. This includes any woman taking hormonal contraceptives. Relevant legislation \200 HSE (2002). Control of Lead at Work Regulations 2002 , Approved Code of Practice and Guidance, L132. HSE Books, Sudbury. available at: M http://www.hse.go v.uk/pubns/priced/l132.pdf HSE (2000). Management of Health and Safety at Work Regulations 1999 , Approved Code of Pra ctice and Guidance, 2nd edn, L21. HSE Books, Sudbury. 22_Smedley_Chap22.indd 437 1/2/2013 12:34:39 PM CHAPTER 22 Health surveillance 438 Surveillance for hand \200\223arm vibration syndrome The health surveillance requirements f or HAVS are described in the Control of Vibration at Work Regulations 2005. Main requirements Health surveillance should be provided for vibration-exposed employees wh o: \200 Are likely to be regularly exposed above the exposure action value of 2.5m/s 2 A(8) Are likely to be exposed occasionally above the exposure action value and where the risk assessment identi \201 es that the frequency and severity of expo sure may pose a risk to health Have a diagnosis of HAVS (even when exposed below the exposure action value). Process and methods The HSE recommends a tiered approach to health surveillance for HAVS. F urther information and example questionnaires are available through the HSE website (M http ://www.hse.gov.uk/vibration/hav). \200 Tier 1 \200\224initial baseline assessment: a shor t questionnaire to be used for people moving into a job involving exposure to vibration. Questionnaire responses determine whether the individual is referred for health assessment (tier 3) Tier 2 \200\224annual (screening) questionnaire: a short questionnaire to be used annually for individuals exposed to vibration, to determine whether they need to be referred to tier 3 Tier 3 \200\224assessment by quali \201 ed person: this involves a HAVS health assessment by a quali \201 ed person, e.g. an OH nurse. A clinical questionnaire asks about relevant symptoms, and limited clinical examination is recommended. If the assessment shows that the individual has HAVS, he/she should be referred to tier 4 Tier 4 \200\224formal diagnosis: at this stage a formal diagnosis is made by a doctor quali \201 ed in OH. The reported history of symptoms is considered to be the most useful diagnostic information. Information from tiers 1 \200\2234 is also used to make decisions on \201 tness for work \200 Tier 5 \200\224standardized tests (optional): th is stage is optional and involves referral for certain specialized tests for individuals wh o have signs and symptoms of HAVS. Tests include: \200 Vascular tests: \201 nger rewarming after cold provocation (CPT) \200 \201 nger systolic blood pressu re test (FSBP) Senosorineural: vibrotactile perception threshold (VPT) \200 thermal (temperature) perception threshold ( TPT). 22_Smedley_Chap22.indd 438 1/2/2013 12:34:39 PM SURVEILLANCE FOR HAND \200\223ARM VIBRATION SYNDROME 439 Symptoms related to carpal tunnel syndrome may need to be investigated by nerve conduction tests (see b p. 294, Compression neuropathies). \200 Specialist training is required to c arry out clinical assessments for HAVS. The Faculty of Occupational Medicine (UK) has developed a syllabus for approved train ing in health surveillance for HAVS \200 As part of the health surveillance program a rec ord-keeping system is needed for results of reports of symptoms and medical examinations. Related legislation Occupational cases of HAVS and carpal tunnel syndrome are reportable to HSE by the employer under RIDDOR 1995. Further information HSE (2005). Hand arm vibration: the Control of Vibration at Work Regula tions 2005 . HSE Books, Sudbury. HSE. Health Surveillance \200\224guidance for occupational health professionals. Available at: M http://www. hse.gov.uk/vibration/hav 22_Smedley_Chap22.indd 439 1/2/2013 12:34:39 PM This page intentionally left blank Section 4 Fitness for work 23 Generic \201 tness for work issues and speci \201 c disorders 443 471 24 Fitness for speci \201 c work 23_Smedley_Chap23.indd 441 1/2/2013 12:36:32 PM This page intentionally left blank 443 Chapter 23 Generic \201 tness for work issues and speci \201 c disorders General principles of \201 tness for work assessments 444 Occupational history 446 Pre-pl acement assessment 448 Psychosocial factors and \201 tness for work 450 Ageing and \201 tness for work 452 Obesity 454 Cognitive impairment and \201 tness for work 456 Depressi on 458 Chronic fatigue syndrome/myalgic encephalomyelitis 460 Diabetes mellitus 462 Epileps y 464 Alcohol misuse and \201 tness for work 468 23_Smedley_Chap23.indd 443 1/2/2013 12:36:33 PM CHAPTER 23 Generic \201 tness for work and disorders 444 General principles of \201 tness for work assessments Purpose The purpose of undertaking \201 tness for work assessments is to try to achieve the best possible job \200\223person \201 t. Knowledge of workplace hazards and job demands should inform the assessment. The objective should be to be inclusive and, where practicable, to make reasonable adjustments to accommodate those with disabilities. Such assessments may be carried out pre-placement, prior to promotion or job transfer, or following sickness absence or work-related injury. Other reasons for carrying out a \201 tness for work assessment include: \200 Legislati ve compliance: for example, medical assessments under the Control of Asbestos Regulations 2 012, Diving at Work Regulations 1997 Infection control: food industry (product safety) \200 health services (patient safety) Baseline data for health surveillance: e.g. audiometry, spirometry. Routine periodic medica ls, unless subject to rigorous assessment, may generate activity but fail to achieve any us eful purpose. Employers may be under the mistaken impression that a \200\230rigorous \200 \231 medical will reduce or eliminate sickness absence. 2 The rationale for the \201 tnes s assessment should be clear to all parties, as should the procedures to be followed where an individual is deemed un \201 t following assessment. Key information \200 Knowledge of workplace hazards and task demands \200 Special requi rements, e.g. emergency response duties, working in isolation, driving Current job description \200 The assessor should be familiar with the workplace, or shoul d speci \201 cally visit the workplace to ensure appropriate knowledge of the job. This is e specially important where the post makes unusual demands of employees Any legislative \201 tness standards should be observed \200 Company or industry sector guidance, where available, is helpful in identifying relative and absolute medical contrai ndications to work. Reports to employer \200 The employer should be informed in writing of the individual \200\231s \201 tness for his/her designated post Any restrictions on \201 tness should be clearly stated \200 Identify any adjustments t he employer may wish to consider under the Equality Act 2010 23_Smedley_Chap23.indd 444 1/2/2013 12:36:33 PM GENERAL PRINCIPLES OF FITNESS FOR WORK ASSESSMENTS 445 No information regarding underlying medical conditions should be disclosed except with the employee \200\231s consent and where disclosure is necessary for health and safety reasons or for the employer to comply with legislation. Record keeping \200 Clear legible contemporaneous notes should be kept (see b p. 748, Recording an occupational health consultation) Entries in the employee \200\231s OH record should be signed and dated \200 Health questi onnaires and records of any medical assessment should be \201 led in the employee \200\231s medical record All OH \201 les should be securely stored in the OH department. It is illegal and unethic al for sensitive health records to be stored where others may have access to them (see b p. 350, Managing occupational health records 2: security, transfer and the archiving of recor ds b p. 362, Con \201 dentiality, consent, and communication, b p. 578, Data Protection Ac t 1998). Relevant legislation and guidance \200 Faculty of Occupational Medicine (2012). Fitness f or work , 5th edn. Oxford University Press, Oxford. Equality Act 2010. \200 Faculty of Occupational Medicine (2012). Guidance on ethics for occupational physicians , 7th edn. Faculty of Occupational Medicine, London. 23_Smedley_Chap23.indd 445 1/2/2013 12:36:33 PM CHAPTER 23 Generic \201 tness for work and disorders 446 Occupational history Purpose \200 Identify occupational risk factors for disease \200 U nderstand job demands \200 Advise on \201 tness for work \200 Inform efforts at rehab ilitation or redeployment 2 It is not suf \201 cient to ask \200\230What is your job? \200\231 although even that may be overlooked by some doctors. Job names vary and may misle ad. It is much more useful to know what an employee actually does at work, or has done in h is/her previous main job. This should be followed by enquiry about the main workplace hazar ds, the likely intensity and route of any exposures, and any control measures in place (inc luding personal protec- tive equipment). (cid:2) Ask about concurrent jobs (paid or unpaid) as otherwise these may not be declared. This includes second jobs, evening or weekend work, participation in family businesses, suc h as farms or shops, and moonlight- ing, i.e. work not declared for tax purposes. Some jobs place workers at high risk of certain occupational diseases. For example, spray p ainters are at risk of occupational asthma (due to isocyanates in \200\230two-pack \200 \231 paints). Such a work history should prompt the physician to consider whether the patie nt may have that disease. Key questions \200 What do you do at your work? \200 Do you have another job? \200 Do es anyone else at work have this problem? \200 Does it get better away from work? and som etimes: \200 Have you ever worked with \200 ? \200 What are your hobbies? Diseases of long latency Some diseases, such as bladder cancer or pneumoconiosis have a lon g latent interval between exposure and presentation. To establish an occu- pational cause i n that situation requires a lifetime occupational history. Sometimes, it is more ef \201 c ient to ask if the patient has ever worked with the suspected agent, e.g. for mesothelioma ask about asbestos exposure. Hobbies Pastimes can lead to signi \201 cant non-occupational exposures especially in those whose hobby occupies many hours per week. Prolonged exposure may be compounded by a lack of health and safety knowledge and inad- equate control measur es. As a result hobbies may cause occupational-type illness. 23_Smedley_Chap23.indd 446 1/2/2013 12:36:33 PM This page intentionally left blank CHAPTER 23 Generic \201 tness for work and disorders 448 Pre-placement assessment Purpose The purpose of a pre-placement health assessment is to est ablish a pro- spective employee \200\231s \201 tness for employment, including his/her ab ility to offer regular effective attendance. Consider relevant previous and current health problems and signi \201 cant workplace risks. Process (see Fig. 23.1) (cid:2) Prospective employees should be advised not to submit their resigna- tion to their current employer unt il their \201 tness is con \201 rmed (including results of drug screen where relevant). Employment offer Should be conditional on passing the pre-placement health assessment. Health questionnaire Should be issued to new appointees for completion and return, in a sea led envelope, to Occupational Health. Reasonable adjustments Assistance with forms may be needed in case of: - learning or readin g disability - visual impairment - literacy or language barriers. Nurse review May be indicated where insufficient information is available in the questionna ire. Ethics It is inappropriate and unethical to seek a copy of the individual \200\231s general medical records as part of the pre-placement assessment. Medical examination By an occupational health doctor may be required by legislation or for detailed clinical assessment. Medical report A medical report from the employee \200\231s own doctors may be required to corroborate or clarify information from the employee. Feedback to employee If pre-employment assessment leads to an examination or investigations , the results should be fed back to the employee; - any significant findings should be disc ussed with the employee in person. - results should be copied to the GP for further investi gation if the employee consents to his/her GP being informed. Review all results All investigations, tests, and medical reports should be reviewed before a decision regarding fitness is made. Equality Act Establish if the employee has a disability that may be covered by the Equality Act, but note that it is for an Employment Tribunal to determine if the Act applies. Appropriate adjustments If the Equality Act is likely to apply, inform the employer and adv ise on appropriate adjustments. Are adjustments practicable? Employer (not Occupational Health professional) must determine if adjustments are reasonably practicable. (See Ch. 26 Equality Act 2010). Record keeping Health questionnaires and any medical assessment should be retained in the e mployee \200\231s OH record. Results A statement of fitness together with any restrictions should be issued to the emplo yer. Fig. 23.1 Flow chart showing the process for pre-placement assessment. 23_Smedley_Chap23.indd 448 1/2/2013 12:36:33 PM PRE-PLACEMENT ASSESSMENT 449 The Equality Act 2010 requires that only the successful applicant should be offered a pre-p lacement assessment. It is crucial that assessment is undertaken after selection or outcome should not be known to employer at the time of selection. Thus, the term pre-placement is often used, rather than the previously common term \200\230pre-employment assessment \200 \231. 2 Where there is high turnover (e.g. service industries) a rapid access scheme (same- day clinical assessment, where indicated, by rapid screening questionnaires) reduces costs, while managing the associated risk. Key information \200 Current job description, including special job requirements \200 K nowledge of workplace risks and task demands \200 Sickness absence record for last 2yrs \200 Any legislative \201 tness standards \200 Industry sector guidance, where availab le. Clinical investigations Depending on the post, these may include tests listed in Table 23.1 . Legislation and guidance \200 Faculty of Occupational Medicine (2007). Fitness for Work , 4th edn. Oxford, Oxford University Press. Equality Act 2010. Available at: M http://www.legislation.gov.uk/ ukpga/2010/15/contents Guidance on Ethics for Occupational Physicians (6th edn). Faculty of Occupational Medicine, London, 2006. Table 23.1 Clinical investigations* Test Example Spirometry Animal house technicians CXR Commercial divers Audiometry Call center workers, pipe \201 tters Visual acuity and visual \201 elds Occupational drivers Color vision Seafarers, electricians Exercise test Fire \201 ghters Full blood count Divers, lead workers Health care workers ( b p. 494, Fitness for exposure prone procedures 1; b p. 496, Fitness for exposure prone procedures 2) Immunity to infectious diseases (rubella, varicella, hepatitis B) Drug screening Safety critical jobs This list is not exhaustive. 23_Smedley_Chap23.indd 449 1/2/2013 12:36:33 PM CHAPTER 23 Generic \201 tness for work and disorders 450 Psychosocial factors and \201 tness for work Psychosocial factors have been recognized in creasingly over the past 10yrs as having an important impact on work capacity and the risk of work-related ill health. The factors listed here increase the risk of occurrence or recurrence of psychological morb idity and musculoskeletal disorders. However, they should also be taken into consideration when advising about \201 tness for work, likelihood of absence, and adjustments required, thus facilitating rehabilitation and reducing risk. Personal psychosocial factors \200 Personality type: type A personality, and perfectionis t and obsessional traits Pre-existing psychiatric morbidity: \200 depression and anxiety \200 psychotic disorder s Health beliefs \200 Somatizing tendency \200 Con \202 icting family responsibilities \200 Poor work \200\223life balance. Workplace psychosocial factors These factors and their control are covered in detail on b p .134, Organizational psychosocial factors. However, the most important are: \200 Job dema nds \200 Excessive or insuf \201 cient workload \200 Control over work: lack of control over the volume or rate of work, or achievement of targets low decision latitude Monotonous or repetitive work: intellectual demands mismatched with the individual \200\231s ability or professional background Low job satisfaction \200 Low perceived value by service users or colleagues \200 Poor relationships with others: managers \200 colleagues \200 customers Bullying and harassment. 23_Smedley_Chap23.indd 450 1/2/2013 12:36:33 PM PSYCHOSOCIAL FACTORS AND FITNESS FOR WORK 451 Control of psychosocial hazards at work \200 Organizational psychosocial hazards (see b p . 134, Organizational psychosocial factors) Violence and aggression (see b p. 136, Violence and aggression), Violence policies (see b p . 388, Violence management policies) \200 Low back pain (see b p. 254, Low back pain), WR ULDs (see b pp. 254, 258) Work-related upper limb disorders 2) Stress (see b p. 311, Stress 2: interventions/risk controls) \200 Depression and \201 t ness for work (see b p. 458, Depression). 23_Smedley_Chap23.indd 451 1/2/2013 12:36:33 PM CHAPTER 23 Generic \201 tness for work and disorders 452 Ageing and \201 tness for work Epidemiology and workforce demographics \200 The demogra phics of populations are changing. The proportion of the UK population who are in the 50 \200\22364-yr age group is increasing. Changes in UK pension arrangements are likely to increase retirement age, with more individuals working beyond the age of 65yrs. It is predicted that within the next 25yrs, 30% of the workforce in Europe will be >50yrs old. Physiological changes with age There is some evidence that certain physiological and cognit ive param- eters change with i age. Physical d Cardiovascular capacity (measured by VO 2 ma x) d Musculoskeletal capacity. d Heat tolerance: unclear whether this is simply a function of age, or whether it re \202 ects a higher incidence of cardiovascular disease i Sleep di sturbance. (cid:2) There is wide individual variation in the baseline level and rate of decline of phy siological parameters. A physically \201 t 50-yr-old can have a greater physical capacity than an un \201 t 20-yr-old. Cognitive d Precision d Speed of perception and cognitive processing i Control of language i Ability to process complex information in dif \201 cult situations. Overall function in ageing workers 2 There is good evidence that job performance does not weaken mark- edly wit h age; indeed, it can improve. \200\230Workability \200\231 is a concept that assumes that overall performance derives fr om a portfolio of skills and attributes. The relative contribution of various attributes ch anges with age; overall performance is preserved. Motivation, loyalty, and experience all g enerally improve with age, and these factors tend to compensate for physiological decline. If better use is made of enhanced attributes in older workers (e.g. using their experience to train and mentor others), their work potential is maximized. Sickness absence Long-term absence is more common in older employees as a group because of the higher incidence of serious or degenerative diseases. However, short-term absence is lo wer in this group because of a combi- nation of factors including lack of immediate depende nts (e.g. time off to look after children) and higher levels of motivation. (cid:2) As with overall function, there is a wide individual variation in absence-taking, a nd generalization is unwise in decision-making about individuals. 23_Smedley_Chap23.indd 452 1/2/2013 12:36:33 PM AGEING AND FITNESS FOR WORK 453 Risks for older workers The following factors are associated with d work ability and i risk of ill health, and it is particularly important to be aware of them in older workers: \200 Role con \202 ict \200 Fear of error \200 Poor control over work \200 Lack of professional development \200 Lack of feedback and appreciation \200 High speed of deci sion-making. Interventions to manage an ageing workforce There is little direct evidence of bene \201 t from the scienti \201 c literature because of a lack of intervention studies. However, th ese adjustments are based on enhancing \200\230workability \200\231 as described here. \200 Careful management of change: tailored re-training for new technology \200 \202 exible career development initiatives for older workers. Train supervisors to be aware of age management \200 Apply age ergonomics: special attention to ergonomics solutions for manual handling tasks and avoiding extremely heavy physical work adaptations to man \200\223machine interfaces for long-sightedness (clear controls, large visual displays) and slower reaction times avoiding extremely hot working environments Health promotion and facilitation of exercise programs to promote general physical \201 t ness. This is clearly a matter of personal choice for employees, but the effect of physical \201 tness on overall work capacity with increasing age is often not appreciated employe es; value their experienced input. Adopt a generally positive approach and supportive culture for older Relevant legislation The Equality Act 2010 ( b p. 562, Equality Act 2010, b p. 572, Age dis - crimination) puts an onus on employers not to discriminate in employ- ment on the grounds of age. Because of the wide variation in \201 tness in older people, it will be necessar y to carry out a careful individual assess- ment of capacity, and make adjustments where th ese are practicable. 23_Smedley_Chap23.indd 453 1/2/2013 12:36:33 PM CHAPTER 23 Generic \201 tness for work and disorders 454 Obesity De \201 nition \200\230A disorder in which excess fat has accumulated to an extent that h ealth may be adversely affected \200\231. (Royal College of Physicians) Epidemiology According to the World Health Organization (WHO) there is an epidemic of obesi ty. In the UK obesity (body mass index > 30kg/m 2 ) affects \200 22% of \231\202 populat ion \200 24% of \231\200 population. Risk factors Predisposing factors for obesity inclu de: \200 Age (obesity rises with age) \200 Gender (females>males) \200 Social class ( risk increases with lower social class) \200 Genetic \200 Marital status (married>singl e). It can be precipitated by: \200 Smoking cessation (e.g. by substituting food for ciga rettes) \200 Physical inactivity (e.g. due to ill health, work and family pressures) \200 Increased dietary calorie intake (e.g. holidays, psychological distress) \200 Rarel y, sympatho-adrenal or other endocrine disorders \200 Drugs e.g. anti epileptics, anti-ps ychotics, anti-depressants, and insulin. Classi \201 cation WHO classi \201 es weight as in Table 23.2). 3 Waist circumference is important because abdominal fat deposition dictate s risk of medical complications. Risk is increased with increasing waist circumference: \200 Europeans/Caucasians: men > 102 cm, women > 88cm \200 South Asians: men >90 cm, wom en > 80 cm. Table 23.2 WHO classi \201 cation of weight BMI (Caucasians) Kg/m 2 BMI (South Asians) Kg/m 2 Overweight 25.0 \200\22329.9 >23.0 Obese (class 1) 30.0 \200\22334.9 >25.0 Obese (class 2) 35.0 \200\22339.9 Obese (class 3) (morbid obesity) >40 Clinical features Obesity is important because is associated with an increased risk of: \200 Type 2 diabetes 23_Smedley_Chap23.indd 454 1/2/2013 12:36:34 PM OBESITY 455 Cardiovascular disease (hypertension, angina, myocardial infarction, cerebrovascular accidents) Respiratory complications, e.g. sleep apnoea \200 Cancers, e.g. of breast, colon, uterus, kidney, and esophagus. \200 Other conditions, e.g. gout, varicose veins, gallstones, fat ty liver, menorrhagia. Sickness absence Obesity is a predictor of: \200 Short-term sickness absence in men and w omen \200 Long-term sickness absence in men and women. Overweight is a predictor of: \200 Short-term absence on men \200 Long-term absence on women. Obesity can accelerate p hysical disorders (e.g. osteoarthritis of the knees). In terms of work limitations, the eff ects of obesity are estimated to be the equivalent of the worker being 20yrs older. Other potential occupational issues \200 Increased travel costs due to the need to use tw o seats (air, rail travel) \200 Impaired \201 t of personal protective equipment, e.g. face masks, clothing \200 Costs of adapted furniture \200 Special arrangements for evac uation during emergencies \200 Inability to mount an emergency response. Prevention The workplace is an important opportunity for the prevention of over- weight and obesity. See b p. 368, Health and safety policies. Clinical management \200 Dietary advi ce \200 Physical activity management National Institute for Health and Clinical Excellenc e (NICE) (SIGN in Scotland) have produced guidelines on the use of drugs and surgery. \200 Orlistat, lipase inhibitor: improves weight loss if taken with a low fat diet \200 Surg ical interventions: laparoscopic banding (least invasive) \200 gastric bypass (effective weight loss, but sig ni \201 cant complications). Compensation/legal aspects Obesity is recognized as a clinical condition and appears in ICD -10. It is associated with frequent reports of disability both in mobility and activities o f daily living, and may be covered by the Equalities Act 2010. Any adjust- ments/adaptation s should be consistent with the medical advice on the importance of physical activity. Furt her information Nerys W (2008). Managing obesity in the workplace . Radcliffe Publishing Ox ford. 23_Smedley_Chap23.indd 455 1/2/2013 12:36:34 PM CHAPTER 23 Generic \201 tness for work and disorders 456 Cognitive impairment and \201 tness for work Causes of cognitive impairment \200 Dement ia \200 Pseudo-dementia in those with severe depression \200 Space-occupying lesions, e .g. subdural haematoma \200 Brain injury \200 Alcohol or substance misuse \200 Hypoth yroidism \200 Vitamin B 12 or folate de \201 ciency \200 Vasculitis. Epidemiology \200 Alzheimer \200\231s disease (AD) and vascular dementia are the most com mon forms of dementia There are 7 17,000 dementia sufferers under age 65 in the UK \200 5% of people over the a ge of 65yrs have dementia, rising to 20% over the age of 80yrs Evidence that work is a risk factor for AD is con \202 icting. Some evidence that blue-col lar work i risk, but this may be confounded by premorbid ability and/or socio-economic stat us Exposures to organic solvents, lead, mercury, aluminum, or pesticides have all been implicated, but the evidence is inconclusive. Symptoms and practical problems at work \200 Impairment of: \200 memory \200 reasonin g \200 personality \200 communication (word \201 nding dif \201 culties) Workers may be referred to the OH service owing to concerns regarding their memory, decision-making, time-keeping, communication, interpersonal relatio nships, attendance, or overall performance Initial signs and symptoms of cognitive impairment are subtle and may go unrecognized, or be misdiagnosed as stress or depression Poor insight can make management challenging. Clinical assessment and diagnosis History It is helpful if managers give speci \201 c exam ples of workplace dif \201 culties as this may alert the assessing physician to the possib ility of cognitive impair- ment. If suspected then explore the following; \200 The employ ee \200\231s perceptions of their dif \201 culties \200 Family history of dementia \200 Past medical history: history of head injury, brain tumor, etc. \200 Drug/alcohol histo ry \200 Educational history 23_Smedley_Chap23.indd 456 1/2/2013 12:36:34 PM COGNITIVE IMPAIRMENT AND FITNESS FOR WORK 457 Occupational history (exposure to occupational neurotoxins). \200 (cid:2) Consider treata ble causes of dementia: pseudo-dementia in those with severe depression \200 space-occupying lesions \200 alcoh ol misuse \200 hypothyroidism \200 vitamin B 12 or folate de \201 ciency \200 vascul itis. Investigation \200 If cognitive dif \201 culties are suspected then tests to screen for cognitive impairment such as the Addenbrooke \200\231s Cognitive Examination \200\223 Revised (ACE-R ) or the widely used, but less sensitive Mini-Mental State Examination (MMSE) 1 may be help ful. An MMSE score of <29 \200\22330 in a person of working age is unusual (anxiety may com promise performance). An MMSE score <24 indicates signi \201 cant cognitive dif \201 cult ies Referral to a psychologist for formal cognitive assessment. Prognosis \200 Prognosis depe nds on cause and the outcome of treatment \200 The prognosis of dementia is one of declin ing cognitive function, and employment cannot usually be sustained in the medium term Workplace adjustments: highly structured/routine work \200 regular supportive supervision \200 predictable wor kload. Factors that reduce the feasibility of remaining at work: highly variable work pattern \200 high decision latitude \200 multi-tasking \200 time pressures \200 cognitively demanding work \200 behavioral problems. Caution should be exercised in assessing workers in safety critical posts or key decision-makers. Medical management \200 Identify reasonably practicable workplace adjustments \200 If, despite adjustments, the worker is unable to cope with his/her current post, he/she may be eligible for ill-health retirement (if the condition is progressive and untreatable). Relevant legislation The Equality Act 2010. 1 Folstein MF, Folstein SE, McHugh PR (1975). \200\230Mini-mental State \200\231: a practi cal method for grading the cognitive state of patients for the clinician. Psychiatry Res , 12 , 189 \200\22398. 23_Smedley_Chap23.indd 457 1/2/2013 12:36:34 PM CHAPTER 23 Generic \201 tness for work and disorders 458 Depression Types The most common type of depression is unipolar depression; bipo- lar disor der (manic depression) affects around 1%. Prevalence \200 Major depressive episode: males \200\223 1.9%. females \200\223 2.8% \200 Mixed anxiety and depression: males \200\223 6.9%, females \200\223 11.0% \200 Li fetime risk of depression: 10 \200\22312% in men, 20 \200\22326% in women. Causation Predisposing factors \200 Genetic (> \227 2 increased risk if \201 rst degre e relative affected) \200 Adverse childhood experiences \200 Previous history of depres sion \200 Underlying physical illness. Precipitating factors \200 Major adverse life ev ents \200 Physical illness, e.g. onset, worsening of symptoms \200 Drug therapy, e.g. c orticosteroids \200 Work-related dif \201 culties, especially bullying. Perpetuating fac tors \200 Lack of con \201 ding relationship with partner \200 Misuse of alcohol or dr ugs \200 Combination of work and domestic problems \200 Isolation and lack of adequate support. Diagnostic assessment \200 Classi \201 cation: DSM-IV (APA) \200\223 \200\230Major depressive disorder \200\231 \200 ICD10 (WHO) \200 \223 \200\230Depressive episode \200\231/ \200\231Recurrent depressive disorder \200\231 both sets of criteria require impairment of social, occupational or other important areas of functioning. Clinical treatment \200 Psychological: CBT \200\223 linking thoughts, feeling and behaviors to challenge negative patterns of thinking Pharmacological: SSRIs most commonly used, e.g \202 uoxetine, sertraline, citalopram \200 Other drugs in clude, e.g. mirtazapine, venlafaxine, agomelatine \200 Maintain treatment for at least 6m ths from point of maximum recovery (2yrs if recurrent depression) Relapse rate of major depression: 60% in 5yrs if untreated. Occupational health input Facilitate early treatment. referral for psychiatric assessment/psychological 23_Smedley_Chap23.indd 458 1/2/2013 12:36:34 PM DEPRESSION 459 Fitness for work \200 Performance: poor motivation \200 reduced concentration and poor decision-making \200 lack of con \201 dence \200 impaired communication, withdrawal and/or irritability \200 lack of ene rgy \200 antidepressant medication. Sickness absence: signi \201 cant impairment of performance \200 non-compliance with medication \200 sid e effects of medication \200 premature reduction of dose. Fitness to attend disciplinary hearing \200 Legal \201 tness to plead criteria relate m ainly to capacity. Main question is whether the employee understands the allegations and their signi \201 cance \200\224can they take part in the decision making process? Useful guide to cognitive ability is the employee \200\231s own correspondence with the employer Understandable that employee is likely to feel anxious and preoccupied, and to eat and sleep badly around the time of any hearing but postponement of the hearing can only protract and intensify this natural reaction Speedy resolution helps to prevent chronicity and secondary morbidity, and can help both parties move on Location of the hearing is important; the workplace might be too aversive and a meeting in the employee \200\231s home would be intrusive. Therefore a neutr al location, e.g. hotel suite, might be more acceptable. Time off work See b p. 308, Stress 1 recognition and assessment; b p. 311, Stress 2: interv entions/risk control. Rehabilitation and reasonable adjustments at work \200 \200\230Rou nd-table \200\231 discussions can be helpful: \200 shared problem-solving approach \200 OH, HR, employee, manager +/ \200\223 treating psychiatrist/psychologist \200 realistic goal setting, job de \201 nition, and work routine \200 agreed hours and days of work, a nd how these change over time \200 manager \200\231s involvement \200 preparation of wo rk colleagues for employee \200\231s return. Further information Workplace intervention for people with common mental health prob- lems: Evidence review and recommendations. British Occupational Health Research Foundation, avai lable at: M http://www.bohrf.org.uk/downloads/ cmh_rev.pdf 23_Smedley_Chap23.indd 459 1/2/2013 12:36:34 PM CHAPTER 23 Generic \201 tness for work and disorders 460 Chronic fatigue syndrome/myalgic encephalomyelitis There is a broad range of disability amo ng patients with CFS. Some at the mild end of the spectrum manage to work normally, while o thers will need protracted adjustments to work. \200 Intervention studies have shown that 7 30 \200\22360% of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) patients do not return to work after treatment. Between 25 and 42% of CFS/ME patients are on disability bene \201 ts Work status is an important predictor of recovery. CFS/ME patients who are out of work have a poor overall prognosis compared with those who manage to maintai n some employment (even after adjustment for severity)