By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage skin breakdown and wounds in the frail elderly

Skin breakdown is common in the frail elderly, often who are consistently putting pressure on a given skin area due to immobility and impaired skin integrity and ability to heal secondary to age and comorbidities. Once a "pressure ulcer" has been identified, it is important to perform an assessment, document findings, and devise an appropriate management plan. It is important to understand the patient's general medical history to identify reversible conditions and precipitating or aggravating factors, as well as to identify what supports are currently in place to assist the patient with wound management and activities of daily living. Physical examination and documentation are also important. UpToDate provides a simple diagram that summarizes a pressure wound staging score (National Pressure Ulcer Advisory Panel), and this is useful in terms of providing followup care to assess progress (or lack thereof) of healing, and to communicate wound severity with other health care providers. 

It is also useful to document physical measurements of wound (location, length, width, depth, discharge, etc.) and capturing photos can also help.

Wound care follows some basic principles, and may include different strategies depending on individual patient circumstances. The UpToDate article, "Clinical staging and management of pressure-induced skin and soft tissue injury" (2018), from which the above staging diagram was also pulled, suggests the following as a general approach to caring for pressure wounds:

• Reduce or eliminate underlying contributing factors by providing pressure redistribution with proper positioning and support surfaces.
• Provide appropriate local wound care, which may include debridement for patients with necrotic tissue, based on the ulcer's characteristics (this may include treating for secondary infection). Depending on community resources, consider home wound care nursing support.
  • According to the staging scale (above), this UpToDate article recommends the following approach depending on wound staging:
    • Stage 1 skin injuries can be covered with transparent film for protection. The development of a stage 1 pressure injury should be taken as an indication that the patient is at high risk for more serious ulcer development, and intensive preventive measures should be taken. 
    • Stage 2 pressure injuries require a dressing that maintains a moist wound environment. These wounds generally require little debridement.
    • Stage 3 and 4 pressure injuries generally require debridement of necrotic tissue and coverage with appropriate dressings and possibly treatment of infection.
• Provide analgesia as indicated. Consider adjunctive therapies, such as negative pressure wound therapy. 
• Optimize patient nutrition and chronic disease management.
• Monitor and document the patient's progress.
• Provide appropriate psychosocial support. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Evaluate and initiate management (including pharmacologic and non-pharmacologic therapies) for transient (acute) and established (chronic) urinary incontinence

Urinary incontinence is a common symptom in the elderly, and it can have a detrimental effect on quality of life. Sometimes it happens not because of a problem with the urinary system but rather as a consequence of other bodily functions, and typically these are the presentations that present as acute processes and that are rectified promptly with management of the primary concern. Examples of such situations could be the patient who has urinary incontinence secondary to polyuria (has the urinary incontinence been associated with a new increase in urine output), and/or the patient who has difficulty reaching a toilet in time to void, either because of mobility or environmental reasons. Sometimes drugs and alcohol can lead to impaired control over urinary function. And it's always important to rule out cauda equina syndrome, which presents as acute urinary incontinence due to nerve compression and is associated with low back pain, lower extremity weakness, bowel incontinence, and/or anesthesia of the perineal region. Acute urinary incontinence may also be secondary to a new urinary tract infection or constipation, and in the elderly population who may present with atypical presentations of common diseases, these could be how these diseases present. If clinical assessment raises concern for any of these issues, a workup and management plan must be considered accordingly (and for suspected cauda equina syndrome, this requires emergency care as it can result in permanent neurological impair).

In the patient with chronic urinary incontinence, the approach to clinical assessment is to conduct a history that susses out wether the urinary continence is due to stress incontinence (characterized by involuntary loss of urine with increases in abdominal pressure such as exercise, coughing, sneezing, or laughing), urgency incontinence (sudden compelling desire to pass urine that is difficult to defer), mixed incontinence (with features of both forms of incontinence), or overflow incontinence (typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying). It's also important to get a sense of their baseline level of functioning and of how the urinary incontinence is affecting their quality of life. There are screening tools that can help in this assessment, such as the 3 Incontinence Questionnaire (see below). Physical examination maneuvres will depend on what you think is going on, and may or may not include genitourinary examination (when patients have atypical symptoms, there is diagnostic uncertainty, there is a suspicion of pelvic pathology, or there is failure of initial therapy), digital rectal examination to assess for prostate enlargement or other abnormalities in males, and neurological examination in the setting of acute urinary incontinence.

As far as investigations go, besides a urinalysis there are no other necessary investigations. Urinary incontinence can largely be diagnosed and managed clinically. But this will depend on patient risk factors. If there is a suspicion for UTI, obtain a urine culture regardless of the results of urinalysis, and if there are risk factors for STI, obtain a urine NAAT for chlamydia and gonorrhea. If the patient has hematuria or risk factors for bladder cancer, order urine cytology. In males who are at risk of urinary retention due to an enlarged prostate, or if there are any concerns for urinary retention/overflow incontinence on history/exam, obtain a post-void residual bladder scan to look for this, and order a serum creatinine to ensure there is no secondary hydronephrosis induced kidney dysfunction if retention is present. Men should also have a PSA done in the setting of urinary incontinence to stratify the risk for prostate cancer. Another useful tool to send patients away with to have done is a voiding and fluid intake diary, which can help provide context for what is really going on (Are they drinking much caffeine, or drinking late at night and having nocturia? Or are they simply drinking boatloads of water or hardly any fluids at all?)

If the urinary incontinence is secondary to an easily treatable underlying cause, you treat the cause. But if it is attributed to stress, urgency, or mixed incontinence, you work with the patient to adopt whatever behavioural strategies they can tolerate and that they find helpful. First-line strategies to recommend include:

• Incontinence pads
  
• Avoidance of excessive fluids and reduced consumption of caffeine, carbonated beverages, and alcohol
  
• Management of constipation
  
• Smoking cessation 
  
• Weight loss
  
• Pelvic floor muscle exercise (Kegel's)
  
• Timed voiding (for patients with urge or mixed incontinence)

If these do not suffice, pessaries are a non-pharmacological and non-surgical option for women with stress incontinence. 

Common medication options include vaginal estrogen in post-menopausal women, an alpha blocker in men with BPH, and in patients with urge or mixed incontinence, an anticholinergic or B3 agonist can be trialled (however these latter medications are not without insignificant side effects). If the above approaches are without good effect, consider a referral to a urologist for procedural repair.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Construct a differential diagnosis (including risk factors) and plans for the evaluation, management and prevention of falls
• Identify consequences of immobility in the elderly patient
• Work with interdisciplinary teams to prevent, manage and treat consequences of immobility in the elderly patient
• Develop and implement plans for the assessment and management of patients with functional deficits, including the use of adaptive interventions, in collaboration with interdisciplinary team members
  

Disability

Key Feature 6: In patients at risk for disability (ex: those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (ex: exercises, braces, counselling, work modification).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Recently, I had a really long post on dementia and mentioned that part of the management of these patients is ongoing cognitive and functional assessment, and screening for the many complications that are the sequelae of the decline. Psychiatric conditions such as dementia are indeed one of the reasons to assess fall risk in the elderly, and there are many others. My differential for etiologies underlying a fall (which are conversely risk factors for a patient to sustain a fall) is as follows:

1. Medical conditions (ex: vertigo, gait disturbances, syncope) 
2. Psychiatric conditions (ex: cognitive impairment, substance abuse) 
3. Medications 
4. Environmental or behavioral risk factors (ex: walking surface, choice of footwear) 
5. Other contributors (ex: decreased vision, urinary urgency)

My approach to evaluate and manage patients who have fallen is derived from the LMCC approach to falls, which includes the following steps:

1. Gather a description of the events surrounding any recent and remote falls
   1. Consider the following points:
      1. When and where the fall occurred
      2. What the patient was doing at the time of the incident
      3. Were there any prodromal Sx (such as dizziness, lightheadedness, imbalance)
      4. Did the patient lose consciousness? (associated with orthostatic hypotension, cardiac disease, and neurologic disease)
2. Review the patient's medical history for risk factors (ex: medical conditions, medication history, substance abuse)
   1. Pain and urinary urgency may precipitate falls, and consider the timing of medications and substance use in relation to falls
3. Assess for any environmental hazards that may have contributed 
   1. Consider: Lighting, floor covering, door thresholds, railings, and furniture
4. Perform a complete physical examination and functional evaluation
   1. Things that I always want to check off my list during such an assessment are as follows:
      1. Postural vitals (BP and HR) supine and then at 1 and 3 min after standing
      2. Mental status examination (especially cognitive assessment)
      3. Cardiovascular examination (heart sounds, volume assessment)
      4. Musculoskeletal examination (examination of lower extremities and footwear)
      5. Neurological examination (visual acuity, hearing screen, lower extremity neuro exam)
5. Obtain a CBC to rule out anemia as this may increase the risk of falling; other labs as indicated
6. Optimize the management of any acute and chronic illnesses, and perform a medication review. General dietary recommendations include good nutrition and supplementation with Vitamin D and calcium, as indicated.
7. Suggest specific interventions to prevent future falls (ex: balance/gait training, muscle strengthening exercises). Consider referral to a physiotherapist to assist with this. As the expression goes, if you don't use it, you lose it, and it rings true for physical ability. Patients who are sedentary will lose muscle strength and become physically deconditioned, which increases their risk of falling. Sometimes a previous fall leads to fear of moving as much, which results in a vicious cycle of decompensation and increased risk of falling, not to mention the other sequelae of immobility including increased risk of skin breakdown (aka pressure sores) and of developing a clot (venous thromboembolic disease).

Although a few conditions require absolute bedrest (ex: unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. Activity orders for bed rest should be avoided unless absolutely medically required. Staff should attempt to get patients out of bed to a chair with meals, which also decreases risk of aspiration and, when possible, encourage patients to walk several times daily.

Patients who have difficulty ambulating on their own or who pose a significant fall risk may need supervision by trained staff (ex: physical therapy) or referral to a specialized mobility program. Increased activity during hospitalization can mitigate functional decline so that patients can transition optimally outside the hospital setting 

1. Suggest appropriate home safety interventions (ex: removing environmental hazards, grab bars, emergency response systems). Enlisting the help of an Occupational Therapist can be very useful. Patients who are capable may also do their own home assessment (https://www.cdc.gov/steadi/patient.html).
2. Consider if there is a need or potential for benefit if consultation is arranged with other medical specialists or allied health care professionals. For complex geriatric patients, they could likely benefit from a referral to a Geriatrician for a comprehensive assessment. Consider the community resources available locally.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Perform a cognitive assessment using standard cognitive testing and collateral history relevant to cognitive and/or functional decline
• Evaluate pre-morbid and current functional abilities using reliable sources of information and standardized assessment tools
• Distinguish between the clinical presentations of delirium, dementia and depression
• Assess and manage delirium
• Assess and manage common forms of dementia (NB Canadian Consensus Guidelines on Dementia)
• Recognize and initiate management of common issues in dementia care (ex: driving, capacity, wandering, pharmacologic therapy, behavioural and psychological symptoms of dementia BPSD, caregiver stress, falls (ex: gait and balance assessment tools))

Dementia

Key Feature 1a: In patients with early, non-specific signs of cognitive impairment: Suspect dementia as a diagnosis.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 1b: In patients with early, non-specific signs of cognitive impairment: Use the Mini-Mental State Examination and other measures of impaired cognitive function, as well as a careful history and physical examination, to make an early positive diagnosis.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 2: In patients with obvious cognitive impairment, select proper laboratory investigations and neuroimaging techniques to complement the history and physical findings and to distinguish between dementia, delirium, and depression.
Skill: Clinical Reasoning
Phase: Investigation

Key Feature 3: In patients with dementia, distinguish Alzheimer’s disease from other dementias, as treatment and prognosis differ.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 4: In patients with dementia who exhibit worsening function, look for other diagnoses (i.e., don’t assume the dementia is worsening). These diagnoses may include depression or infection.
Skill: Clinical Reasoning
Phase: Hypothesis generation

Key Feature 5: Disclose the diagnosis of dementia compassionately, and respect the patient’s right to autonomy, confidentiality, and safety.
Skill: Patient Centered, Communication
Phase: Diagnosis, Treatment

Key Feature 7a: In following patients diagnosed with dementia: Assess function and cognitive impairment on an ongoing
basis.
Skill: Clinical Reasoning
Phase: Follow-up, Physical

Key Feature 7b: In following patients diagnosed with dementia: Assist with and plan for appropriate interventions (ex: deal with medication issues, behavioural disturbance management, safety issues, caregiver issues, comprehensive care plans, driving safety, and placement).
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

Key Feature 8: Assess the needs of and supports for caregivers of patients with dementia.
Skill: Patient Centered
Phase: History

Key Feature 9: Report to the appropriate authorities patients with dementia who you suspect should not be driving.
Skill: Professionalism, Clinical Reasoning
Phase: Treatment

Key Feature 10: In patients with dementia, look for possible genetic factors to provide preventive opportunities to other family members, and to aid in appropriate decision-making (ex: family planning).
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, History

Infections

Key Feature 4: Look for infection as a possible cause in a patient with an ill- defined problem (ex: confusion in the elderly, failure to thrive, unexplained pain [necrotizing fasciitis, abdominal pain in children with pneumonia]).
Skill: Clinical Reasoning
​Phase: Hypothesis generation

Pneumonia

Key Feature 1: In a patient who presents without the classic respiratory signs and symptoms (ex: deterioration, delirium, abdominal pain), include pneumonia in the differential diagnosis.
Skill: Clinical Reasoning
Phase: Hypothesis generation

According to the UpToDate article "Evaluation of cognitive impairment and dementia," "Most patients with dementia do not present with a complaint of memory loss; it is often a spouse or other informant who brings the problem to the clinician's attention. Self-reported memory loss does not appear to correlate with the subsequent development of dementia, while informant-reported memory loss is a much better predictor of the current presence and future development of dementia. Nevertheless, family members are often delayed in recognizing the signs of dementia, many of which are inaccurately ascribed to 'aging.'" In other words, primary care clinicians need to maintain a high index of suspicion as patients who may be in an early phase of dementia may be unlikely to present for medical care for cognitive concerns. I do this practically by assessing how my elderly patients are functioning as part of my routine social history screen. 

Once I have picked up on any questionable or obvious impairment in functional capacity, I perform a focused history (including a psychiatric history) and physical examination (including a mental status examination as well as a neurological screen). This initial assessment is particularly important to rule out the two common dementia "mimics:" delirium and depression, each warranting completely different approaches to management. Delirium is an acute cognitive disturbance secondary to an underlying medical insult that requires an urgent medical workup, and can be screened for using the Confusion Assessment Method, as outlined below. If I make a diagnosis of delirium in the office, I am sending the patient to the ED for a rapid workup that includes blood work and other investigations, sometimes including neuroimaging, unless there is an underlying cause that I can quickly assess and treat from the office (see an algorithmic overview to the treatment of delirium, per UpToDate, below). There can only be more than one thing going on, so the precipitant would need to be very clear from the assessment and I would need to feel confident that there is a low risk for a second reversible precipitant. Delirium is associated with higher morbidity and mortality rates, the latter of which raises true urgency about the situation.

If the patient's presentation is, on the other hand, not in keeping with depression or delirium, I then book the patient in to see me for a formal assessment of their cognitive functioning with a Mini-Mental State Examination. This is one of the more coarse but highly standardized cognitive assessment tools. If they score well on this, I proceed to performing a MoCA, which is a more sensitive test for mild cognitive impairment. I also ask for permission and obtain collateral information from other members of the household or family. If there is indeed substantiated evidence of cognitive decline on formal cognitive testing, I proceed to obtaining relevant investigations, mostly to assess for reversible causes of cognitive decline. This includes the following labs: complete blood count, glucose, creatinine, electrolytes, calcium, albumin, urinalysis, liver enzymes, vitamin B12 level, thyroid stimulating hormone, syphilis ELISA immunoassay, and HIV testing. I obtain a head CT (or brain MRI) for patients with early-onset cognitive impairment (<60 years old)  or brisk cognitive decline (progression to dementia in less than 1 year from onset of cognitive impairment), or if information on history or physical exam suggests focal or vascular pathology. Particularly young patients who display evidence of cognitive decline are atypical and warrant a more exhaustive workup for reversible causes of dementia along with referral to a dementia specialist and access to a memory clinic, and as the Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia recommends, they preferably also have access to genetic counselling and testing. Also consider the impact this may have on their functional life well before retirement was likely expected. This is in contrast to patients who present with the classic late-onset and gradual decline of Alzheimer disease who are so unlikely to benefit from exhaustive investigations that doing so may be over the top for everyone involved.

Now I've begun to separate out Alzheimer dementia from the other causes, and this is an important concept once you have made a diagnosis of dementia and are moving on to what you can do to manage the disease. Alzheimer dementia is the most common form of dementia, and there are medications that are available that can provide benefits, albeit small ones, on cognitive functioning. Although these medications may also be tried for patients with a few other forms of dementia (such as vascular dementia, dementia with Lewy Bodies, and Parkinson disease dementia), the evidence is really most in favour for their utility in Alzheimer dementia.

It is also important to distinguish Alzheimer dementia from others because of the typical gradual decline these patients and their caregivers suffer from, and the dedicated supports that can be offered such as may be offered through the Alzheimer Society of Canada. Beginning conversations early and planning for future times when abilities to care for the patient become more and more challenging can never start early enough. Given the nature of the bad news that must be broken to patients, it is important to share the diagnosis with them and their loved ones in a thoughtful and compassionate way, preferably early enough while the patient still has the ability to be self-autonomous (i.e., still having the capacity to consent). This means that disclosing a diagnosis to the patients' family members or other caregivers would be done only with patient consent, usually followed by a family meeting. It is important that caregivers participate in this shared understanding as safety concerns may become critical, and it is a team effort to be conscientious when a decline happens to the point that activities such as driving must be limited in order to protect the patient and others. This is often very challenging for everyone involved. Being mindful to respect all parties' wishes often takes compromise and ultimately deciding what your bottom line is in terms of when to limit patient autonomy in the interest of protecting safety.

It is important to continue to reassess functional and cognitive abilities on an ongoing basis to be able to anticipate when interventions are needed. Cognitive abilities can be assessed using standardized screening tools such as the MMSE, while functional abilities are often captured on assessment of the patient's ability to perform basic and instrumental activities of daily living (outlined at the end of this post). As the disease progresses, there may need to be changes in medications, interventions to minimised the impact escalating behavioural issues including safety concerns such as driving* or wandering, strategies to address caregiver burnout and ensure they are supported as much as possible, provision of ongoing primary care for general health and wellbeing, fall risk assessment workup as indicated including an assessment of gait and balance, and consideration for more formal supports in the community or considering a move to residential care. Providing all stakeholders with as much time to reflect on decisions allows more time for thoughtful decision-making in each of these domains. If patients demonstrate they no longer have competency to consent when it comes to the management of issues that go along with this disease process, deeming them incapable of specific decision-making domains and then deferring to the substitute decision maker is the next step. A substitute decision maker that is well-informed regarding what the patient would likely want as the disease process continues is apt to make better decisions that respect the patient's right to self-determination. Again, the earlier the planning can happen when it comes to a diagnosis of dementia, the better the opportunity for patients to plan for the future when they can no longer speak for themselves. Some patients and family members may voice an interest in genetic testing. Although this is not typically done given the dearth of disease-modifying treatments or targeted strategies for prevention, consider referring patients to a Genetic Counsellor to explore this request. When patients present wanting assistance with interpreting the results of genetic investigations, such as may be obtained from direct-to-consumer genetic testing, it may be best to send them to a dementia specialist. This is an ever-evolving field, and current testing for dementia is far from definitive.

When a patient with known dementia presents with worsening functional decline, this could certainly be secondary to progression of the underlying brain disease, as we know is destined to happen with progressive dementias. However, if the decline is steeper than what may be expected for the general disease prognosis (a loss of 3 points on the MMSE within 6 months), it is aways important to evaluate the patient for other triggers for functional decline, including depression, delirium, and an adverse medication effect. Although depression and delirium, both common mimics of dementia, are ruled out when the diagnosis of dementia is made according to the DSM V criteria C and D (C. The cognitive deficits do not occur exclusively in the context of a delirium. D. The cognitive deficits are not better explained by another mental disorder [ex: major depressive disorder, schizophrenia].), they can both be processes that arise after dementia has begun. Re-assessing for these potentially superimposed processes can be more challenging in the patient with underlying dementia, but it is vitally important as treating a cause of delirium can be life-saving, and addressing depression can substantially improve quality of life. When it comes to the physical insults that can result in a delirium, consider a differential that includes particularly relevant insults in this population, such as medication effects, infection (commonly, pneumonia or UTI), metabolic disturbances, and trauma.

*Legislation regarding physician reporting of drivers who are suspected of being unfit to drive varies between provinces. This article by the Canadian Medical Protective Association gives a good overview of the situation as it is currently.

Instrumental Activities of Daily Living (iADLs)
An individuals ability to manage their iADLs can be assessed by screening for their capacity to manage the following domains:

• Medication
• Yardwork
• Shopping
• Housekeeping
• Accounting
• Food preparation
• Transportation/Telephoning
• Driving (the ultimate iADL)

Basic Activities of Daily Living (bADLs)
An individuals ability to manage their iADLs can be assessed by screening for their capacity to manage the following domains (the morbid acronym DEATH helps me remember these):

• Dressing
• Eating
• Ambulating
• Toileting/Transferring
• Hygiene

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and alter medication therapy that is most likely to cause adverse drug events in an older individual
• Outline the pharmacokinetic changes that commonly occur with aging and demonstrate the ability to modify drug regimens accordingly
• Describe the usual anatomical and physiological changes seen with aging and understand the concept of frailty
• Describe advance planning directives (including the roles of physicians and substitute decision-makers) dealing with personal and financial decision-making emphasizing a “goals of care” approach
• Identify patients who might benefit from a palliative approach and identify this early in the disease trajectory
  • Identify opportunities for advance care planning discussions, whether or not a patient has a life-threatening or life-limiting illness
  • Initiate a palliative care approach early in the illness trajectory
  • Identify the patients stage of illness using appropriate tools
• Communicate with patient, families and care team about palliative and end of life options and care.
  

Disability

Key Feature 2: Screen elderly patients for disability risks (ex: falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Elderly

Key Feature 1: In the elderly patient taking multiple medications, avoid polypharmacy by:

• Monitoring side effects
• Periodically reviewing medication (ex: is the medication still indicated, is the dosage appropriate)
• Monitoring for interactions

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

Key Feature 3: In the elderly patient, screen for modifiable risk factors (ex: visual disturbance, impaired hearing) to promote safety and prolong independence.
Skill: Clinical Reasoning
Phase: History, Hypothesis generation

Key Feature 4: In the elderly patient, assess functional status to:

• Anticipate and discuss the eventual need for changes in the living environment
• Ensure that social support is adequate

Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, History

Tomorrow I start my first day caring for elderly patients in a residential care home, which I will continue to do intermittently throughout the year as part of my program requirements and vocational interests. One of the most important skills in geriatric medicine is appropriate prescribing practices; frail elderly patients can be at significantly more risk of harm compared to the general fit patient with negligent prescribing. While it is always important to prescribe thoughtfully (as indicated, where benefits outweigh the harm for the individual patient, with thought given to potential drug interactions, and with monitoring for side effects), the frail elderly patient has less reserve to cope with complications from errors with medication prescribing. As well, decreased kidney and liver functioning become much more common with age, so if the body is unable to clear the medications from the system as effectively, we need to consider the effect that the drug may have if it lingers for longer or builds up to higher levels than it otherwise would. Depending on the drug, and the patient's  kidney and liver function profile, doses may need to be reduced in quantity or frequency.

UpToDate provides a table that summarizes an approach to performing a geriatric medication review:

Medication review in the frail elderly should be part of all routine comprehensive medical care, just like screening is done as part of a periodic health examination. Specific screening interventions that may be particularly indicated in elderly patients include vision screening, hearing screening, and screening for osteoporosis. Impaired vision and hearing increase risk of functional limitation, falls, and if there is comorbid osteoporosis, increase the risk that a patient may sustain a significant fracture such as of the hip, associated with significant increase in morbidity and mortality. 

A defining feature of the frail elderly patient is having limitations on functional abilities. It is also something that occurs along a continuum, with different supports indicated depending on the degree of functional limitation. It is important to incorporate monitoring frailty severity into routine clinical practice of all elderly patients. The Clinical Frailty Scale is one tool that is validated and easy to use clinically.

A comprehensive assessment of a patients overall functional status but also specific functional needs is important to be able to offer beneficial targeted interventions and supports. This also involves considering what supports the patient currently has, their personal values and goals (including Advance Care Planning), and the supports available in their community. An interdisciplinary approach to supporting the frail elderly patient is standard of care, including involving family members or other loved ones as valued and active members of the care team, as the patient wishes, and referring patients for a comprehensive geriatric assessment may be the best place to initiate an assimilation of key members for an individualized support team. In a patient who has chronic mobility or disease that is not reversible, and who is having quality-of-life reducing symptoms on a regular basis, it's never too early to consider palliative care interventions, which are not just for those who are facing life-threatening illness. For those who are approaching end of life or who have symptoms affecting quality of life that can no longer be cured, palliative care interventions are necessary. Having frequent discussions with the patient and all members of the care team helps to keep people on the same page, to optimize care and to anticipate how care can best be optimised as symptoms progress. The Palliative Performance Scale is a tool used by many palliative care physicians to help in the conversation and understanding of the trajectory of palliative care needs.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Describe the use and risks of indwelling catheters versus intermittent catheter
  

Bladder catheterization is a procedure that is done frequently in the emergency room, operating room, and in-patient hospital setting. It may be done for investigations such as monitoring urine output or to obtain a sample of urine for analysis, or it may be done as a therapeutic intervention to relieve urinary retention or to manage urine output while undergoing an operation. Depending on the reason, it may be done as an in-and-out catheter, or may remain in-situ for some amount of time, which comes with increased risk of infection, which could evolve into urosepsis, and so is avoided when possible. It is contraindicated if there is suspected urethral disruption from pelvic trauma based on history +/- the observation of blood at the urethral meatus. If there are features complicating the patient's case, such as recent urethral surgery or a known urethral stricture, consider consulting a Urologist to perform the procedure. If someone has a urinary tract infection, consider if they truly need the procedure, and if so, proceed as indicated. 

Equipment

• Urethral catheter
  • Size measure in French units, with one French being approximately 0.33mm in diameter. The standard size used in an adult is a 16 or 18 French.
  • There are different types of catheters, but the one the general practitioner needs to be comfortable inserting is the Foley catheter, which has 2 or 3 lumina. Urine flows through the main large lumen, a second is used to inflate the balloon to keep the Foley in-situ, and the occasional third lumen is used if fluid is to be irrigated into the bladder

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Identify and manage common end of life care issues (e.g. nutrition, dysphagia, code status, hospital transfer, home and LTC visits)

Key Feature 1: In all patients with terminal illnesses (ex: end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e., do not limit the use of palliative care to cancer patients). 
Skill: Patient Centered, Clinical Reasoning
Phase: Treatment

Key Feature 2: In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e., use a team approach when necessary). 
Skill: Patient Centered
Phase: Treatment

Key Feature 5: In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (ex: wishes for treatment of infections, intubation, dying at home)
Skill: Patient Centered, Clinical Reasoning
Phase: History, Hypothesis generation

Today I began my palliative care rotation at St Paul's Hospital. I met 4 different patients on the ward all receiving palliative care for very different reasons. All patients had incurable but not unmanageable disease states, including end-stage chronic obstructive pulmonary disease, impaired postoperative wound healing in the setting of severe frailty, advanced congestive heart failure, and metastatic esophageal cancer. Although only one of these patients had a diagnosis of cancer, all of them had symptoms that warranted management according to the principles of palliative care. For a succinct overview of what palliative care entails, see the WHO Palliative Care webpage.

Central to the palliative care approach is the appreciation of an individual's total suffering, which includes sources of physical pain  but also areas of emotional, social, and spiritual pain, among other domains. The benefit of a multidisciplinary team strategy when taking a comprehensive perspective of pain cannot be understated; while the physician is certainly an expert in treating physical sources of pain with analgesia, this is but one method of alleviating pain associated with life-limiting and life-threatening illness. The book, "Palliative medicine: A case-based manual" by Oneschuk, Hagen, and MacDonald (2012) provides examples of the ways in which various health care professionals may contribute to alleviating a patient's total suffering:

• A spiritual care provider can provide counselling and support for patients and their families
• A social worker can address the family’s stress, as well as coordinating hospital discharge planning
• A psychologist can provide psychological assessment and treatments
• Physiotherapists and occupational therapists can contribute to pain management interventions (ex: acupuncture, splinting, energy conservation strategies)
• Dieticians can assist with symptoms, including anorexia–cachexia
• Professionals skilled in complementary therapies—including relaxation, meditation, massage, and distraction—can address stress and anxiety
• Trained volunteers can provide valuable support to patients and their families through companionship and activities

There are many methods of mitigating suffering, many of which may or may not be useful or desirable to a specific individual given the context of their circumstances and how it interacts with their beliefs, values, and wishes. As a treating physician, it is important to have conversations that explore these considerations, as indicated by the context. Whenever any medical decision is made, it is always important to ensure the decision is being made with informed consent. Furthermore, it may be important given certain circumstances to begin thinking about the decisions one may want for their health in anticipation of a future time when they may no longer be able to speak for themselves. This is particularly important when a patient is at greater risk of an incapacitating illness or event (although some say it is never too early to start having these conversations because you just never know). Regardless, it is always important to have these conversations with patients diagnosed with a terminal illness, and the sooner the better, when more time can be given to proper reflection. When done well in advance, this is typically the process of Advance Care Planning (ACP), and consists of reflecting on one's values and wishes for future health care decisions, along with identifying a person whom they would want to make decisions for them if/when they cannot make decisions for themselves (aka a substitute decision maker [SDM]), and communicating this verbally or as documented in writing (far preferable). This may include conversations about Goals of Care, which are more focused health care goals given a situation at hand (ex: What a patient's goals are for a given hospital admission and the scope of what they would and would not want to receive in terms of medical management. This would include but is not limited to clarification of the patient's Code Status.) The conversation does not end here of course, and each medical decision should be done with informed consent as given by the patient or the SDM if indicated. And as patients' circumstances and occasionally their beliefs, values, and wishes change, it is important to revisit ACP accordingly. If there has has been no ACP, then urgent decisions will need to be made regardless for medical decisions at hand, but research indicates that the outcomes are far more ideal for patients and care providers if these conversations are begun well in advance. The Pallium Palliative Pocketbook lists benefits of ACP as follows:

• End-of-life wishes are known and followed
• Less stress and anxiety for family members
• More satisfaction with care
• Better quality of life and quality of death
• Less use of inappropriate health resources

For more information on ACP, check out www.advancecareplanning.ca.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a patient-centred approach to care of patients and families through exploration of both the disease and illness experience, understanding the whole person, and negotiating informed shared decision making regarding management
• Act in a caring and compassionate manner
• Initiate screening for mental health disorders in high-risk situations (ex: patients with cancer, chronic pain, war veterans, refugees, victims of domestic violence, etc.)
• Obtain a structured medication review including identification of potential drug-drug and drug-disease interactions (if appropriate, in consultation with a pharmacist)
  

Chronic Disease

​Key Feature 4: In patients with chronic disease, actively inquire about:

• The psychological impact of diagnosis and treatment
• Functional impairment
• Underlying depression or risk of suicide
• Underlying substance abuse

Skill: Patient Centered, Clinical Reasoning
Phase: History

Difficult Patient

Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
Skill: Patient Centered, Professionalism
Phase: Treatment, Follow-up

Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain).
Skill: Selectivity
Phase: Hypothesis generation, Diagnosis

Disability

Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present.
Skill: Clinical Reasoning, Patient Centered
Phase: Diagnosis, Hypothesis generation

Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
Skill: Patient Centered
Phase: History

Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
Skill: Patient Centered, Professionalism
Phase: Treatment

Multiple Medical Problems

Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:

• Simplify their management (pharmacologic and other)
• Limit polypharmacy
• Minimize possible drug interactions
• Update therapeutic choices (ex because of changing guidelines or the patient’s situation)

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

​Stress

Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
Skill: Clinical Reasoning, Communication
Phase: Hypothesis generation, History

Key Feature 2:  In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress.
Skill: Patient Centered, Clinical Reasoning
Phase: History

The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. 

At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications.

There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. 

Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. 

After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." 

When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient.  In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life. 

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to... 

• Assist the patient to express their own beliefs and values in solving ethical issues
• ​Exhibit ethical decision-making such as discussion of capacity of patients to make decisions
• Demonstrate an understanding of informed consent
• Assess mental competency
• Apply the key principles of the Mental Health Act, Personal Directive Act, and Adult Guardianship and Trusteeship Act
  
• Apply appropriate medical, ethical, and medico-legal frameworks to decision making

Dementia

Key Feature 6: In patients with dementia, assess competency. (Do not judge clearly competent patients as incompetent and vice versa.)
Skill: Clinical Reasoning
​Phase: Diagnosis

Mental Competency

Key Feature 1a: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Initiate assessment of mental competency, including use of a standardized tool.
Skill: Clinical Reasoning, Communication
Phase: History, Physical

Key Feature 1b: In a patient with subtle symptoms or signs of cognitive decline (ex: family concerns, medication errors, repetitive questions, decline in personal hygiene): Refer for further assessment when necessary.
Skill: Clinical Reasoning
Phase: Referral

Key Feature 2: In a patient with a diagnosis that may predict cognitive impairment, (ex: dementia, recent stroke, severe mental illness) identify those who require more careful assessment of decision-making capability.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

Key Feature 3: When a patient is making decisions (ex: surgery/no surgery, resuscitation status) think about the need to assess their mental competency.
Skill: Clinical Reasoning, Professionalism
​Phase: Hypothesis generation

Key Feature 4: In a patient with cognitive impairment, identify intact decision-making abilities, as many may be retained.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Treatment

{A bit of preamble context: Today was the first day of my one-month rotation at Three Bridges, a community health clinic with a mandate to serve patients who have been marginalised and underserved in traditional institutions of health care delivery. These may be patients with substance use disorders, without a fixed address, who are single teenage mothers, who are HIV+, who fall within the LGBTQ umbrella, etc.}

Three patients I met in clinic today prompted me to consider my ability to assess competency and highlighted my lack of confidence in knowing whether or not I could make the call regarding their decision-making capacity if I was the most responsible physician overseeing their care. One of these patients was an elderly gentleman with moderately severe major neurocognitive disorder (aka dementia) and melancholic depression. His therapy was clearly not optimised, and he was coping rather poorly, but yet he did not want to consider a change in therapy as was being suggested during the visit. I wondered if he was competent to make this decision. The second patient was a 19 year old transgender female (birth-assigned male) who wanted to initiate an application for genital surgery and appeared quite competent to make this decision based on my clinical assessment. But I was unsure of how exactly I could confirm - for a decision with as permanent of consequences as the one being requested - that it was a fully informed one. The third patient was a middle-aged man with a history of query bipolar disorder and alcohol use disorder who appeared hypomanic on assessment and not on any mood stabilisers. He was precontemplative as far as his alcohol use was concerned, with unrelenting alcohol consumption despite liver failure and a recent discharge from hospital for complications of heavy alcohol use. I wondered if he had capacity to make many of the decisions he was making on a day-to-day basis that were causing himself harm. 

So like a good little resident, I left clinic feeling motivated by the dejection of not knowing another whole chunk of how to be a doctor. As I walked home, I considered what I felt I would need to know to feel confident deciding one way or another if patients have decision-making capacity. When I sat down at home and flipped open my laptop to get to my notes on Capacity & Consent, all I found was a bare and anonymous paragraph that was certainly not my own composition: 

"For a patient to provide consent they must have the mental capacity or competency (legal equivalent) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention."
-Anonymous 

How can I translate this into my day-to-day decision-making in the clinic when I need to know if the patient in front of me has the mental capacity to make a given decision, and how do I know what constitutes me giving enough information so that they can be sufficiently informed to provide informed consent?

According to UpToDate (2017), "In the absence of a reason to question an individual’s decision making, adults are generally assumed to have adequate capacity." Fair enough. So what are the reasons that ought to prompt me to question decision-making capacity? I read over the rest of the article, Assessment of decision-making capacity in adults (2017), and came up with a mnemonic I am going to call the 6Ds.

1. Dementia (moderate to severe)
2. Delirium
3. Delusion (psychosis)
4. Depression
5. Drug intoxication
6. Damage (brain)

Great! So now I know what patient factors ought to prompt me to think about assessing a patient's capacity when facing the need to make a decision that may impact their health. Now how do I go about assessing the patient's capacity? The UpToDate fairies have provided a succinct and superb table summarising the 4 domains that need to be assessed regarding any decision whenever there is any doubt about patient capacity, or even if there is no obvious reason to doubt patient capacity but the ramifications of the health decision are of increased significance (pay particular note to the instructions beneath the table).

What exactly are the "relevant facts" that must be disclosed to ensure consent is informed?

Per UpToDate (2017) paraphrasing, informed consent necessitates that:

1. The person received the information about the treatment that a reasonable person in the same circumstances would require to make a decision, including the
   1. Nature of the treatment
   2. Expected benefits of the treatment
   3. Material risks and side effects of the treatment
   4. Alternative courses of action
   5. Likely consequences of not having the treatment
2. The person was offered access to resources with more information about the treatment and received responses to his/her requests for additional information about the treatment

Legally, there are 3 ways in which the courts may decide that a physician has followed through on their duty to inform when obtaining consent regarding a treatment or other medical decision. Considering all 3 of these standards can help provide clarity when considering, for a given medical decision, wether all of the reasonably relevant facts have indeed been disclosed for the decision at hand. Per Informed procedural consent (UpToDate, 2017):

1. Professional Standard: The professional standard of care requires that a physician must disclose those facts that a reasonable physician who was faced with this particular set of circumstances would disclose.
2. Objective Patient-centered Standard: The physician must disclose those facts that a reasonable patient in a similar situation would need to know in order to make an informed choice.
3. Subjective Patient-centered Standard: The subjective standard for disclosure requires the physician to relay facts that a particular patient deems important in the decision-making process.

Although I cannot now retroactively seek answers from the patients I encountered today to determine their decision-making capacity, I believe my new approach (see below) based on the above information can provide me with the guidance to determine future patients' decision-making capacity moving forward. I am certain I will have many opportunities to put this to the test. 

Madalena's (aka UpToDate's) Decision-making Capacity Framework

1. Is there a decision that needs to be made that can affect the patient's health?
2. Are any of the 6Ds present that would prompt me to consider whether the patient lacks the capacity to make such a decision? Capacity in an adult is otherwise assumed.
3. Consider the importance of the decision that needs to be made, and if the repercussions of the decision are significant, consider assessing the patient's capacity to make the decision even if none of the 6Ds are present.
4. Assess capacity to make the decision if indicated:
   1. Ask the patient to explain to you their understanding of the facts you explained to them
   2. Ask the patient what choice they want to make given the facts
   3. Ask the patient what they believe are the benefits and risks of this choice as it applies to themselves 
   4. Ask the patient to explain why they think the benefits and risks of this choice outweigh those of the other options
5. If patient appears capable, feel confident that they have the capacity to make the decision at hand and proceed with this option. If the patient does not appear capable, consider the need for a formal capacity assessment by a second health care provider. In emergency situations or when a patient already has documentation incompetency, defer to the substitute decision maker (certainly the topic of another blog post). If the patient is deemed to lack capacity, remember that this may apply to a specific type of decision-making domain (ex: the patient may not have the capacity to manage their own chequebook, but they may retain the ability to make personal health care decisions).
6. Disclose the relevant facts:
   1. Nature of the treatment
   2. Expected benefits of the treatment
   3. Material risks and side effects of the treatment
   4. Alternative courses of action
   5. Likely consequences of not having the treatment
7. Consider the facts that have been disclosed in relation to the physicians' legal duty to inform, and provide any other information that may be relevant to making the decision, if indicated. 
8. Provide the opportunity for answering any questions the patient may have, and offer resources to further support the decision at hand
9. Document:
   1. Date and time
   2. Who was present
   3. What was discussed (relevant facts)
   4. A summary of the capacity assessment (that the patient understood the concepts as discussed and agreed to proceed, with further details of this assessment as warranted by the significance of the decision).
   5. In addition, the physician should document that the patient was offered/provided with appropriate literature, that the patient had the opportunity to ask questions, and that those questions were answered.

This all seems like a lot of work, but in practice I imagine it could be done rather efficiently with a bit of practice. And regardless, it is important to put in the work because this is just the ethical thing to do. As UpToDate (2017) summarises: 

"The benefits of truly informed consent include

• Protecting the patient's right of self-determination
• Engaging the patient in his or her health care
• Enhancing the physician-patient relationship
• Encouraging physicians to thoroughly review the patient's therapeutic options
• Reducing discontent and litigation when there are complications"

In summary
"For a patient to provide consent they must have the mental capacity or competency (legal equivalent*) to provide consent, consent must be given voluntarily, must be informed and must apply to a specific act or set of acts. The ultimate responsibility for ensuring informed choice, mental capacity of the patient to provide consent, and documenting a valid consent rests with the caregiver proposing and providing the intervention."
-Anonymous

*Legal competency decisions are set out by law, in such acts as the Mental Health Act and the Personal Directive Act and Trusteeship Act (actual name varies but with the same idea), which vary provincially in Canada.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...

• Describe how the presentation and management of disease in children differs from adults
• Assess and manage atypical presentations of common medical conditions in the elderly
• Diagnose the common acute and non-acute disease entities requiring surgical treatment

Key Feature 1b: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Generate a complete differential diagnosis (ddx).
Skill: Clinical reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4: In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. 
Skill: Clinical reasoning, Selectivity
Phase: Physical, Diagnosis

Key Feature 5: In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. 
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis

A 13 year old female presented to clinic with her mother today concerned about acute abdominal pain. She localised the pain as being midline in the lower abdomen. What is my ddx?

Like my previous post regarding the categorisation of acute vs chronic abdominal pain, sometimes (oftentimes) we encounter patients who challenge our clinical ability to categorise symptoms. Certainly this is true with pediatric patients, as their report of symptoms, if they are even old enough to verbally report symptoms, can be challenging to decode. Their inexperience with the pain of a headache may be entirely new, and perhaps associating feeling sick with feeling sick to their stomach, they may point to their tummy when you ask them where there pain is. Or maybe some kiddos actually feel sick to their stomach when they have a headache. The possibilities are endless, and without a reliable way to confidently know where pain or other manifestations of disease is originating from on history, as treating physicians we need to maintain a healthy dose of suspicion in searching for the culprit(s). As their own demographic, children also present with different probabilities of disease, and when it comes to abdominal pain, this is as true as any other undifferentiated symptom. 

My abbreviated ddx for pediatric abdominal pain (informed by the LMCC learning objectives) depending on the area to which the pain is localised (if they are old enough to be able to localise and communicate this information) is as follows:

• Epigastric pain
  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Biliary tract disease
  • Pancreatitis
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Inguinal hernia (incarcerated)
  • Inflammatory bowel disease
  • Gastroenteritis
  • Constipation
  • Gynaecological causes in pubertal children
  • Urinary tract  infection
• Generalised pain
  • Peritoneal inflammation
  • Bowel (infantile colic, obstruction)
  • Malabsorption
  • Inflammatory bowel disease
• Flank pain
  • Nephrolithiasis
  • Pyelonephritis
• Functional abdominal pain

Of course, this list is not exhaustive, but it does prompt me to consider some of the most common diagnoses in pediatric patients, as well as important ones not to miss, including the ones that require urgent or emergent surgery. And when I encountered that 13 year old female in clinic today who was able to reliably tell me that she was having midline lower abdominal pain, I was able to use this ddx to inform my clinical data collection, my springboard to  collect pertinent negatives to arrive at a working diagnosis (which for this patient was constipation). I don't know that I was correct in reaching this conclusion, or that it was the only thing contributing to the pain, but my attending concurred with this conclusion, and it helped me look for the absence of findings suggesting a worrisome not-to-miss condition. If I cannot feel confident about localisation in a pediatric patient, then I can simply broaden my ddx to include all common and worrisome pediatric diagnoses. And if that still is unsatisfactory, I can consider the more extensive ddx I have for adult abdominal pain (which is still relatively abbreviated, but does take into consideration most bodily systems that may be sources of pain).

For completeness, here is my ddx for acute abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Acute hepatitis, hepatic abscess
  • Biliary tract disease
  • Gastroesophageal reflux disease
  • Peptic ulcer disease, gastritis
  • Pancreatitis
  • Splenic infarct, splenic abscess
  • Referred cardiothoracic pain
  • Musculoskeletal pain
• Lower abdominal pain
  • Appendicitis
  • Mesenteric adenitis
  • Diverticulitis
  • Incarcerated hernia
  • Inflammatory bowel disease
  • Bowel obstruction
  • Renal colic
  • Urinary tract infection
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Ovarian (torsion, ruptured ovarian cyst)
• Diffuse pain
  • Generalised peritonitis
  • Ruptured abdominal aortic aneurysm
  • Ischemic bowel disease
  • Gastroenteritis
  • Irritable bowel syndrome

And my ddx for chronic abdominal pain (adult patient, also informed by the LMCC objectives):

• Upper abdominal pain
  • Hepatic disease
  • Biliary disease
  • Ulcer and nonulcer dyspepsia (ex: heartburn)
  • Gastric cancer
  • Pancreatic disease
  • Referred cardiothoracic pain
• Lower abdominal pain
  • Bowel disease
    • Inflammatory bowel disease
    • Diverticular disease
    • Irritable bowel syndrome
  • Genitourinary disease
    • Pelvic inflammatory disease
    • Benign or malignant tumours
    • Endometriosis
    • Urinary tract disease

To elaborate a bit further on inclusion of surgical causes of acute abdominal pain, it is important to know which diagnoses require surgical referral, be it after a bit of a workup to confirm the diagnosis, or more urgent or emergently if the patient is seriously unwell or with signs of peritonitis*. In the pediatric patient, for example, this could mean first doing an ultrasound** to rule out appendicitis if you think it is possible but not highly likely as the cause of the abdominal pain, or it could mean ordering imaging concurrently as you urgently consult general surgery if you think an acute appendicitis is in fact likely to be the underlying etiology for the pain. For any case in which a patient is presenting with peritonitis and a broad working differential for acute abdominal pain, a consult to general surgery is indicated. If the working differential is more focused, given the clinical presentation and patient-specific risk factors, then the surgeon to consult will depend on suspected etiology and local specialist accessibility, and may warrant consultation with general surgery, gynaecology, urology, cardiac surgery, vascular surgery, or otolaryngology. Of course, consultation with a nonsurgical medical specialist may also be warranted given the working diagnosis, such as a gastroenterologist, nephrologist, or infectious disease specialist, among others. The timing of when to involve such specialists must be driven by the urgency of the situation in combination with the working differential, be it to provide diagnostic clarity when there is confusion or to administer therapy that is not in the general practitioner's scope of practice.

*In a patient presenting with acute abdominal pain, it is particularly important to examine the patient's abdomen to decide if it is "peritonitic" (otherwise known as a surgical abdomen). Peritonitis is the inflammation of the peritoneum, the sac that encases much of our abdominal organs, and is an ominous finding that suggests surgical intervention is needed. Features most suggestive of peritonitis on physical exam that warrant urgent surgical consultation, in the order in which they would be assessed as per the Inspect-Auscultate-Percuss-Palpate (IAPP) approach to the abdominal exam as is standard medical school teaching, include:

• "Bump the stretcher test"
  • Literally you pretend to accidentally bump the stretcher and see if the patients respond with pain. It's not nice if there really is peritonitis, as any sudden movements can cause significant pain, but if it helps you to figure out they have peritonitis, I think the pain caused by bumping their stretcher is far outweighed by the pain of a missed diagnosis of peritonitis.
• Percussion tenderness
  • ​Another test of something that should otherwise not cause any measurable degree of discomfort, in a patient with peritonitis, even gentle percussion on the abdominal wall can produce pain out of proportion to the tap, increasing the likelihood that the patient has a peritonitic process occurring in their abdomen.
• Guarding/rigidity
  • Guarding and rigidity are phenomena whereby patients tense their abdominal wall muscles in order to protect the underlying organs in the abdomen. On examination, the abdominal wall feels firm. The difference between guarding and rigidity is that in the former, the muscle tension is voluntary, such that if you can get a patient distracted, maybe by asking them questions that take their mind ever-so-momentarily off the fact that you're feeling their tender abdomen, the abdominal wall becomes softer. Rigidity, on the other hand, is involuntary contraction of the abdominal wall musculature. With a peritonitic process, the irritation of the peritoneum causes a reflex contraction of the muscles in processes not requiring conscious contraction. So neat. As you may expect, rigidity has a much greater likelihood ratio in predicting the presence of peritonitis than does guarding, but even guarding does increase the likelihood of peritonitis so is important not to overlook if full on rigidity is absent.
• Rebound tenderness
  • ​To elicit this finding, you push down on the abdominal wall as you do when palpating in general, and then you release. In the force of pushing in on a peritonitic abdomen, this will likely cause the patient significant pain already, but the likelihood of the patient with acute abdominal pain having peritonitis is actually greater if the pain on removal of the force inward on the abdomen (the pain on rebound) is worse.

**A tangent on how the management of disease in children differs from adults: A consideration that a  physician must have when working up a pediatric concern is how the potential for harm and benefit of various interventions is different from that of an adult or geriatric patient. For example, the potential for harm from repeated CT scans could increase a person's risk of cancer down the road, and having hopefully much more time to live and bear secondary mutations possibly related to effects of radiation, the risk to benefit ratio of performing CT scans in pediatric patients is not the same as in older patients. Although the harm of a single CT scan is not so significant if it means possibly saving a life, it is something to consider if your pre-test probability of ominous disease is low. The converse is also true for the elderly or other patients that have risk factors for true and serious pathology: where the weight balances on the risk vs benefit scale shifts. The same general rationale regarding management decisions applies to considering interventions in pediatric patients as compared to other demographics, and the wise physician will remember to consider that the benefit to harm ratio of anything we choose to do or abstain from doing will differ depending on the individual before us.