Further reading NICE online : M www.nice.org.uk . National Service Framework for Older Peop le ( 2001 ) online: M http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/Publi cationsPolicyAndGuidance/DH_4003066 . The rationing debate. BMJ 1997 ; 314 : 820 (case for) and 820 (case against) . 674 CHAPTER 27 Ethics Elder abuse De \201 ned as any act, or lack of action that causes harm or distress to an o lder person. Under-recognized, with few prevalence studies. One esti- mated around 5 % of c ommunity dwelling older people have suffered verbal abuse, and 2 % physical abuse. Probably more prevalent within care homes, but precise extent unknown. Types of abuse Psychological \200 Bullying, shouting, swearing, blaming, etc. \200 Look for signs of fear, helplessness, emotional lability, ambivalence toward caregiver, withdrawal, etc. Physical \200 Hitting, slapping, pushing, restraining, etc. \200 May also include inapp ropriate sedation with medication \200 Look for injuries that are unexplained, especially if they are different ages, evidence of restraint, excess sedation, broken glasses, etc. Financial \200 Inappropriate use of an older person \200\231s \201 nancial assets \200 Includes using checks, withdrawing money from an account, transferring assets, taking jewelry or other valuables, failing to pay bills, altering will s, etc. Sexual \200 Forcing an older person to participate in a sexual act against their will \200 Look for genital bruising or bleeding, or sexual disinhibition Neglect \200 Depriva tion of food, heat, clothing, basic care \200 Occurs in situations where an older person is dependant \200 Look for malnutrition, poor personal hygiene, and poor skin condition \200 Easier to spot in situations where a certain standard of care is anticipated (eg patients from care homes being admitted to hospital who are unkempt, dirty, or inappropriately dressed may raise concerns) Who abuses? \200 Commonly someone in a caregiver role \200 Often arises because of care r anger, frustration, and lack of support, training or facilities along with social isolation Relationship dif \201 culties between carer and recipient, and carer mental illness or substance misuse (eg alcohol) exacerbate the situation Sleep deprivation or dealing with fecal incontinence may also precipitate abuse 2Most are under extreme stress ( \200\230at the end of my tether \200\231) and extremely re morseful afterwards. ELDER ABUSE 675 HOW TO Manage suspected elder abuse The UK Government \200\231s \200\230No Secrets \200\231 guidance, published in 2000, aims to identify \200\230vulnerable adults \200\231 who should be the focus of local safeguardi ng policies and procedures. The term \200\230safeguarding \200\231 means a range of activ- ities aimed at upholding an individual \200\231s fundamental right to be safe and local pr otocols should be in place, under the guidance of safeguarding adults boards. The following is a guide: An individual does not have to prove abuse to take action, only have a strong suspicion that it is occurring The \201 rst step is to involve other agencies \200\224 this may include social services, involved agencies (eg home carers), the general practitioner, the local health au thority and (rarely at \201 rst) the police \200 Assessment of the carer and recipient should be detailed, multiagency, and individually tailored As abuse is usually as a result of caregiver stress, a common approach is to attempt to relieve that stress (eg providing home care, day care, respite ca re, health support, advice about sleep or continence, \201 nancial help, rehousing, etc.) while maintaining the patient at home Close multidisciplinary supervision is essential until the situation improves Removal of the patient from an abusive situation may occasionally be done using laws design ed primarily for other purposes, eg the Mental Health Act (provision to act in the best int erests of patients with mental illness) Police involvement may occasionally be necessary where there are no remediable factors or a very high risk of future harm Further information is available f rom the following UK charities: Action on Elder Abuse \200\224 M www.elderabuse.org.uk \200 Age Concern \200\224 M www. ageuk.org.uk This page intentionally left blank 677 Chapter 28 Finances Making a will 678 Taxation 679 Pensions 680 Bene \201 ts 682 678 CHAPTER 28 Finances Making a will \200 Everyone over 18 should make a will. This need not be complicated \200\224 there are cheap will writing \200\230kits \200\231 available to buy, and forms can be down loaded from the Internet even more cheaply, eg M http:// freeguard.co.uk/aboutus.aspx The will should be kept in a safe place, and family members informed \200 Wills that are more complex should be made through a solicitor \200 It is common for the question of wil ls to arise for the \201 rst time when someone becomes ill, often in hospital Doctors may become involved where there is doubt about the patients capacity to make a will Capacity (competence) is covered in detail elsewhere (see b \200\230Capacity \200\231, p.654). It is decision-speci \201 c so must be reassessed for each important decision a person makes Testamentary capacity This is de \201 ned in England and Wales by a speci \201 c set of l egal criteria. These criteria were established in the 1870 court case of Banks v Goodfellow . A person drawing up a will must: 1. Understand the nature of the act and its effect \200\224 ie know that they are choosing whom to give their property to after death 2. Understand the extent of the property being willed \200\224this need not be precise, bu t the person should know roughly what they are willing (eg a house and savings) along with details of any joint ownership and debts. The larger the estate, the clearer this understan ding should be 3. Understand the nature and extent of claims on them \200\224 both include d and excluded parties. This means the person should be able to say who might reasonably ex pect to bene \201 t from their will (spouse, children, etc.) and if people are excluded, g ive reasons why 4. Have no mental disorder directly in \202 uencing points 1 \200\2233 \200\224this does not mean that a will cannot be made if someone has a mental disorder \200\224 rather that this is not coloring his or her speci \201 c testamentary capacity. This can be hard to pr ove, but an example may be where a demented patient develops paranoid delusions about a car ing spouse, and excludes him or her from the will as a result 5. Be under no undue in \202 uence from third parties \200\224 this again may be hard to prove except in very overt circumstances It is sensible to assess capacity at the time the will is drawn up, and then brie \202 y c heck at signing (these can be some time apart). A doctor asked to assess testamentary capacity should question the person with direct refer ence to Banks v Goodfellow criteria, and make clear contemporaneous notes (with direct quot es) that support the conclusions drawn. It is probably better to avoid being a witness to a will signing for patients in your care (this can be done by anyone), as this may be confused with a formal capacity assessment. Further reading Posener HD , Jacoby R ( 2002 ). Testamentary capacity . In: Jacoby R , Oppe nheimer C (eds) Psychiatry in the Elderly , 3 rd edition. Oxford : Oxford University Press , pp. 932 \200\223 40 . TAXATION 679 Taxation \200 Most income received by older people in the UK is taxed \200 The allowanc e of tax-free income rises with age \200\224 in 2011, people under 65 can have an income of 7475 per annum without paying tax, whereas this \201 gur e rises to 10,090 age 75 and over Some income is not taxed \200\224 eg attendance allowance, pension credit, winter fuel payments, council tax and housing bene \201 t, and war pensions Some lump sums are also not taxed, for example from certain private pension schemes. Good \201 nancial advice will help to optimize an older person \200\231s resources The rate of tax then depends on the total income, ranging from 10 % at lower incomes up to 50 % for incomes over 150,000 per annum 680 CHAPTER 28 Finances Pensions As life expectancy extends many older people can now look forward to long periods in retirement. Although there is a shift away from being totally \201 nancially dependent on the state towards \201 nancial planning and personal pensions, there is still a real risk of poverty for many very elderly people. Fuel poverty is one marker (de \201 ned as s pending more than 10 % of disposable income on fuel) which is a political priority. UK state pension \200 Paid when pensionable age is reached (currently 60 for women, and 6 5 for men, but will change to 65 for both sexes between 2010 and 2020) \200 Age of retire ment was originally decided on economic grounds, based on life expectancy after stopping wo rk with little relation to physical ability to work. As people live longer, it becomes less economically viable (see b \200\230Demographics: population age structure \200\231, p.6) It is not automatically given under the age of 80 \200\224 a person must qualify by making enough National Insurance (NI) contributions during their working lives Since 1975, all workers and their employers have made these contributions via NI payments as a percentage of earnings (prior to this a weekly stamp was paid) Credits are awarded if a person cannot pay NI because of sickness, disability, or being a carer The full basic state pension is paid if enough NI contributions have been made (in 2010 thi s is 100 per week for a single person) \200 A spouse quali \201 es for a state pension based on his or her partner \200\231s contributions \200\224 around half the full pension if they are still living together, but this amount rises if divorced or widowed If contribution conditions are not met, then a proportion of the pension may be paid, but some do not qualify at all The \200\230additional state pension \200\231 is an earnings related top-up to the basic s tate pension for low and moderate earners who are not involved in occupational or private p ension schemes Over the age of 80, a pension is paid regardless of NI contributions if the person has been resident in the UK for 10 years since the age of 60 State pensions are now paid directly into an account \200 This money is often supplemente d by income from other pensions or investments or in lower-income households by bene \201 ts Occupational pensions \200 Schemes set up by employers to provide pension and life assura nce bene \201 ts for employers (eg tax free lump sum on retirement) \200 May be contributory (where around 5 % of earnings are taken in addition to an employer contribution) or non-contributory (employer makes all the payments) The employer pays most of the administrative costs of the scheme and there are also some tax bene \201 ts PENSIONS 681 Personal pensions \200 Schemes designed to provide an income after retirement (includes stakeholder pensions which have more \202 exibility) Individuals set these up for themselves, often with the help of a \201 nancial adviser Major tax incentives to save in this way in the UK War pensions Paid to people injured in the forces, or as a civilian during a war, and to th eir dependants. Further reading The Pension Service online : M www.thepensionservice.gov.uk . Age UK online : M www.ageuk.org.uk . 682 CHAPTER 28 Finances Bene \201 ts Many pensioners are poor. In 2008/9 there were 1.8 million pensioners in pove rty (de \201 ned as below 60 % of contemporary median income). Despite this, many do not c laim all the bene \201 ts they are entitled to, usually because they are not aware of them , perceived stigma about \200\230hand-outs \200\231 (that can often be diminished by a few well-judged words from a doctor) or are daunted by application forms. Care managers can help ensure all bene \201 ts are claimed, as can professional welfare ri ghts advisers (working for Citizens Advice Bureau, Age UK, social services departments, etc .). Some charity volunteers will also assist with \201 lling in forms (eg Age UK). Bene \201 ts vary with changes in government, and from country to country. The following describes the situation in the UK. Bene \201 ts for low-income households Pension credits Given to > 60s, to top income up to a set amount (guarantee credit). This does not depend on NI contributions. In 2010, a sing le person is topped up to around 140 per week. This amount may be more in certain circum- stances, eg severe disability. Housing bene \201 t Help towards rent and service charges for low-income households. Council tax bene \201 t Allows low-income households to pay less council tax, depending on income and savings. The Social Fund Provides lump sum payments, grants, and loans: \200 Community care grants can be given to help with exceptional expenses, such as home adaptations for disability Funeral payments can be made to low-income households if needed \200 Cold weather payment s are made to low-income households to help with heating costs when the temperature is belo w 0 C for a week \200 Budgeting loans available to low-income households to cover one- off expenses (eg clothing, household equipment). Repaid (interest-free) from weekly allowan ce Crisis loans are available to all income households, if there is an immediate dif \201 culty in paying for something in an emergency. Repaid without interest Attendance allowance Given to > 65s who need help with personal care because of an illness or disability (equivalent to the disability living allowance which is paid to younger peopl e, but no account taken of mobility). Eligibility based on need for help or supervision, so even if a spouse is already providing this care, the bene \201 t is still awarded. BENEFITS 683 Carers \200\231 allowance Paid to low-income carers of people receiving attendance allowanc e or disability living allowance. Healthcare assistance \200 Free prescriptions for all over the age of 60 \200 Low-incom e households can apply for free dental treatment, wigs, travel to hospital, eye tests and get assistance with paying for glasses Travel assistance \200 Free or reduced fare bus travel for > 60s \200 Reduced train far es with an appropriate rail card for pensioners \200 Free renewal of driver \200\231s lic ense > 70, subject to \201 lling a medical questionnaire regarding \201 tness to drive every 3 years. A report from a doctor is not routinely required Other bene \201 ts \200 Free television license for > 75s \200 Winter fuel payments ma de to all households where there is a person > 60 years Many of these are available regardless of income and savings, to re \202 ect the additiona l costs of disability. Often older people (and the professionals caring for them) assume th at they will not be entitled because they are not poor. Further reading Department of Work and Pensions online : M www.dwp.gov.uk . Age UK online : M www.ageuk.org.uk . This page intentionally left blank 685 Appendix Further information Dermatomes 686 Geriatric Depression Scale 687 Barthel Index 688 The abbreviated mental test score 690 Mini-Mental State Examination 691 Confusion Assessment Method (CAM) 692 Clock-dr awing and the Mini-Cog TM 693 Clock-drawing test interpretation 694 Malnutrition universal screening tool (MUST) 695 Glasgow Coma Scale 696 686 APPENDIX Further information Dermatomes (Fig. A.1 ) C2 C4 C5 T4 T2 T2 T7 T1 C6 T10 T1 T12 L1 S5 L2 S4 S3 C8 L3 L4 C7 S2 C7 L2 S1 L5 Myotomes Muscle group Diaphragm Shoulder abductors Elbow flexors Supinators/pronators Wrist extensors Wrist flexors Elbow extensors Finger extensors Finger flexors Intrinisc hard mus cles Hip flexors Hip adductors Knee extensors Anide dorsiflexors Toe extensors Knee flexors Ankle plantar flexors Toe flexors Anal sphincter Reflexes Nerve supply C(3), 4 (5) C5 C5, 6 C6 C6 C7 C7 C7 C8 T1 L1, 2 L2, 3 L3, 4 L4, 5 L5 L4, 5 S1 S1, 2 S1, 2 S2, 3, 4 Biceps jerk C5, 6 Supinator jerk C6 Triceps jerk C7 Abdominal reflex T8 \200\22312 Knee jerk L3, 4 Ankle jerk S1, 2 Bulbocavernosus reflex S3, 4 Anal reflex S5 Plantar reflex Fig. A.1 Overview of the dermatomes, myotomes, and associated re \202 exes. Reproduced fro m Ward et al. (2009) Oxford Handbook of Clinical Rehabilitation , 2nd edn, Figure 20.1, p.3 17, with permission from OUP. GERIATRIC DEPRESSION SCALE 687 Geriatric Depression Scale Suitable as a screening test for depressive symptoms in the elde rly. Ideal for evaluating the clinical severity of depression, and therefore for monitoring treatment. It is easy to administer, needs no prior psychiatric knowledge and has been wel l validated in many environments \200\224 home and clinical. The original GDS was a 30-item questionnaire \200\224 time consuming and challenging for s ome patients (and staff). Later versions retain only the most discriminating questions; the ir validity approaches that of the original form. The most common version in general geriat ric practice is the 15-item version. Instructions The test (Table A.1 ) is undertaken orally. Ask the patient to reply indi- cat ing how they have felt over the past week. Obtain a clear yes or no reply. If necessary, re peat the question. Each depressive answer (bold) scores 1. Table A.1 The Geriatric Depression Scale 1 Are you basically satis \201 ed with your life? YES / NO 2 Have you dropped many of your activities and interests? YES / NO 3 Do you feel that your life is empty? YES / NO 4 Do you often get bored? YES / NO 5 Are you in good spirits most of the time? YES / NO 6 Are you afraid that something bad is going to happen to you? YES / NO 7 Do you feel happy most of the time? YES / NO 8 Do you often feel helpless? YES / NO 9 Do you prefer to stay at home, rather than going out and doing YES / NO new things? 10 Do you feel you have more problems with memory than most? YES / NO 11 Do you think it is wonderful to be alive now? YES / NO 12 Do you feel pretty worthless the way you are now? YES / NO 13 Do you feel full of energy? YES / NO 14 Do you feel that your situation is hopeless? YES / NO 15 Do you think that most people are better off than you are? YES / NO Scoring intervals 0 \200\2234 5 \200\22310 11 + No depression Mild depression Severe depression 688 APPENDIX Further information Barthel Index Bowel status 0 Incontinent 1 Occasional accident (once a week or less) 2 Cont inent Bladder status 0 1 Occasional accident (maximum once in 24hr) 2 Continent (for more than 7 days) Incontinent, or catheterized and unable to manage Grooming 0 Needs help with personal care (face, hands, teeth, shaving) 1 Independent (with equipment provided) Toilet use 0 Dependent 1 Can do some tasks, needs assistance Independent (on/off, wiping, d ressing) 2 Feeding 0 Dependent 1 Can do about half, needs help with cutting, etc. 2 Independent (food within reach) Transfers 0 Unable (no sitting balance) 1 Major help (eg two people) 2 Minor help, able to sit (eg one person verbal or physical) 3 Independent Mobility 0 1 Wheelchair independent 2 Able to walk with the help of one person 3 Immobile Independent (can use walking aids if necessary) Dressing 0 Unable 1 Can do about half unaided, needs some help 2 Independent Stairs 0 Unable 1 Needs some help (including stair lift) 2 Independent up and down Bathing 0 Dependent Independent 1 TOTAL POSSIBLE SCORE = 20 BARTHEL INDEX 689 Aim to record what the patient actually does do in daily life, not what he/she can do (ie a poorly motivated but capable patient may score poorly) The score re \202 ects the degree of independence from help provided by another person: \200 If supervision is required, the patient is not independent \200 If aids and devices are used but no help is required, the patient is independent Use the best available evidence, asking the patient or relatives, carers, nurses and therap ists, and using common sense. Observing the patient is helpful, but direct testing is not n ecessary Middle categories imply that the patient supplies over 50 % of the effort \200 It is usef ul to also ask about abilities before admission or acute illness, and to compare both the t otal Barthel score and elements of it to determine the magnitude and nature of the setback Source Adapted from: Mahoney FI , Barthel D. ( 1965 ). Functional evaluation: the Barthel I ndex . Maryland State Med J 14 : 56 \200\223 61 . Used with permission. 690 APPENDIX Further information The abbreviated mental test score \200 The AMTS is a widely applicable, well validated, b rief screening test of cognitive function. Derived by Hodkinson from a 26-item test, by dispensing with those questions which were poor discriminators of the cognitively sound and unsound (Table A.2 ) Table A.2 The abbreviated mental test Age Must be correct (years) Time Without looking at timepiece; correct to nearest hour Short term memory Give the address \200\23042 West Street \200\231 Check registration Check memory at end of test Month Exact Year Exact, except in January when the previous year is satisfactory. Replies \200\230206 \200 \231, \200\230207 \200\231, etc in place of 2006, 2007 should be considered correct, as th ey con \201 rm orientation Name of place If not in hospital ask type of place or area of town Date of birth Exact Start of World War 1 Exact Name of present monarch Exact Count from 20 to 1 (backwards) Can prompt with 20 \200\22319 \200\22318, but no further prompts. Patient can hesitate and self correct but no other errors are permitted Scoring intervals 8 \200\22310 Normal 7 <6 Probably abnormal Abnormal Source Reproduced from Hodkinson , HM. ( 1972 ). Evaluation of a mental test score for asse ssment of mental impairment in the elderly . Age Ageing 1 : 233 \200\223 8 , with permission from OU P. MINI-MENTAL STATE EXAMINATION 691 Mini-Mental State Examination The MMSE is a widely applicable and well-validated test of co gnitive function. It is a 30-point test, takes 10 \200\22315min to complete, and covers a b roader range of cognitive domains than the AMTS. It is therefore less useful as a brief scr eening test in general medical or geriatric practice, but is very useful in: \200 Con \201 rming the nature and magnitude of de \201 cits identi \201 ed by clinical suspicion, or by the AMTS Tracking change, for example following the introduction of cholinesterase inhibitors in dementia The MMSE is widely used. Its copyright is now being robustly defended, and permission to pu blish it has not been granted. It is however widely available in older texts. It is possible that the robust defense of copyright will result in a rapid decline in the u se of what has been a useful clinical tool, to be replaced by other well-validated instrume nts such as the clock-drawing test. 692 APPENDIX Further information Confusion Assessment Method (CAM) A positive test requires the presence of items 1 and 2, a nd 3 or 4. The positive likelihood ratio is 5.06 and negative likelihood ratio is 0.23. 1. Acute onset and \202 uctuating course. Evidence of acute change in mental status from baseline; behavior \202 uctuates during the day 2. Inattention. Easily distracted, dif \201 culty focusing attention and keeping track with conversation 3. Disorganized thinking. Irrelevant conversation, unclear \202 ow of ideas, unpredictable switching from subject to subject 4. Any mental state, other than alert, is abnormal. Describe altered states as: (a) vigilant, (b) drowsy, (c) dif \201 cult or unable to arouse Source Adapted from Inouye SK , van Dyck CH , Alessi CA , et al . ( 1990 ). Clarifying conf usion. The Confusion Assessment Method. A new method for detection of delirium . Ann Intern Med 113 ( 12 ): 941 \200\223 8 . Confusion Assessment Method: Training Manual and Coding Guide, copy right 2003, Sharon K. Inouye, M.D., MPH. CLOCK-DRAWING AND THE MINI-COGTM 693 Clock-drawing and the Mini-Cog TM Clock-drawing tests (CDT) are widely accepted and well va lidated screening tools for dementia. Their strength is in the brisk assessment of multiple cognitive domains including long-term memory, auditory and visual processing, motor planni ng and execution, etc. There are many test methods. All ask subjects to draw a clock face s howing a speci \201 c time, but other details and vary. Despite these differences, most ap pear sensitive and speci \201 c and are well tolerated. There is also evidence that non-sy stematic assessment \200\224 simply asking a patient to draw a clock-face showing a named time and assessing it informally \200\224 has great value in ruling in or ruling out signi \201 cant cognitive dysfunction. The Mini-Cog TM One test that has found widespread favor is the Mini-Cog, which com- bines a 3-item recall test with a CDT. It takes 2 \200\2233 mi nutes to administer, is sensitive and speci \201 c, and largely unin \202 uenced by level of education, language or other cultural factors. Administration 1. Get the patient \200\231s attention then say three unrelated words (eg ba nana, sunrise, chair). Ask the patient to repeat the words to con \201 rm registra- tion. If the patient is unable to repeat the words after three attempts move onto the next item 2 . Ask the patient to draw a clock face on a blank sheet of paper. You should prompt with: \200 \200\230First draw a large circle \200\231 \200 \200\230Now put all the numbers i n the circle \200\231 \200 \200\230Now set the hands to show ten past eleven (11.10) \200\231 Instructions may be repeated, but no more detail/help given. If they have not comp leted the clock in three minutes move to the next item. 3. Ask the patient to repeat the th ree words Scoring Give a point for each word correctly recalled after the CDT. A normal clock scores 2, an abnormal clock scores 0 (see Fig. A.2). Total score is therefore out of 5 points. Positive screen for dementia is indicated by: Score of 0, 1 or 2 Negative screen for dement ia is indicated by: Score of 3, 4 or 5 Source S Borson . Reprinted with permission of the author, solely for clinical and teaching use. May not be modi \201 ed or used for research without permission of the author (soob@u.washington.e du). All rights reserved. Further reading Borson S , Scanlan J , Brush M , et al . ( 2000 ). The mini-cog: a cognitiv e vital signs measure for dementia screening in multi-lingual elderly . Int J Geriatr Psychiatry 15 : 1021 \200\223 7 . 694 APPENDIX Further information Clock-drawing test interpretation (Fig. A.2 ) . 2 o t : S T N E M E L E G N W O L L O F D E R O C S t c e r r o c g n i t n o p D E R O C S i e h t e n o d n a S I r e b m u n S T N E M E L E n I i t n e s e r p S I K C O L C A W A R D O T L A S U F E R 1 1 o t g n i s s i ) S D N K R E H T O Y N A M E R A E R E H T ( e r a g n i t n o p E S E H T F O Y N A G N I S S I M K C O L C Y N A M E H T F O L L A S A H K C O L C L A M R O N A , e c n o y l n o h c a e I i . ) e s i w k c o l c ( e n O . t n e s e r p n o i t c e r i d , 2 1 \200\223 1 e r a s r e b m u n s d n a h o w T d n a . . L A M R O N B A L A M R O N B A r e d r o G N R O C S K C O L C l l A S K C O L C L A M R O N B A F O S E L P M A X E I K C O L C L A M R O N E M O S . t s e t s d n a h g n w a r d - k c o C i l a m r o n b A l 2 A . . g i F MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) 695 Malnutrition universal screening tool (MUST) (Fig. A.3 ) Step 1 BMI score + Step 2 Weight loss score + Step 3 Acute disease effect score Unplanned weight loss in past 3 \200\2236 months % Score = 0 <5 = 1 5 \200\22310 = 2 >10 If patient is acutely ill and there has been or is likely to be no nutritional intake for > 5 days Score 2 BMI kg/m2 >20(>30 Obese) 18.5 \200\22320 <18.5 Score = 0 = 1 = 2 If unable to obtain height and weight, use alternative measurements or subjective criteria \200\224see M www.bapen.org.uk Step 4 Overall risk of malnutrition Add scores together to calculate overall risk of malnutrition Score 0 low risk Score 1 medi um risk Score 2 or more high risk Step 5 Management guidelines 0 Low risk Routine clinical care 1 Medium risk Observe Document dietary intake for 3 days if subject in hospital or care hom e If improved or adequate intake \200\223 little clinical concern; if no improvement \200 \223 clinical concern - follow local policy 2 or more High risk Treat* Refer to dietitian, nutritional support team or implement local policy Improve and increase overall nutritional intake Monitor and review care plan Hospita l \200\223 weekly Care home \200\223 monthly Community \200\223 monthly * Unless detrime ntal or no benefit is expected from nutritional support eg. imminent death. Repeat screening Hospital \200\223 weekly Care homes \200\223 monthly Community \200\223 annually for special groups eg. those >75 yrs Repeat screening Hospital \200\223 weekly Care home \200\223 at least monthly Community \200\223 at least every 2 \200\2233 months All risk categories: Obesity: Treat underlying condition and provide help and advice on food choices, eating and drinking when necessary. Record malnutrition risk category. Record need for special diets and follo w local policy. Record presence of obesity. For those with underlying conditions, these are generally contr olled before the treatment of obesity. Re-assess subjects identified at risk as they move through care settings See The \200\230M UST \200\231 Explanatory Booklet for further details and The \200\230MUST \200\231 Report for supporting evidence. Fig. A.3 The malnutrition universal screening tool. Source Reproduced here with the kind permission of BAPEN (British Association for Parentera l and Enteral Nutrition) from the MUST Explanatory Booklet. For further information see M www.bapen.org.uk . 696 APPENDIX Further information Glasgow Coma Scale The GCS provides a framework with which to describe a patient \200\231s state in terms of three elements of responsiveness: eye opening, verbal, and motor. The GCS score is an arti \201 cial index that is obtained by adding scores for each of the three responses. The range of scores is 3 to 15, 3 being the worst, and 15 the best. Best eye response 4 Spontaneous opening 3 Open to speech 2 Open to pain 1 No eye opening Best verbal response 5 Orientated 4 Confused conversation 3 Inappropriate words 2 Incompreh ensible sounds 1 None Best motor response 6 Obey commands 5 Localize pain 4 Withdrawal from pain \200\224 pulls limb away 3 Abnormal \202 exion to pain (decorticate posture) 2 Extension to pain (decere brate posture) 1 No motor response Note that the term GCS 11 has limited meaning. It is important to state the components of the GCS, eg E2V2M4 = GCS 8. Broadly, a GCS of: (cid:116) 13 suggests mild brain injury \200 9 \200\22312 suggests moderate injury \200 (cid:100) 8 suggests severe brain injury (coma) 697 Index A abbreviated mental test 690 ACE inhibitors 136 , 270 \200\2231 , analgesia 140 NSAIDs 140 opioid analgesia 140 deafness 548 disease acquisition 256 endocrine system 420 eyes 568 gastrointestinal system 352 angina 260 309 aggravating cautions 136 starting 137 conditions 260 genitourinary system 508 glucose metabolism 420 haematopoietic system 452 illness 8 , 10 im mune system 606 kidney 384 lungs 312 neurology 152 oxidative damage 3 protein modi \201 ca tion 3 respiratory changes 312 skin 586 \200\2237 successful/unsuccessful 9 theories of 3 medication 260 palliation 261 revascularization 260 risk factor reduction 260 acetylcholinesterase inhibitors 224 \200\2235 achalasia 363 acidosis and angiodysplasia 378 angiotensin receptor blockers 271 hyperkalaemia 394 ACTH stimulation (short Synacthen) test 411 ankle swelling actinic keratoses 602 activities of daily living nocturnal polyuria 301 peripheral oedema 300 (ADLs) 78 acute coronary anorexia 645 depression 248 anti-arrhythmics, pitfalls 275 syndromes 262 acute ischaemia 306 acute kidney injury 386 , 390 ageism 672 alcohol, confusion and anti-nuclear antibodies 69 anti-thyroid antibodies 441 antianginals 261 antidepressants 252 antidiuretic hormone, syndrome of inappropriate secretion 410 antiepileptics 439 antihyper tensives 309 complications 388 \202 uid challenge in AKI/ alcohol 244 alcohol dementia syndrome 244 alcohol withdrawal 244 alpha-adrenergic anuria 389 management 388 post-renal causes 387 pre-renal causes 386 renal causes 386 blockers 271 , 512 acute renal failure see acute prostatism and kidney injury acute services 14 , 16 acute surgical abdomen 380 Addison \200\231s disease 4 46 \200\2237 adenocarcinoma of hypertension 513 alpha-glucosidase inhibitors 427 comorbid conditions 271 5-alpha-reductase inhibitors (eg \201 nasteride) 512 alprostadil (prostaglandin antimicrobials 610 pneumonia 321 precribing 610 resistant organisms 610 , lung 335 adenosine 275 admission avoidance schemes 20 E1) 529 Alzheimer \200\231s disease 212 622 antivirals 316 anuria, \202 uid challenge in vs vascular dementia 213 adrenal incidentalomas 447 adrenal insuf \201 ciency, primary 446 adrenocorticotrophic amaurosis fugax 474 amiodarone 138 , 275 AKI 389 cautions 138 oral 138 and thyroid disease 139 , aortic sclerosis 299 aortic stenosis 299 arrhythmias 286 diagnosis 274 examination 273 inve stigations 273 management 274 precipitants 274 presentation 272 treatment 275 hormone, stimulation test 411 443 amlodipine 150 Amsler grid 578 anemia advance directives 664 \200\2235 adverse drug reactions 135 age-associated memory impairment (AAMI) 205 of chronic disease 458 investigations 453 of malignancy 631 iron de \201 ciency age-related macular degeneration 576 ageing effects 1 arterial leg ulcers 593 arti \201 cial nutrition see clinically assisted nutrition asbesto s-related disease 350 asbestosis 350 cardiovascular system 256 changes due/not due to 2 cognitive ageing 204 cumulative exposure to risk factors (extrinsic ageing) 256 anemia 454 , 456 kidney disease 394 macrocytic 457 megaloblastic 457 pernicious 457 unexplained 458 , 631 698 INDEX aspiration pneumonia/ housing bene \201 t 682 pension credits 682 Social Fund 682 travel assistance 683 bundle branch heart pneumonitis 332 , 358 , 365 block 286 risk, clinically assisted feeding 361 bunion 490 aspirin 309 assessment 51 , 70 asthma benign essential C calcium, oral 470 calcium channel blockers 271 Campbell de Morgan tremor 154 , 164 benign paroxysmal assessment 342 assisted ventilation 346 drug treatment 344 non-drug treatment 346 vs COPD 3 43 positional vertigo 559 , 561 benign prostatic hyperplasia 510 spots 604 assessment 510 examination 510 herbal preparations 512 international prostate symptom score (IPSS) 511 investigations 510 surgery 513 treatment 512 \200\22313 urinary cancer atherosclerosis, kidney and ageing 628 approach to disease 394 atrial \201 brillation 276 investigation 634 skin, and pre-cancers 602 treatment 632 see also malignancy cancer with u nknown primary 634 acute AF 277 assessment 276 chronic AF 277 complications 276 and hyperthyroidism 443 paroxy smal AF 277 rate/ rhythm control 277 risk of stroke 278 stroke prevention 278 warfarin 280 atrial \202 utter 276 atropine 275 attendance allowance 682 audiology 551 biopsy specimens 635 investigation catheterization 513 benign senescent approach 634 forgetfulness 205 prognosis 635 treatment 635 benzodiazepines delirium 243 epilepsy 168 insomnia 177 candidiasis mouth 355 oesophageal 363 thrush 591 vaginal 528 capacity 654 bereavement 640 \200\223 1 bereavement services 650 beta-blockers 150 , 271 hyperthyroidism 443 bicipital tendonitis 498 biguanides 426 bisphosphonates 470 , 481 blepharitis 582 blin d registration 570 cochlear implants 553 hearing aids 551 \200\2232 , 554 practical advice 551 \200\2232 speci alized hearing tests 551 advance directives 664 \200\2235 assessment 654 \200\2235 incompetent patients 658 independ ent mental capacity advocates 656 B B-type natriuretic peptide Mental Capacity bene \201 ts 570 Act (2005) 230 , 656 blistering diseases 600 (BNP) 290 back pain 496 bacteriuria, see also competency; lasting power of attorney (LPA) bullous pemphigoid 600 causes of blistered skin 601 blood, urine test 618 blood pressure asymptomatic 620 carbimazole 442 cardiac failure acute 291 assessment 288 \200\2239 chronic 292 diastolic 29 6 and renal failure 295 terminal care 294 balance and dysequilibrium 112 Bamford \200\231s classi \201 cation, British Hypertension Society de \201 nitions 269 stroke 181 measuring ABPI 305 Boutonniere deformity banned terms, history taking 57 492 Barrett \200\231s esophagus 362 Barthel Index 688 basal cell carcinoma 583 , 602 bed sores see pressure Bowen \200\231s disease 602 bradycardia 282 causes 282 management 282 pacemakers 284 presen tation 282 cardiac rehabilitation 266 cardiopulmonary resuscitation (CPR) 668 sores befriending 42 behavior disturbance decision making process 670 \200\2231 cardiovascular system 255 breaking bad news 638 \200\2239 breathlessness, dementia 228 depression 248 ageing 256 physical examination 64 multifactorial 313 bronchial carcinoma 334 , bene \201 ts 682 care homes 34 attendance allowance 682 blind registration 570 carer \200\231s allowance 683 council tax b ene \201 t 682 healthcare assistance 683 Care Standards Act (2000) 36 350 bronchitis, acute 314 bronchodilators 344 bullous pemphigoid 600 dementia patients 34 diabetic people 427 funding 36 INDEX 699 medicine 34 residential care 35 staf \201 ng 34 confusion, terminal illness 645 confusion and alcohol 244 skin changes 592 varicose veins 592 venous ulcers 592 alcohol dementia syndrome 244 alcohol withdrawal 244 Korsakoff \200\231s syndrome 244 Werni cke \200\231s careers in UK geriatric circadian rhythm disorders 178 medicine 48 consultant careers 48 Diploma in Geriatric cirrhosis 368 investigations 368 non-alcoholic fatty liver Medicine, (DGM) 49 non-consultant careers 48 non-European overseas encephalopathy 244 disease 368 Confusion Assessment Model (CAM) 692 CJD 218 claw toes 490 clinically assisted feeding aspiration risk 361 ethics of withdrawing treatment 360 \200\2231 initiating treatment 360 doctors 48 constipation 370 causes 370 diagnosis 370 prevention and primary care physicians 48 carer \200\231s allowance 683 carotid sinus massage 123 carotid sinus syndrome 122 carpal t unnel syndrome 493 cataract 572 \200\2233 catheters 538 treatment 371 treatment 544 , 644 consultation skills 52 \200\2233 contractures 485 coronar y artery bypass clock-drawing test 693 interpretation 694 clopidogrel 309 Clostridium dif \201 cile - associated diarrhea 614 \200\2236 cochlear imp lants 553 cognition, physical examination 64 cognitive ageing 204 cognitive impairment depr ession 248 without dementia 205 benign prostatic hyperplasia 513 complications 540 managing without 539 grafting 264 coronary syndromes 262 comorbidity 262 late presentation 262 pathology 262 cellulitis 589 cerebellar dysfunction 154 cervical spondylosis 486 Charles Bonnet Coroner 651 corticosteroids 476 syndrome 571 chemotherapy 632 chest medicine 311 chest pain 258 chronic cough 333 chronic d isease asthma 344 cortisol, serum 446 cough, chronic 333 CRP 472 , 474 , 609 , 630 cremation forms 649 crutch es 89 CURB score 320