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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...
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:
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):
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Antibiotics
Key Feature 5: In urgent situations (ex: cases of meningitis, septic shock, febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis). Skill: Selectivity Phase: Treatment Fever Key Feature 6: Aggressively and immediately treat patients who have fever resulting from serious causes before confirming the diagnosis, whether these are infectious (ex: febrile neutropenia, septic shock, meningitis) or non-infectious (ex: heat stroke, drug reaction, malignant neuroleptic syndrome). Skill: Selectivity Phase: Treatment Key Feature 7: In the febrile patient, consider causes of hyperthermia other than infection (ex: heat stroke, drug reaction, malignant neuroleptic syndrome). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Infections Key Feature 3: Treat infections empirically when appropriate (ex: in life threatening sepsis without culture report or confirmed diagnosis, candida vaginitis post-antibiotic use). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 6: When treating infections with antibiotics use other therapies when appropriate (ex: aggressive fluid resuscitation in septic shock, incision and drainage abscess, pain relief). Skill: Clinical Reasoning Phase: Treatment In my last post I talked about how there is not always a need to empirically treat a fever if we don't know what the cause is. This is based on the patient in front of you appearing rather well. If, on the other hand, the patient does not appear well, or has risk factors for not being able to compensate in a way that an otherwise healthy person would, or if, based on your clinical assessment or preliminary workup you think the cause may cause a serious threat to life, then treating empirically is indicated. If aggressive and immediate treatment for fever or hyperthermia is warranted, treatment may need to be started without knowing what the reason is for the core body temperature elevation. Per the UpToDate article, Pathophysiology and treatment of fever in adults (2018), "Although the vast majority of patients with elevated body temperature have fever, there are a few instances in which an elevated temperature represents hyperthermia. (...) There is no rapid way to differentiate elevated core temperature due to fever from hyperthermia. The immediate events prior to the onset of hyperthermia usually play an important role in determining its cause." So it is important to gather a basic history to look for any clues suggestive that the patient has hyperthermia rather than a fever as there will be some different steps to consider in treating such a patient. I will outline my approach here to the patient with hyperthermia, while my approach to the febrile patient was covered in my last blog post*. Both possibilities may need to be worked up at the same time. Approach to a patient with suspected hyperthermia:
I have only once encountered a patient in an emergency medicine rotation (in medical school) who presented with hyperthermia. It was the prototypical elderly lady who spent a good chunk of the day gardening in the sun. She was a bit dehydrated, and so we gave her IV fluids. She responded well, and it was fairly uncomplicated. My hope is to never need to apply the above approach, but to still be prepared should I encounter a patient with serious hyperthermia in the future. *In my last blag post, I described an approach to working up a fever of unknown origin, but I didn't really talk about management of what to do in the interim when waiting for the results of diagnostic testing. If the patient appears unwell or is someone who would be at risk of decompensating or of not being able to tolerate decompensation, then gather your swabs etc. and begin empiric broad spectrum antibiotics. What does this looks like? My rules of thumb are as follows (with a description of the bugs they typically cover), but if you are more suspicious of certain types of infections, you can obviously tailor your empiric antibiotics accordingly.
Antibiotics
Key Feature 1: In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 4: Use a selective approach in ordering cultures before initiating antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunocompromised patients). Skill: Selectivity Phase: Investigation Fever Key Feature 3: In a febrile patient requiring antibiotic therapy, prescribe the appropriate antibiotic(s) according to likely causative organism(s) and local resistance patterns. Skill: Clinical Reasoning Phase: Treatment Infections Key Feature 1a: In patients with a suspected infection: Determine the correct tools (ex: swabs, culture/transport medium), techniques, and protocols for cultures. Skill: Clinical Reasoning Phase: Investigation Key Feature 1b: In patients with a suspected infection: Culture when appropriate (ex: throat swabs/sore throat guidelines). Skill: Clinical Reasoning, Selectivity Phase: Investigation Key Feature 2a: When considering treatment of an infection with an antibiotic, do so: Judiciously (ex: delayed treatment in otitis media with comorbid illness in acute bronchitis). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 2b: When considering treatment of an infection with an antibiotic, do so: Rationally (ex: cost, guidelines, comorbidity, local resistance patterns). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 5: When a patient returns after an original diagnosis of a simple infection and is deteriorating or not responding to treatment, think about and look for more complex infection. (i.e., When a patient returns complaining they are not getting better, don’t assume the infection is just slow to resolve). Skill: Clinical Reasoning Phase: Hypothesis generation Pneumonia Key Feature 5: Identify patients, through history-taking, physical examination, and testing, who are at high risk for a complicated course of pneumonia and would benefit from hospitalization, even though clinically they may appear stable. Skill: Selectivity Phase: Diagnosis Key Feature 7: For a patient with a confirmed diagnosis of pneumonia, make rational antibiotic choices (ex: outpatient + healthy = first-line antibiotics; avoid the routine use of “big guns”). Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 8a: In a patient who is receiving treatment for pneumonia and is not responding: Revise the diagnosis (ex: identify other or contributing causes, such as cancer, chronic obstructive pulmonary disease, or bronchospasm), consider atypical pathogens (ex: Pneumocystis carinii, TB), and diagnose complications (ex: empyema, pneumothorax). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 8b: In a patient who is receiving treatment for pneumonia and is not responding: Modify the therapy appropriately (ex: change antibiotics). Skill: Clinical Reasoning Phase: Treatment, Diagnosis Key Feature 10: In patients with a diagnosis of pneumonia, ensure appropriate follow-up care (ex: patient education, repeat chest X-ray examination, instructions to return if the condition worsens). Skill: Clinical Reasoning Phase: Follow-up Key Feature 11: In patients with a confirmed diagnosis of pneumonia, arrange contact tracing when appropriate (ex: in those with TB, nursing home residents, those with legionnaires’ disease). Skill: Clinical Reasoning Phase: Follow-up, Referral Urinary Tract Infection Key Feature 4: In a patient with a diagnosed urinary tract infection, modify the choice and duration of treatment according to risk factors (ex: pregnancy, immunocompromise, male extremes of age); and treat before confirmation of culture results in some cases (ex: pregnancy, sepsis, pyelonephritis). Skill: Selectivity Phase: Treatment When I think a patient is likely to have a bacterial infection, I turn to Bugs & Drugs, the app on my phone that guides me to select appropriate investigations and empiric antibiotics as I await the results. This resources takes into account local resistance patterns and has a whole many other features including how to tailor antibiotics for specific bugs and gold nuggets of clinical information that are concise and ever-so-helpful regarding patient management. It gives you options for first-line choices and second-line choices in case a patient is allergic to the preferred option, or depending how unwell they are or are at risk for becoming. It even has risk calculator scores such as the CURB-65 to help determine patient disposition for those diagnosed pneumonia (Calculate by QxMD is another medical app filled with useful risk score calculators to support clinical decision making). Bugs & Drugs was originally developed to assist physicians in Alberta make appropriate antibiotic selection, but being only one province over, generally the microorganism resistance patterns are similar and so the recommendations also typically apply in the province of BC. There is another app I use called Spectrum that is far less glorious but that has even more targeted antimicrobial suggestions for patients in Vancouver specifically. I use this app to cross-reference Bugs & Drugs if it has information for the same infection. (If there is discrepancy, I make a judgment call all facts considered, but typically I default to Spectrum if I have to make a difficult choice, because it is designed to be more attune to the local microorganism resistance exactly where I am.) Bugs & Drugs unfortunately is not free from the app store, but I GUARANTEE that if you're a physician in Western Canada and you haven't tried it, it'll be some of the best less-than-$20 you'll ever spend on your CME. Got a question on a bug or a drug? Chances are it will solve your woes. Get at it. Does one need to obtain microbial studies prior to starting empiric antibiotics? It is often ideal to know what you're treating to be able to select appropriate antibiotics; empiric antibiotics are designed as a best guess option considering the bugs that are typically responsible for the given infection. However, with some run-of-the-mill infections, the bugs are so notoriously common for the infection that empiric treatment can be started without the need for definitive results from a microbial culture. This would apply to uncomplicated cellulitis, pneumonia, urinary tract infection, and abscesses. Treating empirically is standard of care for these infections. However, a patient should be advised to follow-up if they continue to worsen or simply aren't responding to antibiotic treatment as expected, as there could be more going on than was apparent clinically (ex: microorganisms with antibiotic resistance, atypical pathogens, complication or comorbid disease process, wrong diagnosis, etc.) and they may need further investigations and/or a change in their treatment regimen. If atypical organisms are responsible for the infection then public health authorities may need to be notified in the interest of contact tracing and prevention of outbreaks of infectious disease. Some types of infection may not need treatment at all in an otherwise healthy person with a good immune system, or at least can be postponed with clinical observation as their resolution with and without antibiotics is just not significantly different, or worth the side effects of the medicine. If, on the other hand, the patient appears unwell or would be at risk of decompensation, obtaining microbial cultures and providing empiric treatment is warranted even for infections that usually have the typical and well-characterized bacterial causes, because the stakes are just higher. Another time to consider getting microbial cultures would be if there is an active public health strategy to characterize regional infection rates, with corresponding microbial sensitivities to assess local microorganism resistance patterns. |
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