Multimorbidity

Question 1

What is the definition of multimorbidity?

Answer 1

The presence of two or more long-term health conditions

This includes defined physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments, and alcohol or substance misuse.

Question 2

What is more common in young adults?

Answer 2

Combined mental and physical comorbidity

Question 3

True or false: Multimorbidity is more common in males than in females.

Answer 3

FALSE

Prevalence is higher in females than in males.

Question 4

What are the most common comorbid conditions associated with multimorbidity?

Answer 4

• Hypertension
• Depression
• Anxiety
• Chronic pain
• Prostate disorders
• Thyroid disorders
• Coronary artery disease

Hypertension is the most prevalent disorder, while depression and anxiety are the most common mental health disorders.

Question 5

List the risk factors for multimorbidity.

Answer 5

• Increasing age
• Female sex
• Low socioeconomic status
• Tobacco and alcohol usage
• Lack of physical activity
• Poor nutrition and obesity

These factors contribute to the likelihood of developing multiple health conditions.

Question 6

What are the complications associated with multimorbidity?

Answer 6

• Decreased quality of life
• Increased treatment burden
• Mental health issues
• Polypharmacy
• Negative impact on carers’ welfare

These complications can significantly affect patients’ overall health and wellbeing.

Question 7

What should be assessed to identify patients who may benefit from a multimorbidity approach?

Answer 7

• Difficulties with daily activities
• Frailty
• Prescription of over 10 medications
• Frequent emergency care services usage

These factors indicate a need for a comprehensive management strategy.

Question 8

What is the goal in managing comorbidity?

Answer 8

Reducing treatment burden and optimising care

This includes maximizing the benefits of existing treatments and offering alternative follow-up arrangements.

Question 9

What screening tools can be used to recognize medicine safety concerns in older people?

Answer 9

• STOPP
• START

Question 10

What should be considered when discussing bisphosphonate use after three years?

Answer 10

Discuss stopping bisphosphonates

Include patient choice, fracture risk, and life expectancy in the discussion.

Question 11

What is the recommended frequency for reviewing medications for people aged over 65?

Answer 11

Yearly

NHS England recommends a yearly review, but medications should be reviewed periodically.

Question 12

What does STOPP measure?

Answer 12

STOPP identifies medications where the risk outweighs the benefits, while

Question 13

What does START measure?

Answer 13

START suggests medications that may provide additional benefits.

Question 14

How is frailty assessed?

Answer 14

Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire

Question 15

What is the reporting tool for frailty?

Answer 15

The PRISMA-7 involves questions considering the age, sex, health problems, assistance required and walking aid use of the patient

Question 16

Which medications should be considered to stop in peptic ulcer disease?

Answer 16

NSAIDs
Warfarin
Aspirin

Question 17

What is the STOPP criteria for warfarin?

Answer 17

STOPP criteria states that it has no proven added benefit when given for longer than 6 months for uncomplicated DVT

Question 18

According to STOPP-START, what medication should be avoided in dementia patients?

Answer 18

Tricyclic antidepressants which can worsen cognitive impairment

Question 19

As individuals age, they become more likely to _______.

Answer 19

fall

Falls are associated with significant mortality and morbidity in the elderly population.

Question 20

Approximately what fraction of elderly people living in the community fall every year?

Answer 20

one-third

Falls not only lead to injuries but also impact patients’ confidence and independence.

Question 21

Normal gait involves which three systems?

Answer 21

• Neurological system
• Musculoskeletal system
• Effective processing of the senses

These systems must function properly to maintain balance and prevent falls.

Question 22

What are some risk factors for falling in the elderly?

Answer 22

• Lower limb muscle weakness
• Vision problems
• Balance/gait disturbances
• Polypharmacy (4+ medications)
• Incontinence
• Age >65
• Fear of falling
• Depression
• Postural hypotension
• Arthritis in lower limbs
• Psychoactive drugs
• Cognitive impairment

Individuals with 4 or more risk factors have up to a 78% chance of falling.

Question 23

True or false: Individuals who have fallen previously are at a lower risk of falling again.

Answer 23

FALSE

Previous falls significantly increase the risk of future falls.

Question 24

What is the importance of risk assessment in fall prevention?

Answer 24

To establish the level of support needed for patients

Screening for falls risk is crucial, especially in hospital or home settings.

Question 25

What key information should be established from the **history** of a patient who fell?

Answer 25

* Where was the patient when they fell? * When did they fall? * Did anyone else see the patient fall? * What happened? * Why do they think they fell? * Have they fallen before? ## Footnote This information helps in understanding the circumstances surrounding the fall.

Question 26

Why is reviewing a patient's **medication** important in fall prevention?

Answer 26

To reduce the chances of falling again ## Footnote Patients on more than four drugs are more likely to fall; unnecessary medications should be stopped or swapped.

Question 27

As individuals age, they become more likely to _______.

Answer 27

fall ## Footnote Falls are associated with significant mortality and morbidity in the elderly population.

Question 28

Approximately what fraction of elderly people living in the community fall every year?

Answer 28

one-third ## Footnote Falls not only lead to injuries but also impact patients' confidence and independence.

Question 29

Normal **gait** involves which three systems?

Answer 29

* Neurological system * Musculoskeletal system * Effective processing of the senses ## Footnote These systems must function properly to maintain balance and prevent falls.

Question 30

What are some **risk factors** for falling in the elderly?

Answer 30

* Lower limb muscle weakness * Vision problems * Balance/gait disturbances * Polypharmacy (4+ medications) * Incontinence * Age >65 * Fear of falling * Depression * Postural hypotension * Arthritis in lower limbs * Psychoactive drugs * Cognitive impairment ## Footnote Individuals with 4 or more risk factors have up to a 78% chance of falling.

Question 31

True or false: Individuals who have fallen previously are at a **lower risk** of falling again.

Answer 31

FALSE ## Footnote Previous falls significantly increase the risk of future falls.

Question 32

What is the importance of **risk assessment** in fall prevention?

Answer 32

To establish the level of support needed for patients ## Footnote Screening for falls risk is crucial, especially in hospital or home settings.

Question 33

What key information should be established from the **history** of a patient who fell?

Answer 33

* Where was the patient when they fell? * When did they fall? * Did anyone else see the patient fall? * What happened? * Why do they think they fell? * Have they fallen before? ## Footnote This information helps in understanding the circumstances surrounding the fall.

Question 34

Why is reviewing a patient's **medication** important in fall prevention?

Answer 34

To reduce the chances of falling again ## Footnote Patients on more than four drugs are more likely to fall; unnecessary medications should be stopped or swapped.

Question 35

Which medications cause postural hypotension?

Answer 35

Nitrates ACE inhibtiors Levadopa Anticholinergic Antidepressants

Question 36

Which medications are assoicated with falls due to other mechanics?

Answer 36

Benzodiazepine Opiates Digoxin Antipsychotics

Question 37

Which imaging should be performed following a falls due to?

Answer 37

X-ray of chest/injured limbs, CT head and cardiac echo

Question 38

What test should be done for patients with fall history/risk?

Answer 38

Timed up and Go

Question 39

How does the timed up and go test work?

Answer 39

The patient starts seated in a standard chair. On the clinician’s command (“Go”): The patient stands up from the chair. Walks 3 metres (10 feet) at a comfortable pace. Turns around, walks back, and sits down again. The clinician observes how steady and safe the movements are. In the Timed Up and Go (TUG) version, the total time is recorded (from standing up to sitting down again).

Question 40

What is a normal value for timed up and go test?

Answer 40

Less than 10 seconds from standing up to sitting down

Question 42

What does 10-20 seconds for TUG mean?

Answer 42

Fair – mostly independent but may have mild gait/balance issues

Question 43

What does over 20 seconds mean?

Answer 43

Impaired mobility – increased risk of falls

Question 44

What does over 30 seconds mean?

Answer 44

Suggests high fall risk and likely functional dependence

Question 45

Which patients should be offered a multidisciplinary galls assessment?

Answer 45

all patients over 65 with: >2 falls in the last 12 months A fall that requires medical treatment Poor performance or failure to complete the 'Turn 180° test' or the 'Timed up and Go test' Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls

Question 46

What level of MMSE to start drugs for Alzheimer;s?

Answer 46

Mild at 25 maximum

Question 47

What causes blurry vision, dizziness and arrythmia in patient with history of afib and type 2 diabetes?

Answer 47

Digoxin, which Digoxin has a narrow therapeutic index and toxicity can be potentiated by renal failure and hypokalaemia

Question 48

What is an **Advanced Decision**?

Answer 48

A legally binding document to refuse specific treatment(s) in the future ## Footnote It ensures that an individual can refuse treatments they do not want.

Question 49

List the **criteria** for an Advanced Decision to be legally binding.

Answer 49

* Must be valid * Must be applicable * Made when over 18 and fully informed * Not made under influence or duress * Written down, signed, and witnessed (for life-saving treatment) ## Footnote These criteria ensure the decision is respected and enforceable.

Question 50

What must be considered when applying **advanced decisions**?

Answer 50

* Validity * Applicability * Emergency care considerations ## Footnote Medical professionals must ensure the advance directive is relevant to the current situation.

Question 51

What types of **treatments** can be refused in an Advanced Decision?

Answer 51

* Life-sustaining treatments * Cannot refuse basic care, food/drink by mouth, comfort measures, or treatment for mental health if sectioned ## Footnote Advanced Decisions cannot demand specific treatment or something illegal.

Question 52

True or false: An Advanced Decision can be withdrawn at any point.

Answer 52

TRUE ## Footnote Withdrawal can be done verbally or in writing.

Question 53

What are **DNACPR decisions**?

Answer 53

Do Not Attempt Cardiopulmonary Resuscitation decisions relevant to advance care planning ## Footnote Common forms include ReSPECT and TEP, which guide clinicians in emergencies.

Question 54

Can DNACPR forms be made without the patient's consent?

Answer 54

Yes, if CPR may cause more damage than good or is unlikely to be successful ## Footnote Patients are entitled to a second opinion in these cases.

Question 55

What is an **Advance Statement**?

Answer 55

A document for general statements about wishes, beliefs, feelings, and values regarding future care ## Footnote It is not legally binding but must be considered under the Mental Capacity Act.

Question 56

What can be included in an **Advance Statement**?

Answer 56

* Religious/spiritual views * Food preferences * Daily routine information * Preferred care location * People to consult for best interest decisions ## Footnote It provides evidence of a patient's wishes and values.

Question 57

Is it better to make an **Advance Statement** verbally or in writing?

Answer 57

In writing ## Footnote Written statements provide clear documented evidence of an individual's wishes.

Question 58

What is an **Advanced Decision**?

Answer 58

A legally binding document to refuse specific treatment(s) in the future ## Footnote It ensures that an individual can refuse treatments they do not want.

Question 59

List the **criteria** for an Advanced Decision to be legally binding.

Answer 59

* Must be valid * Must be applicable * Made when over 18 and fully informed * Not made under influence or duress * Written down, signed, and witnessed (for life-saving treatment) ## Footnote These criteria ensure the decision is respected and enforceable.

Question 60

What must be considered when applying **advanced decisions**?

Answer 60

* Validity * Applicability * Emergency care considerations ## Footnote Medical professionals must ensure the advance directive is relevant to the current situation.

Question 61

What types of **treatments** can be refused in an Advanced Decision?

Answer 61

* Life-sustaining treatments * Cannot refuse basic care, food/drink by mouth, comfort measures, or treatment for mental health if sectioned ## Footnote Advanced Decisions cannot demand specific treatment or something illegal.

Question 62

True or false: An Advanced Decision can be withdrawn at any point.

Answer 62

TRUE ## Footnote Withdrawal can be done verbally or in writing.

Question 63

What are **DNACPR decisions**?

Answer 63

Do Not Attempt Cardiopulmonary Resuscitation decisions relevant to advance care planning ## Footnote Common forms include ReSPECT and TEP, which guide clinicians in emergencies.

Question 64

Can DNACPR forms be made without the patient's consent?

Answer 64

Yes, if CPR may cause more damage than good or is unlikely to be successful ## Footnote Patients are entitled to a second opinion in these cases.

Question 65

What is an **Advance Statement**?

Answer 65

A document for general statements about wishes, beliefs, feelings, and values regarding future care ## Footnote It is not legally binding but must be considered under the Mental Capacity Act.

Question 66

What can be included in an **Advance Statement**?

Answer 66

* Religious/spiritual views * Food preferences * Daily routine information * Preferred care location * People to consult for best interest decisions ## Footnote It provides evidence of a patient's wishes and values.

Question 67

Is it better to make an **Advance Statement** verbally or in writing?

Answer 67

In writing ## Footnote Written statements provide clear documented evidence of an individual's wishes.

Question 68

What should be applied for elderly patients with cognitive impairment that lack capacity?

Answer 68

Deprivation of liberty safeugard

Question 69

Where is DoLS used?

Answer 69

Hospitals and care homes

Question 70

How long is DoLS valid?

Answer 70

12 months

Question 71

When should DoLS not be used?

Answer 71

If patient meets criteria for sectioning under mental health act