1
Q
whats the purpose of the mental capacity act 2005?
A
to provide a framework to empower and protect people who may lack capacity to make some decisions for themselves
2
Q
what are the 5 statutory principles of the mental capacity act 2005?
A
- presumption of capacity
- right to be supportted to make their own decisions
- right to make eccentric or unwise decisions
- healthcare providers should make decisions for those without capacity according to patients best interests
- before making a decision on a person’s behalf they mst consider whether the outcome is the least restrictive option
3
Q
what are the 4 abilities needed in order to have capacity?
A
understanding information, retaining it, weighing it up and then communicating a decision
4
Q
if a patient lacks capacity what should you do?
A
see if there is an advanced decision refusing treatment or a lasting power of attorney appointed. and if neither, a doctor and healthcare provider must make a decision on the basis of the patient’s best interest and least restrictive
5
Q
what is a lasting power of attorney?
A
someone who you have chosen to make decisions on someone’s behalf
6
Q
what is advances care planning?
A
planning for a future time when a person may no longer have capacity so cannot make their own decisions
7
Q
what are the 2 aspects of advanced care planning?
A
advances statement of wishes and advanced decisions to refuse treatment
8
Q
is advanced care planning legally binding?
A
advanced statement of wishes is not but advanced decisions to refuse treatment are legally binding and therefore must be respected
9
Q
what treatment can a patient refuse in advanced decisions to refuse treatment?
A
any treatment apart from basic comfort and care
10
Q
what makes an advanced decision valid?
A
- aged >18 and had the capacity to make, understand and communicate the decision at the time
- you specify clearly what treatments you want to refuse
- you explain circumstances in which you wish to refuse treatment
- its signed by you (and a witness if you want to refuse life-sustaining treatment)
- you have made the decision of your own accord, with no co-ercion
- you havnt said or done anything that would contradict the advanced decision since you made it
11
Q
how can mental health conditions like dementia interfere with a person’s capcity to make decisions?
A
dementia can make it difficult to understand, retain, weigh up info anf communicate decisions
12
Q
what does the right to make unwise decisions mean?
A
a doctor should not presume a patient lacks capacity just because they view a decision as eccentric/unwise
13
Q
what are ethical arguments for use of advanced decisions?
A
having a legal right makes it more likely for patients to feel empowered and for their decisions to be respected which leads to patient autonomy
it encourages openess and thoughtful planning
14
Q
what are the ethical arguments against advanced decisions?
A
how do you know if these particular circumstances are what the patient meant when they created the AD
at the time of making the AD, the patient may not fully understand what it will be like when they do lose capacity and need to make use of AD
there is always a possibility of coercion
you cannot be sure that the patient has not since change their opinion so you may not be respecting patient autonomy
15
Q
what is the personal identity argument against advanced decisions?
A
some people with dementia undergo radical personality changes so advanced decisions should not be used as the person who needs it is not numerically identical to the person who created it
16
Q
CRITICAL APPRAISALS!!!!
A
NOT ON CARDS
17
Q
what are the potential benefits of systematic reviews?
A
- include all the available evidence to answer a question
- include research that is unpublished or has been published in non-English language journels
- increase total sample size which also increases levels of certainty and recision
- indicates heterogeneity (variation) among studies
- can indicate the need for further research
- permit sub-group analyses
- permit sensitivity analyses
18
Q
what study design is used for a diagnosis type of question?
A
cross-sectional analytic study
19
Q
what study design is used for an aetiology question?
A
cohort or population-based case-control study
20
Q
what type of study design is best for a prognosis question?
A
cohort study
21
Q
what study design is best for a treatment question?
A
RCT or systematic review of RCT
22
Q
what study design is best for an evaluation question?
A
qualitative research
23
Q
what is a critical appraisal?
A
the process of carefully and systematically assessing the outcome of scientific research to judge its trustworthiness, value and relevance in a particular context.
24
Q
what are the 3 discrete steps of a critical appraisal?
A
are the results of the study valid?
what are the results?
can i apply the results to this patients care?
25
what is GRADE?
a system for grading quality of evidence and making recommendations
26
what are the pros on a critical appraisal in practice?q
* systematic way of assessing validity, results and usefulness of published research papers
* route to closing the gap between research and practice, and as such makes an essential contribution to improving healthcare quality
* encourages objective assessment of the usefulness of information
27
what are the cons of using critical appraisals in practice?
* time-consuming initially
* doesnt always provide an easy answer
* can be dispiriting if it highlights a lac of good evidence
28
what checklists do we use for critical appraisals?
CASP
29
why do we have waiting lists in the NHS?
because there is a limitless demand for health as people can always be healthier
but there are limited resources
30
what is the price mechanism?
where the forces of demand and supply determine the prices of commodities and the changes therein
31
whats the problem with waiting lists?
waiting times are a major source of dissatisfaction for patients
lists are used to prioritise but who should take priority
32
outline the theories of NHS waiting lists?
it allows the NHS resources to be fully employed - no waste of resources as all in full use
waiting lists act as a price to deter frivolous use
waiting lists are caused by underfunding and inefficiency
33
what are some ways in which we can reduce waiting lists?
have more doctors
pay doctors per item of service they provide
pay hospitals per activity
34
what was the 2000-2008 policy to reduce wait times in the NHS?
hospitals recieved an overall performance score and amnagers would lose their jobs if targets were missed
35
what were the outcomes of the 2000-2008 policy to reduce NHS wait times?
no inpatients were waiting longer than 3 months
outpatient reductions
however..
this sacrificed professional autonomy as doctors may be forced to treat less urgent cases because of wait times
things that dont have a target time suffered as were left to last
adverse behavioural responses e.g. emergency patients having to wait in ambulances so they were not yet classed as being in A&E
data manipulation and fraud
36
what are some possible criteria for prioritising in the management of waiting lists?
clinical urgency, sevrrity, potential health gain, productivity and economic loss, equity waiting, length of time waiting
37
what is the maximum waiting time for non-urgent, consultant-led treatments?
18 weeks
38
whats the maximum wait time for urgent cancer referrals?
2 weeks
39
how much higher is the incidence rate of falls in institutions compared to elsewhere?
3 times higher
40
outline how incidence of falls increases with age
35% of 65-80 yo
45% of 80-90 years olds
55% of 90+ yos
41
what is the most common cause of injury in older people?
falls with 10% of them resulting in serious injury
42
of those who fall and fracture a hip, how many die within a year?
and how many cannot live independantly afterwards?
>20% die within a year
| 50% no longer live independantly
43
other than injuries, what are the other consequences of falls?
psychological - fear of falling, self-imposed activity restriction, social isolation and depression
increase in dependancy
disability
anxiety and time impact on carers
44
what are the clinical risk factors for hip fractures?
```
low bone mineral density
increasing age
female
low body weight
Fhx hip fractures
prior history of hip fractures
smoking
ethnicity- afrocarribeans have a very low fracture risk
corticosteroid use
medications e.g. psychotropic drugs
```
45
what are some risk factors for falls?
```
muscle weakness
history of falls
gait deficit
balance deficit
visual deficit
arthritis
impaired ADL
cognitive impairment
age >80
```
46
how can we prevent fractures?
bone protection e.g. bisphosphonates, vit D and calcium supplements, HRT, terparatide, denosumab
hip protectors
47
how can we decrease the risk of falls?
weekly walks
education
balance exercises
gradual withdrawal of active psychotropic medication
occupation therapists assessing the home environment and trying to reduce the fall risk e.g. putting in lifelines
podiatry inventions
48
what are the 4 Bowlbys stages of grief?
numbness
yearning
disorganisation and despair
reorganisation
49
what are symptom of grief?
feeling sad, angry, anxious, lonely, tired, helpless, shockerd, yearning or numb
stomach chest or throat pain, sensitivity to noise, depersonalisation, breathless, weak
impaired concentration, hallucinations
sleep and appetite disturbance, social withdrawal, avoidance or reminders, crying, carrying reminders of sentimental value
50
what are Worden's tasks for mourning to be complete?
to accept the reality of the loss
to process the pain of grief
to adjust to a world without the deceased
emotionally relocate the deceased and move on with life
51
what factors affect grief severity?
```
closeness of relationship
meaningfulness of relationship
nature of relationship prior to death
expectedness and manner of death
age and development stage of griever
individual resislience
attachment and dependancy
religious belief
social support
```
52
what is the psychological impact of a close death?
loss of presence of a person
foced to confront own mortality
traumatic underminding of the persosns view of thr world
53
what is a sign that a person is in denial about the loss of a loved one?
mummification e.g. not changing things in a dead persons room
54
globally, what is the largest cause of death
CVD
55
is CVD more common in men or women?
men
56
if obesity, diabetes and phsyical inactvity are rising, why are CVD deaths still declining?
because smoking, cholesterol levels, bp and deprivation are decreasing at a greater rate
57
what are risk factors for CVD?
```
social deprivation
age
male
FHx
deletion polymorphism in ACE gene
hyperlipidemia
smoking
hypertension
DM
lack of exercise
blood coagulation fators
homocystenaemia
obesity
gout
drugs such as HRT and contraceptive pill
heaty alcohol consumption
```
58
what is risk?
the probability of an event in a given time period
59
how do you calculate risk ratio?
risk exposed / risk unexposed
60
how do you calculate risk difference?
risk exposed - risk unexposed
61
what is the population attributable risk?
how much of a disease in the population is attributable to a particular exposure
risk in population - risk in unexposed
62
what is the population attributable fraction?
the proportion of the disease in the population that is attributable to a particular exposure
population attributable risk / risk in population
63
what is the prevention paradox?
a preventative measure that brings large benefits to the community often offers little to each participating individual.
64
what 2 approaches can we take to reduce disease incidence?
high-risk prevention appriach - target the intervention at those who are at the highest risk
population prevention approach - reduce the burden of disease across the entire population
65
what are the benefits of the high-risk prevention approach for reducing disease incidence?
its appropriate to the individual so motivates patient and clinician
is cost efefctive as isnt treating those who dont need it
benefit:risk is good
66
what are the negatives of the high-risk prevention approach for reducing disease incidence?
screening is hard - hard to find high risk groups
limited potential as onyl targeting a small group
temporary
labelling
67
what are the benefits to the population prevention approach for reducing disease incidence?
large potential as targets who populayion
68
what are the negatives to the population prevention approach for reducing disease incidence?
population paradox
poor motivation
benefit: risk is low
69
what is the subjective expected utility theory of decision making?
the attractiveness of an economic opportunity as perceived by a decision-maker in the presence of risk.
70
what are the 2 main problems with evidence based decision making in medicine?
reduced clinical autonomy
| tends to downplay the importance of patient values
71
what do the square nodes mean on the decision tree?
a decsion node - represents a choice
72
what do the circle nodes represent on the decision tree?
a chance node - represents uncertainty
73
what is a correlation coefficient?
it determines the degree to which movement of 2 different variables is associated
e.g. R=0 no correlation
R > 0 = positive correlation
R<0 = negative correlation
74
what is the opportunity cost?
the potential benefits that an individual misses out on when choosing 1 alternative over another
the profit lost when one alternative is selected over another
75
what percentage of UK adults smoke?
14%
76
what percentage of men smoke in the UK? and women?
15% men
| 13.7% women
77
in 2019, what percentage of all deaths of adults >35 were attributable to smoking?
15%
78
after quitting smoking, how many years does it take for risk of CVD to drop by 50%
1
79
after quitting smoking, how many years does it take for risk of lung cancer to drop by 50%
10 years
80
after quitting smoking, how many years does it take for risk of CVD to the same as a non-smoker?
15 years
81
after quitting smoking, how many years does it take for risk any disease to drop back to the same risk as a non-smoker?
20 years
82
which groups of people is smoking more common in?
```
socioeconomic deprivation
LGBTQ
mental health issues
unemployed
homeless
lone parents
```
83
what are health inequalities?
preventable differences in health outcomes between different population groups
84
which part of africa is AIDS most prevalent?
Sub Saharan
85
explain the age groups affected by AIDs?
it infects sexually active people and has about a 10 year period to death so time to reproduce isnt affected which means we get a reduction in young/middle aged adults rather than children
86
what are some disadvantages to screening?
false positives cause anxiety and unnecessary interventions
opportunity cost for the NHS
they can lead to personal difficult decisions
some people will then be treated for a condition that may never harm them in their lifetime
some screening tests can be harmful
87
what are some advanatges of screening?
allows you to make an informed decision
allows you to get treatment sooner, increasing the effectiveness
less radical treatment if caught earlier
reassurance for those with a negative test
88
what do we screen babies for after birth?
hearing
blood spot test - sickle cell, congenital hypothyroidism, CF, PKU, MCADD< maple syrup urine disease, isovaleric acidaemia, homocystinuria, glucaric aciduria type 1
physical examination - eyes, heart, hips testicles
89
what are some NHS initiviatives to reduce waiting times?
increase staff
give targets and penalties
give activity based remunerations for doctors
give activity based remunerations for hospitals
star ratings
contact other service providers
90
what are the beenfits to waiting lists?
maximises NHS resources to be fully employed
| deters frivolous use
91
how can we measure wait times/
average waiting time
number of people on the list
proportion of people waiting >x time
time to clear the list
92
what is the symptoms iceberg?
the phenomenon that most symptoms are managed in the community without people seeking help
93
what are zolas triggers?
interpersonal crisis
percieved interference with work
perceived interference with social and leisure life
sanctioning by others
symptoms persisting beyond a set time limit
94
what are some barriers to healthcare?
```
time off work and the consequences of the loss in earnining
past experiences
geographical distance
childcare issues
transport
inverse care law
time and effort
waiting times
```
95
what is the social model of disability defined by the disability rights movement?
it suggests that disability is caused by the way society is organised rather than by a persons impairment
96
what is some evidence for the link between diet and GIT cancers?
different cancers have different prevalences in different populations and regions of the world
migrant studies showed that lifetime cancer risk in japanese migrants who moved to hawaii increased compared with japanese men who stayed in japan
97
what proportion of cancers are preventable?
50%
98
what are the top risk factors for cancer?
```
smoking
alcohol
poor diet
physical inactivity
excess bodyweight
UV radiation
```
99
what is causality?
the science of cause and effect
100
what are the bradford hill criteria for establishing causality?
```
temporality
specific
consistent
strength
dose response
coherent
plausible
experiment
analogy
```
101
what are 2 issues with causality?
confounding
| reverse causality
102
what are some pros and cons of case-control studies?
pros - fast, cheap, good for rare disease, good for diseases with long latecy periods
cons - recall bias, difficulties in measuring risk, impact of disease on risk
103
what are the pros and cons of cohort studies?
pros - near definitive data, you can measure a whole range of risks and associated outcomes, incidence can be calculated,
cons - expensive, long time to occur, difficulties in measuring risk, risk of bias and confounding, bias due to losses to follow up
104
what are some pros and cons of RCTs?
pros - basically the only way that identifies causal relationship. reduces confounding and bias through randomisation
cons - expensive, take a long time to read out, questions on generalisability i.e. is the study population representative of the population at large
105
what are the pros and cons of a met anayliss?
top of the evidence hierarchy
always contains the most recent updates of evidence
needs periodic revision
takes a long time
publication bias
106
what did the broken plate 2021 discovere?
they highlight access to healthy food is a huge barrier i.e. eating healthier is a more expensive way to live. 1/4 places selling food are fast food outlets and these are over represented in the poorer places.
107
what are clinical decision support systems?
They provide clinicians with patient-specific assessments or recommendations to aid clinical decision making
108
what are examples of clinical decision support syste,s?
reminder systems
| diagnostic symptoms
109
what are the benefits of clinical decision support systems?
increased rates of screening, vaccination, medication use.
| improved practitioner performance
110
what might hinder the use of clinical decision support systems?
negative experiences of IT in the past
potential to harm the doctor patient relationship
loss of autonomy and clinical reasnoning
reminders increase work load
111
what is the accepted units of alcohol per week for men and women? has this changed?
14 units a week for men and women
| used to be 21 for men and 14 for women but now we have imprpved knowledge of cancer risk
112
are the risks of alcohol worse for men or women?
long term risks are greater for women
| short term risks ar greater for men. Men are more likely to die from cirrhosis
113
how have drinking rates changed since the 1960s?
drinking has increased and reached a peak in 2008 when alcohol was more affordable than ever before
114
what has higher risks, binge drinking or daily drinking?
daily drinking
115
how much does the UK spend on alchol per year?
| how does this compare with other european countries
40 billion
| this is lower than many other countries
116
In the Uk how are our drinking norms different to other countries?
we start drinking at a younger age and tend to binge drink more than other countries
117
what percentage of england drink alcohol every week?
54%
118
what percentage of all hospital admissions are for alcohol specific?
2%
119
what conditions are wholly attributable to alcohol?
```
alcoholic liver disease
alcoholic neuropathy
chronic pancreatitits
alcoholic cardiomyopathy
alcoholic gastritis
```
120
how have number of hospital admissions for alcohol causes changed in the last 20 years? what could be a reason for this?
they have doubled
| better recording of cause on admission
121
what proportion of domestic violence involves alcohol use?
73%
122
how can alcohol affect work?
poor productivity
absences
sick leave
123
outline the trends of abstinence in the UK?
more than 25% of young people class themselves as non-drinkers
124
how does alcohol use affect family life?
alcohol is associated with arguments, violence, debt, relationship problems
125
what are some heath promoton strategies for alcohol?
```
mass media campaigns
restricting exposure of young people to adverts
increase price and taxation
restrict availability
lower BAC limits
sort price by unit
banning multipack alcohol delas
```
126
what percentage of alcohol use disorders are genetically linked?
50%
127
what individual factors affect a persons vulnerability to alcohol use disorders?
```
age
gender
familial factors
socio-economic status
poor familial monitoring and endorsement
conduct and mood disorders
low self control
```
128
what societal and envrionmental factors affect alcohol use?
societal norms - used as celebration and coping
affordability
whether intoxiifcation is approved and promoted by the media
accessibility
influence of peers
129
how much does alcohol use cost the NHS a year?
2.5 billion - 80% of this cost is in the ED
130
what percentage of patients who come into hospital for alcohol related causes are re admited within 30 days?
20%
131
how can the hospital help alcoholics?
the government invests in hospital based alcohol care teams
132
what is a harmful pattern of alcohol use?
a pattern of alcohol use that has caused damage to a persons physical/mental health or has resulted in behaviour leading to harm to the health of others
133
what are the criteria for alcohol dependance?
2 of the following...
- impaired control over alcohol use
- increased alcohol use such that it continues/escalates despite harm or negative consequences
- physioogical - tolerance, withdrawal upon cessation and use of alcohol to avoid withdrawal symptoms
134
what are 2 examples of alcohol harm screening tools?
Fast Alcohol Screening Test
| Alcohol use disorders identification test
135
outline the brief intervention stratgey for alcohol known as FRAMES?
Feedback of the screening score so the patient can recognise the need for change
Responsibility - encourgae them to take ownership of their decision
Advice - offer advice on modifying alcohol use
Menu - give them options to choose from
Empathetic, respectfu and non judgemental
Self-efficacy - promote this and their ability to succeed
136
what percentage of those who complete alcoholism treatment relapse the year following?
70-80%
137
what are factors associated with poor outcomes to completing alcoholism treatment?
```
social instability
poor support
having an alcohol free network
family history of dependance
mental ill health
previous failed attempts
severity
chronicity
complexicity
```
138
how can we reduce the stigma on alcoholics?
consider alcoholism as a chronic coniditon
139
what happens in a phase 1 clinical trial?
conducted on healthy volunteers, the aim is to find the highest dose of the new treatment that can be given safely without causing severe side effects
140
what is a phase 2 clinical trial?
it involves a small number of patients affected by a particular disease to assess the efficacy and dosing
141
what is a phase 3 clinical trial?
involves hundreds-thousands of people with the disease, often as an RCT, to compare the treatment to established treatments and assess effectiveness
142
what is a phase 4 clinical trial?
studies the side effects caused over time by a new treatment after it has been approved and is on the market
143
What is the CAGE questionnaire?
Do you ever feel you should Cut down on the amount of alcohol you drink?
Do you ever feel Angry when people criticise how much you drink?
Do you ever feel guilty about the amount you drink?
Do you ever need an Eye opener in the morning
144
How do you calculate alcohol units?
Percentage x volume in litres
145
What’s the York team for CBT for alcohol dependency?
Changing lives
