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Hi guys. Can you just let me know in the chat if you can hear me? Ok, great. Just gonna wait maybe a minute or two just to see if anyone else joins and then we'll get started. Ok. So, hi, my name is Pavia. Um I'm one of the fifth years at Manchester. Uh So today it's gonna be a split session. The first hour is gonna be teaching on geriatrics and that's gonna be led by Angus. Um and then afterwards it's gonna be another hour of ay practice. So please do stick around for that as well. Um But I'm just hosting the session so I'll keep an eye on the chat and just make sure everything's running smoothly. Um, but I don't think there's really anything else to say. So I'll just hand over to Angus now. Hi guys. Um I'm gonna be taking your teaching this evening. So thanks for coming. Um I'm 1/5 year at the moment based at, at, with Ensure. But yeah, I'll er, I'll start sharing uh my screen and uh we'll, we'll get onto it. Ok. So better, better teaching on geriatrics. Um So just a, a quick message first. Um, just that we're, we're linked with geeky medics. I'm sure you've kind of been using these over years, three in the start of four so far. But if you haven't, you know, it's something that we'd highly recommend, they've got really useful OSK stations and you know, the more you practice, the better you're gonna be when you come to actual OSK. And if you use, er, CB OSK crew 24 at check out, um it gets you 10% off. So it's a, it's, it's a worthwhile membership to have. This is just kind of er how the sessions gonna go today. Er, so we're gonna talk a little bit about falls history first, really common ay station, some differentials for falls and how we can think about, you know, narrowing down differentials, then we're gonna move a little on to kind of confusion, delirium. Er, th then we're gonna move on to the structure for breaking bad news and then an ethical scenario which is gonna be DNA CPR. Um So it's no fun getting older, which actually a quote from my nan. Um So before we kind of go on to um a falls history, we're gonna think about a little bit about physiology. What changes as we age cos this is all gonna contribute um as to why people have falls. Um So when we age uh in terms of our heart, we get a reduced cardiac contractility. So we've got a reduced cardiac output. Uh we also get valvula, valvular issues in the heart. So you're more likely to have kind of aortic stenosis mitral regurgitation. And this is due to kind of calcification processes over time. Um In addition to this, you've got long term vessel changes as well. Uh Again, calcification, atherosclerosis, you get stiffening of the vessels and all these essentially link to having an elevated systolic BP. Um This can kind of make us all these factors more liable to fall. And then also we've got reduced baro sensor sensitivity. So we are less able to respond to changes going from positions such as, you know, sitting to standing. Er and this is a, a real big problem in the elderly. Um We've also got reduced lung capacity, reduced elasticity and weaker respiratory muscles as well. And when you couple this with a reduced cough reflex, you're more likely to get chest infections, pneumonias and infections that contribute in factors of falling as well. Then we've also got long term environmental exposure of the lungs leading to things like fibrosis, co PD and cancers. Uh when it comes to the kidney and the gut, we've got reduced gut motility, especially in the large intestine. Um and this can predispose us to well, predispose elderly people to constipation. Um and this kind of comes in to the delirium portion of the talk. Um and then, you know, as we age reduce cell turnover, you get a decline in eg fr um in terms of the brain, you've got just decline in cognition in general. And obviously, as we age, one of the big things that hits a majority of people now are dementia. Sorry to interrupt. I think you need to share. I think you need to start presenting because Oh, there you go. Yeah. Can you see that? Yeah, I can see that now. It was just stuck on the first. Can you see that um, slide? It's on the, it's no fun getting old slide right now? OK. I'll tell you what is that? Is it easier if I just kind of go through it like this? Yeah, maybe just keep manually switching. That's fine, that's fine. Um So in terms of, um, you know, when it comes to the brain, we've got dementias, which is something I'm gonna touch on. Er, in terms of the skin, you get atrophy, atrophy of the epidermis, which makes people prone to getting pressure ulcers, especially whilst in hospital. Um, in terms of the immune system, we undergo something called immuno senescence, which is where there's kind of a dulling or a blunting of the innate adaptive adaptive immune system. Um, and this makes us more prone to bacterial viral infections, less response to vaccines. And then on top of that, you've got uh hearing and vision decline, osteoporosis, depression, social social isolation, reduced muscle mass and slower reflexes. So, you know, it, it really is pretty rubbish, getting old. Um, so now I'm just gonna move on to a little bit about uh a false history, so structure for taking a false history. Um, it might be something if you've already done a geriatric placement so far, er, that you've come across. But in a false history, it's really important that we go through kind of a certain structure. It's similar to what you already know in terms of history of presenting complaint, past medical history, drug history, et cetera. But in terms of your history of presenting complaint, you're going to want to know about before, during and after. Um, so in terms of before we're going to want to know, you know, where and when did they fall? Um, and kind of, what time did they fall, you're gonna find that in terms of the elderly, the most common time that they're gonna fall is at night. So they're gonna be in bed, they're gonna have got, get up to go to the toilet and they're gonna trip over, you know, their cat, the carpet, their husband who's already on the floor, cos they've fallen over as well. It's just a really, really common time, especially when they've got impaired vision, uh, impeded reflexes. Um, if, if they're wandering around at night, it's easy for them to fall. Um, we also want to know what they were doing prior to the fall. Were they doing something exertional? You know, and then we can think, have they potentially got an aortic stenosis. Um We wanna think, have they recently changed position, er, and he Ortho static hypertension and then were there any triggers, er, or did they have kind of like a prodrome? Because if, you know, if someone's got that feeling, oh, you know, I felt dizzy, felt lightheaded, felt weak and then I fainted. This can sometimes point towards like a, a syncopal episode. Uh And then were there any physical symptoms as well? So, dizziness, chest pain palpitations, uh these can all kind of either point to potentially a cardiac cause. Um, or, you know, if they're dizzy, were they dehydrated during, er, when it comes to, during, in a falls history? It's really good to have a collateral history. Um, because the person who's fallen is gonna have a poor, poor history of what happened during the fall. So you're gonna want to know if they tripped, if they fell, if they fainted or how did it appear to the person who saw them fall? Er, really importantly, you're gonna wanna know if they've hit their head at all cos if they've hit their head, er, in more or less every scenario you're gonna get act for them ct head. Uh, just noted that anyone to witness a fall. Was there any loss of consciousness? Um, and then if there was any loss of consciousness, you wanna know how long for, um, and then do they remember falling or hitting the ground? So, a lot of the time, if they've had what people call a mechanical fall where they've just tripped, they'll kind of realize that they've fallen or if they've had something like a seizure or a stroke, er, they'll have a period afterwards where they're not quite with it. They're a bit disorientated until they come to and then did they try and break their fall as well? So, that's kind of again helping you think, you know, was there a loss of consciousness? Because if they tried to break their fall, it was unlikely to be a loss of consciousness. And then some questions I like to ask on a jarring part as well. Is just, was there any jerking incontinence or tongue biting? Cos these can all all point towards a neurological cause of the fall? So, potentially something like a seizure. Er how long were they on the floor for? So if, when we're moving to after the fall now? So how long were they on the floor for? It was really important cos this is why we're thinking about things like rhabdomyolysis. Um cos this causes muscle breakdown release of electrolytes such as potassium and this can lead to some serious arrhythmias. Um Were they orientated versus disorientated when they came to? Um if they were quite orientated, were maybe thinking a cardiac cause or a simple fall or if they were disorientated, maybe like a neurological cause like a stroke or a seizure. Um And then were they able to get up by themselves and wait there immediately, you know, things like stroke and have some lasting weakness after the events actually occurred. Um, and then have they got any pain, swelling, weakness? Cos that's something we're going to want to look at after potentially get an X ray or just investigate further. Any vomiting dizziness. Is, you know, are there any ongoing symptoms or if they've had some vomiting, do we need to give them some fluids? So it's kind of just put in, um, the history and kind of narrowing down your differentials that way by asking these questions for before, during and after. Um, you know, at Manchester, they're really big on ice, so never forget to do ice. Er, realistically if someone's had a fall and you're doing a fall history in a CCA, one of their concerns is probably going to be a fear of falling, which is, you know, quite understandable. Er, and it's important just to kind of recognize this and respond appropriately. So, um, if you just address it and say, you know, I understand that, er, you're worried about falling, er, we're gonna do some, we're gonna put some measures in place to make sure that you're a bit safer at home so we can get the occupational therapy team involved and we're also not gonna discharge you until we think you're safe to return home. And again, it's just kind of chasing up things that you know, who do you live with? Have you got any carers? Uh, in terms of past medical history, we're looking out for things like orthostatic hypertension. Er, Parkinson's might make someone unsteady on their feet, any arrhythmias or any conditions causing dizziness, er, drugs history. There are really kind of four, drug categories that we're, we're looking out for at this point. So it's anti hypertensives. Um, are they on a number of hypertensives? And if they are, um, maybe there is something that's needed reviewing diuretics, you know, if they cause fluid loss, drop in BP lead to a fall sedatives. You know, it can be quite common and they're not always sedatives that, you know, people have been prescribed, sometimes they take them because they've got poor sleep. But when they've got kind of a reduced consciousness, this can make someone kind of, or it makes precedes them having a fall. And then we've got antidepressants as well because these can cause things like hypernatremia, hyponatremia, sorry, it can cause cardiotoxicity sedation. And then once we've kind of got their drug history, we want to be thinking about, have there been any recent changes to their drugs? Um, so, you know, have they had another antihypertensive added recently? Do we need to review this or has their diuretic, er, dose increased? Um, and then we also wanna be thinking about antiplatelets, anticoagulants, things like that because this is, er, increases their risk of bleeding. So, especially if they've had a fall, if they've hit their head, if they're on antiplatelets, we're gonna wanna look for act just to make sure they haven't had or they haven't got an active bleed on the brain. Um, when it comes to geriatric, social history is really important. Um, cos you wanna wanna assess, you know, how safe they are at home and also what their baseline is. So it's important to kind of assess how capable they are with their activities of daily living. So, you know, can they dress themselves, can they cook for themselves? Do they do their own shopping? Do they have a package of care in place at the moment? Um, because this enables you to see what their baseline is. So that's where you're aiming for. Essentially, you want to get them back to baseline before they're discharged. You also want to know if they live in a house versus a bungalow. Obviously your house has got stairs and how do they normally manage on the stairs as well? And if they've got stairs at home, you're gonna wanna do a stairs test in hospital, er, you're gonna wanna look at their kind of general nutrition, you know, are they eating and drinking? Er, because, er, dehydration and hypoglycemia both really common causes of force, especially in the elderly when people don't really keep track of, you know, eating or drinking or they don't have the appetite that they used to. Er, and then just some general, er, health questions as well. You know, your smoking status, your alcohol is someone drinking excessively that's causing them to fall or have they had issues with alcohol in the past? Once you've got, uh, your general falls history, you're going to want to do a review of systems. Um, and the way I like to do this is kind of going from head to toe. So start off with your systemic symptoms. So any fever, night sweats, unintentional weight loss covering some red flag symptoms as well there as well. If you think of malignancy, er, then keeping on board with the head, you know, any confusion, loss of consciousness, er, changes in sensation or headaches, er, and then eyesight, vision changes moving down to the chest. Have they had any chest pain palpitations? Uh have they had any productive cough, shortness of breath or any pain, breathing in and out moving down to the stomach? Any diarrhea, vomiting, abdo pain, any pain when they go for a week really, really common cause of both confusion and falls in the elderly. A uti and they're really quite common. So it's always something that you don't want to miss because it's an easy fix. Um, and that can essentially bring an end to their confused state at the time. And then MS Ks Well, have they got any joint pain? Have they got any ongoing arthritis? Either osteoid, whatever that's caused them to have a full, um, in terms of kind of your investigations and differentials. So once you've taken your false history in the CC eight or the OS, the examiner's probably gonna ask you, you know what your next step are, you're gonna wanna start off kind of your examinations. Um, then you're gonna wanna go to your kind of bedside investigations and then bloods and then imaging, that's kind of how I've always broken it down to. So, examinations it's gonna be based on, I suppose your top differential, you can't really go wrong with either a neuro or a cardio respiratory examination. It covers quite a lot. So your neuro, you're gonna be looking at um, cranial nerves and then, you know, upper and lower limb. So you're gonna be looking for signs of stroke or, you know, any upper motor neurone damage, lower motor neurone damage. In terms of your cardiovascular, you're gonna be doing a capillary refill time gives you a, a kind of indication of hydration. You can look at, um, if they've got moist mucous membranes, any signs of dehydration clinically, you can feel for a pulse. Um, you know, are they bradycardic? Has that led them to have a fall? Have you got any regularly irregular pulse? Have they got af has that caused a fall? Listening for murmurs on the chest, see if the lungs are clear. Um, again, it's just all, all things that are going to give you an indication as to what's potentially caused this fall. Uh, you're also gonna wanna, you know, if you can get a little bit more niche after that. So, you know, if you think they've tripped because they've got a reduced sensation in their feet, you could offer and they've got a history of diabetes as well. You can offer diabetic foot. Er, if you think they're clinically hydrated, you could do a full hydration exam and then you also want to assess things like gait, balance, er, vision and cognition. Uh So gates are really important. One cos you know, as we get older, people tend to be increasingly unsteady on their feet, poor balance, er, vision tends to go as well. You get the build up of like cataracts. Uh So these are all things you can offer in the examination period when it comes to things like um bedside assessments. So we can offer long standing BP. It's a really good one to put in any false history, especially in a geriatric patient because it's just, it's just so so common, you can also check things like BM. So your blood glucose if they had a hypo and then do a urine dip, looking for a UTI and an ECG. Um and once you've done your bedside assessments, you can move on and off of blood, you can just reel off, you know, full blood count using these LFT S any underlying kidney impairment that's caused them to have a fall, you know, have they got signs of infection, raised white blood cells. Uh, have they got deranged LFT S or T FT S? Bone profile is quite good. Cos you can have a look if they've got, um, signs of, you know, osteopenia or osteomalacia or whatever, they might need some bone protection medication and then your imaging. So, things like your chest X ray ct head, um, have they got a pneumonia or have they had potentially a stroke? These are all things you want to go, er, investigate for? And then my table on the right is just kind of your four differentials. So I've split them up into different categories. So general being your, what people will call potentially like a mechanical fall. So, you know, they, they've tripped over the carpet more like a, a one off or they've got some, you know, visual impairment because they weren't wearing their glasses and then consider your polypharmacy as well. So, have they got a number of drugs that could potentially have contributed to this fall? Do, does that need review? And, you know, do they need a, a full medication review potentially with the pharmacist? Um, just to decide if all these medications are currently in their best interests, cos a lot of the time, uh, elderly people are just put on medication after medication after medication and they're not always stopped, um, when they need to. So it's always a good idea just to review medications in the elderly cardiovascular. It's your, it's your arrhythmias, orthostatic hypertension, bradycardia and valvular heart disease. Yeah. If you think there are some valvular heart disease as well, you can also offer an echo. If you've heard a murmur on examination, neurological, it's your strokes, seizures, peripheral neuropathy, specifically relating to kind of, I suppose most commonly diabetes. But you can also get it from, I suppose, vitamin deficiencies as well. Urinary tract infections, hypoglycemia if they haven't been eating and then your, your causes of dizziness or your ent like BPB. Um, so now we're kind of, I suppose moving on to history structure for confusion or delirium, er which is again, super, super common in the elderly. Um, so I've just started a little bit about, I suppose what delirium is. Um, so delirium, really importantly, it's acute. So it, it comes on over, you know, a day or two, it's transient or fluctuant. So you'll find that they have periods of where they're quite lucid and then they'll deteriorate and then they'll become lucid again and then they'll deteriorate in this kind of odd pattern and it's also reversible as well. Now it's usually always reversible, like the vast majority of times it's reversible. Um But yeah, that's, that's one of its kind of tell tales. So it's acute transient and reversible confusion where if you compare that to dementia, you'll notice in the history, it's a really long ongoing slow deteriorative process where there's not much recovery there won't be any kind of recovery, they'll just continue to deteriorate. But uh deliriums, one that we can give you in kind of a CCA is, I think I had it in my CCA where I had to er, interpret some data. So they gave me, I suppose bloods uti er urine dip and they had a raised inflammatory markers and leukocytes and nitrates in the urine. So they had a UTI and then there was a family member there and you had to explain to them what delirium was kind of why it's occurred and what you're going to do about it. So it's just in terms of recognizing the delirium and then communicating to a family member that, you know, this is, they're acutely confused. So they've got the short term confusion. It's because they've got a urinary tract infection, vast majority of time, it's reversible. This is what we're gonna do to treat it. Once we've treated it, we expect them to make a recovery and not be as confused anymore. And it's just communicating that and addressing um family member concerns cos they'll be, you know, quite upset that there's been a deterioration where you explain that once it's been treated, once you treat the underlying cause of the delirium, it usually resolves causes of delirium. Er I've always used the um acronym pinch me, which I'm gonna go through on the next slide. I've always found that really helpful just to keep in mind the different causes of delirium. So you can screen for those when you're doing your history um assessment. So you want to be assessing people kind of using a, a mini mental state exam or the ace three to see if there's any er, cognition impairment. And you want to do this multiple times as well. So you can see if there's that fluctuation, if you can see a, a fluctuation in the scores. This is a good indicator that it's delirium. Er, you've also got a hyper versus hypoactive delirium. So, I suppose when people think of delirium commonly they'll, they'll lean towards the hyper active state. So it's, when they're agitated, they're wandering around at night. They, they may be aggressive, er, they can have these kind of hallucinations and delusions, seeing things that aren't there. But you've also got hypoactive delirium, which I suppose is harder to spot. They'll just tend to be quite, they'll just spend a lot of time, er, in bed, they won't really say anything and they won't really pay attention to you when you're listening and it's almost kind of like they, they're not even recognizing that you're there. So it's, it's important to recognize when you do see it because there's, there's probably that underlying cause that you need to treat and once you've treated that cause they'll make a much more uh, well, a much better recovery, um, environmental strategies as well, er, really important in delirium. So you want to try and orientate your patients, er, make them feel kind of as comfortable as possible. So it's, it's things like putting a clock on the wall, um, putting pictures of family members next to their bed, having the same kind of care team, see them time and time again. If that's possible. I know it's not always possible but say having the same nurse look after them, so they're not seeing a different person every time. Um And then you, you also need to do your confusion screen as well, which is er essentially like a set of bloods. So it's a full blood count using these after ts most of what you can think of bone, bone profiles, you want to signs of hypercalcemia, which is quite a common cause in the elderly and you can also do your, your er imaging and urinalysis as well. So this is the kind of pinch me acronym that I was just talking about. These are the most common causes of delirium in the elderly. So, pain when patients are in pain, if they're in that much pain, they can just become kind of acutely confused. And also when you start to treat it as well, if you, if you dose them up with opiates or strong painkillers, this can almost have like a knock on effect and also cause delirium. So pain is a bit of a tricky one infection. Uh It could be anything from, you know, a pneumonia uti um all really kind of common causes of delirium in the elderly nutrition. So if they're not eating, um if they're having a bit of a hypo, you know, quite a lot of these are also causes of falls. It all ties in like a lot of the problems with uh geriatric patients. So they just cause like universal problems. So like any kind of pain can cause either, you know, a fall or delirium constipation really common. So you want to be checking abdomen, you know, is it soft, non tender? You want to be checking, when do they last open their bowels? If they remember hydration, um, common cause of delirium, especially with elderly patients at home. If they're not keeping on top of their hydration or they don't remember when they last drank, it's less of an issue in hospital because, you know, we, we're often keeping on top of, you know, are they getting fluids? We're doing fluid charts for them, we're monitoring urine output but at home. So if someone's kind of become acutely confused in a home, er, and they don't know when they last drank, it's something to be mindful of uh medications again. So this is kind of mostly like your sedative medications, your painkiller medications. So it's always something to review. If someone's become acutely confused, what kind of medications are they on and then environment as well. So if they've recently been changed or their environments recently changed, so say they've so they picked up an infection at home, they've been brought in to the hospital that recent change in environment can be really disorientating for them, especially if you, they can't really piece together how they got from one area. So say they're home to the hospital. If you can't really put that two and two together, they can be really disorientated and lead to kind of like this delusional state. Er, and then there, there are three pictures on the right I've got in terms of the, the management. So it's treat your reversible causes, um, monitor them to see if they're improving or not, to see if the changes that you've implemented are working. Er, and then if you've tried kind of all your, your passive, um, I suppose, what's the word? Yeah. So it's, the pharmacology is only really used in minimal cases in delirium and it's when patients have got the, the hyperactive delirium and it's when they've started to become really aggressive and you've tried to deescalate the situation as best as you can. Uh, but deescalation techniques haven't worked. So you can use medications such as haloperidol, I think is first line. Um, and if they've got Parkinson's LORazepam, so that's just, it's only used very short term in, er, scenarios where patients become aggressive in, in a delirious state and they just essentially need to be calmed down if deescalation hasn't worked. Um, but this again. Ok. So this is just part of again, your, your confusion, history, taking, if possible, a collateral history is really important and it's your onset. So when did it start? If it's, if it's really quite sudden, you're gonna be thinking delirium or if it's had more of that, um, insidious long onset, you're gonna be thinking leaning towards more dementia. And then, is it continuous that supports dementia fluctuating that sort of delirium and then it's establishing that baseline function. So where, where do you essentially, where are you gonna get them back to? Is, is it possible to get them back to that baseline? Um, the progression as well. So, you know, Alzheimer's tends to be a slow decline over time, talking years and years of kind of like a slow deterioration in memory. Um, whereas delirium is almost like it can be like a switch overnight, it can become really, really confused and a massive change in behavior really quickly. And again, those triggers of that Pinch me acronym that I use. I'm not too familiar with Chip's phone, but pinch me is the one that, that I typically go by. Uh, then we've got some associated symptoms on the right. So in both, I suppose in the elderly, you know, depression is increasingly common due to things like social, social isolation and general deterioration in health. Er, it's, yeah, it's just generally quite, not fun. Um, you've got behavioral changes as well. So, depending on if they've got kind of like a hyperactive delirium, they may become increasingly aggressive or disinhibited. And that's also something we can see in a certain type of dementia as well. And that would be the fronto temporal type of dementia. They can have kind of these hallucinations and delusions and then the sleeping patterns can be like really out of kilter. So they can find themselves wandering quite late at night. So sometimes it's just helpful to have a little bit of 1 to 1 nurse in contact if they're, er, tending to wander in the night, cos if they're wander in the night, it just goes back to that falls again. So they start off delirious, they have a fall and it's just compacting um, their health issues at the time. So it's just keeping an eye on and trying your best to alleviate delirium cos it can lead to uh poor poor health outcomes in hospital as well. Um, and your confusion, history taking history. So it's very, it's essentially the same as your standard history taking that you'll be very familiar with, er, by this point. So you want to know, is there anything in their past medical history which links to, you know, a general state of confusion? So, you know, have they got any Parkinson's uh, symptoms? Have they had a history of vascular dementia? Is this just a another step in their history of vascular dementia? Uh, have they had any head injuries previously or any current infections um, in the drug history, you're going to be looking for certain drugs such as Galantamine, Donepezil and Rivastigmine, which are acetylcholine esterase inhibitors. And these are used in the treatment of Alzheimer's. So, if you see someone's on these medications, there's a good chance, um, that they're being used to kind of treat their Alzheimer's when I say kind of treat their Alzheimer's. It's not, it's not treating the symptoms or, or reversing anything, I suppose. It's just kind of like aiding their memory ever so slightly. I'm not too sure on the exact mechanism, but they're just used to not stop the disease but kind of aid the patient's cognition as it's deteriorating. You also want to know, you know, family history, dementia, there's, there's strong family links with kind of dementia vascular dementia depression. So anyone else in the family have similar issues. And then just as you did in the fs history, social history is really important. So, you know, who are they living at home with? Are they home alone? Do they have a partner? Do they have a care team? Uh How do they kind of get about the house Walking Aids sticks? Um, looking at how they get on with their ADL S. Are they currently, you know, working or driving? Um, you'd be surprised at how many kind of elderly patients are still driving after, um, or, you know, after quite a few of the health problems that they've had. So this is, it's not something you'll have to worry about in your osk, you know, raising that someone might, shouldn't probably be driving anymore, but just when you're taking history, just something to be mindful of and then risks as well. So, you know, are they a risk to themselves, are they going to be, uh, if you've had 34 falls in the past year, are they a risk to themselves at home? You know, maybe you've got to be thinking where's best for their care and then this is going to involve an MDT approach. Um, are they a risk to others? You know, are they acting aggressively risky behavior disinhibited? Um, and then, you know, if they've got carers at home, how are their carers coping? Um, and it's potentially someone you need to, to bring in to have a chat with if things have deteriorated further. Um, so these are kind of the, the four major types of uh dementia. These are potentially something that you could be asked about in a CCA, you know, someone comes in with some cognitive impairment and you potentially have to distinguish between the four. so Alzheimer's dementia. Uh So it's the most common form of dementia and it's 50% of er, all dementias and it affects the, the hippocampus if you, what our little hippos there for and you'll find that it's kind of like a slow progressive deterioration over time. So, if you had like a graph, it would just be kind of steadily getting worse and worse over time. And this is your deficit in memory and planning cognition. So you'll find that, you know, they start off by, you know, er, potentially in their sixties, seventies, they'll start, they'll forget their keys when they go out or they'll forget some bits of shopping that they've left at the shops and then they'll start to remember, then they'll start to forget the names of places and names of people. And it just kind of long term memory isn't as badly affected. It's like short term memory which is affected first and then it kind of progresses and progresses until, you know, it's really quite debilitating where they can't even form new memories. Really vascular dementia is this step wise progression that you want to be careful of. So, in your history, it will be an elderly patient who's or you'll probably be talking to a relative and they'll say, yeah, he was, he's, he's been really bad recently. He's been losing his memory and then he was fine for, you know, six months, eight months. And then he kind of took a really big dip again. And now he's, you know, he's stumbling about his because what's happening in vascular dementia is it's kind of a a chronic um lack of blood supply to the brain. So you've got your kind of micro vessels in the, in the brain that are a little bit more atherosclerotic, but not to the point where it causes a stroke and kind of abrupt ischemic injury. It's this like long term ischemic injury and you'll find that it occurs in this step wise pattern and it's your higher function as well. Um, so it could be, they could have kind of like functional neurological deficits at the time, could have issues walking, um, issues. Well, it's just a really bad deterioration, essentially, er, Lewy body, I always remember is Bowie body because they have er visual hallucinations. That's just how I always remember that one. So they'll say that that, you know, they've seen a, a dog or people in their living room that aren't there. Um and this can always kind of, this can also have a, a fluctuating progression, er, but it tends to be kind of more longstanding than compared to your delirium. So, although it can look a bit like a hyperactive delirium, this tends to be more longstanding and without those kind of reversible causes. Um and then it affects the substantia Nigra as well, which is the same as Parkinson's. So there is kind of a link with Parkinson's people who develop Lewy body dementia may then go on to develop some Parkinson's symptoms as well or they might develop Parkinson's first and then go on to develop a Lewy body dementia. So that's just one to keep an eye out in the past medical history because they are kind of linked and then your last one is your frontotemporal dementia. So it's where you get uh neuronal damage in the frontal and the temporal lobes and you kind of get three kind of subsets of frontotemporal dementia. So probably the maybe the most common one is the altered emotion apathy. Er, so it's kind of, you know, people lose that ability to empathize with people, they'll become slightly more blunted and aggressive and they might become disinhibited as well. Um whether this is a change in personality, potentially gambling or increase in kind of like sexual activity, which would be uncharacteristic for them. Um, then there's these two others which is like a semantic and a breakdown of language. So they struggle to kind of understand language and struggle to kind of communicate back as well. Um, so last couple of bits, er, we've got now is, so this is your, your breaking bad news, er, which is again a really kind of common CCA station for Geriatrics. Um, I was just looking at my kind of geriatric stations from, er, when was it January? Was it January June, er, last year? Anyway. And I think mine were, I think there was a Parkinson's exam, there was a communicating delirium, there was a, a stroke history and pharmacology. And so because we didn't get a break in bad news for geriatrics, there's, you know, a good, good chance it could come up this year but it's, it's following that same pattern that you've kind of been used to for your breaking bad news sessions throughout third year and they'll come, continue through fourth year as well. So, it's your setting. So you wanna obviously your cca, you can't choose the setting. Your setting is gonna be in that little box that you're in with that patient with the examiner. But it's still important to, you know, act as if you were, er, on the ward. So you just, you just talk to the patient or talk to the family member and say, you know, I've come to talk to you a little bit about, you know, John or whoever, um, would you like anyone else to be present? And is it ok if we, you know, have this conversation here and they say yes or whatever and then you can continue but it's just building that rapport with the patient, you get your introduction done, you make sure you're in the correct setting cos it, it sets you up nicely for the whole conversation really. Um, and then it's perception as well. This one's really important. So you want to gauge what the family member knows already and this will just benefit you in the long run because if you just say I keep, you know, keep telling me what, you know, so far about Jack's conditioner and then they'll say, oh, you know, he, he's come in with, you know, whatever he's come in with a pneumonia and he's had, you know, three or four over the past year. So he's, he's not doing great and this just kind of set you up. So a you don't repeat anything that they already know. Um And then b you don't kind of put your foot in it and say something that's really gonna surprise and shock them and then it's gonna put you on the back foot and then you're going to have to kind of recover from there. So once you've got their perception, you can kind of tailor where you're going next in terms of what, what information you're going to provide them. Um, in terms of your invitation, it's always nice to ask them, you know, is it ok if I tell you a little bit more about how things have been going, um, because then, I mean, they're going to say yes, but it's just, it prepares them that, you know, there's a bit of information coming. Um, and then that's when you kind of drop your knowledge. So a lot of these scenarios in your breaking bad news, I think I had one where it was a patients come in, they think they've had a pneumonia, they've done a chest X ray and then it looks like they've got, er, potential lung cancer from the look of the x-ray. And you've got to communicate this to the patient's daughter. Um, and it can be quite difficult, quite daunting, but you've just got to, I suppose you can't really kind of the more you dance around it, the the more awkward it's going to be for you and the patient. So if you should be clear with them, but empathetic at the same time. So if you're dropping the knowledge, so you know that we have, we've got, we've done some more tests on, on Jack. Um we were looking for a pneumonia, um and when we did the chest X ray, unfortunately, from what it looks like there is a potential lung cancer there. And then once you've kind of dropped whatever bomb it is that you're dropping, um, or, you know, the, the bad news that you've broken, what you wanna do is just, just generally just sit on it. So once you've kind of dropped the news that you think is going to be the hardest for them to hear, don't say anything. Just let them sit on it because they're gonna reflect on it. It might be generally like 20 seconds. But let them say the next thing once, once you've dropped the bomb, they'll say, oh, ok. And then just, just wait 20 seconds and then let them come to you and say, you know, what, what does this mean now, or? Oh, I really didn't expect to hear that. And then you can say, you know, I'm, I'm really sorry that I've had to be the one to tell you this today. But, you know, it's, it's our responsibility to keep you informed and then you can kind of go on and just, this is, I suppose, rolling into the empathy, which is the next bit as well and just say, you know, if there's anyone who you'd like us to get in contact with you who can support you at the hospital or, you know, if there are any other family members that you want us to contact and if you wanted us to tell them or you want them to be here now, then we can do that for you and it's just actively listening to what the, er, simulated patient is saying and responding to it appropriately. So, you know, if they get really upset, you say, oh, I'm sorry, are there any tissues around? Can I get you a tissue? Can I get you a drink? Er, these are all things that, you know, the simulated patients, the examiners really like, it's just you want to make that pa er, the, I suppose the patient's family member feel as comfortable as possible. Uh And then after that it's, you know, it's, it's what it's, what's gonna go, well, what's gonna happen next? So your, your strategy, you follow up basically. So you wanna kind of solidify with the, er, patient's family members say, look, you know, we've got the same goal here. We both want what's best for, er, for Jack or whatever. We, we, we essentially want the same thing here. Um, I appreciate there's a lot of information to take on if you want to contact us again. Give them your name, you know, you say my name is Angus. I'm going to be on this ward now for months. So if you need anyone to kind of as a, as a talking point or an update come and follow me and I'll be the one to do that. So you can keep seeing the same person over and over again. Give them a bit of a lifeline so that, you know, they know that, you know, you're interested and you care about them, kind of being up to date about the information and then kind of you wanna be chunking and checking, I suppose throughout as well and then just at the end. So, ok, so I know I've given you a lot of information here, but can you just let me know what you understand what we're gonna be doing next? And then you can say, have you got any concerns? Have you got any questions for me if you can't think of any right now, you know, take my name and come back to me if you can think of anything, you know, in a few weeks, time, days, time, whatever. And it's just kind of rounding it off really nicely in a way. So that you've, although you've broken some really bad news, you've, you're kind of making sure that you're, you're their arm in this situation, you're their shoulder, sorry, you're their support because that's what the the patient's family is gonna need. Once you know, some bad news has been broken, they're gonna wanna be supported by the medical team, they're gonna wanna feel like the medical team cares. Um So it's, it's how do you kind of convey that you care to the patient whilst kind of not sugar coating it, giving them kind of direct honest information but also letting them know, you know, it's even if it's not information they want to hear, there are things that you can be doing or there are things that the, the, the medical team are doing to support them throughout it. Um, but these scenarios are, they're just really good to practice. You know, if you, if you go on like the, or if you try and practice in the session after this and the hour that you've got, uh, doing the CCA practice, I'd really recommend trying just to get a couple of, er, practices in and just, just also jotting things down that you notice that other people say if you think, oh, you know, that was, that was a really good way of wording that or I really like how they did that jot it down and use it and just practice it as much as you can because these breaking bad news situations, they are difficult, you know, they're designed to be quite difficult, quite uncomfortable but the more you do them and if you follow your structure, you know, they can be really good stations where you get kind of good marks if you're kind of following this structure and you're empathetic and you're actively listening. So it's just kind of nail your structure and then it, and then adapt it to what scenario you've been given. So no matter what kind of comes up in the breaking bad news, if you've got that kind of spikes in your head and you think, OK. Right. We'll see what they know first. OK? I'll ask them to talk about it, I'll drop the knowledge, I'll let them reflect on it. Um You know, empathize with them, summarize what we're gonna do, what the next steps are, if there's an apology that needs to be made, make the apology. Um And then, you know, let them follow up with you directly. Um What can kind of come up in one of the challenging communication stations is the DNA CPR again, really common, but a really good station once you've got your structure for it, so it can be quite daunting and it's an easy one I suppose to get your, your feet stuck under you sometimes if you say the wrong thing, but this kind of structure on the right is really, really good. It's kind of following on from the the spikes uh spike structure that we've just gone through. So you want to nail your introduction, you build a good rapport to start off with. Um And then you er, gain their perception again. So it's all about what do they currently know about, er, their family's condition? So they'll say, oh, you know, they've been bouncing out of hospital for months and months now they've been in and out, in and out but, you know, they always bounce back or sometimes they'll say, oh, you know, it's, it's not looking too good this time. So it's just kind of seeing what they know about the current, um, I suppose health of their relative and you can introduce, then you can gain sorry. What's our further understanding of, I suppose, planning towards the end of life. So, you know, do you know, kind of what sort of things we can put in place if we think that someone's coming to the end of their life? Or do you know how we kind of plan ahead if someone's health was to deteriorate? And this is kind of like how you can introduce the topic if they haven't already brought it up at this point. And then, so you can say one of the things that we put in place is DNA CPR, you know, is this something you've heard about before? If they say yes, ask them what they kind of understand about it already, more likely they're gonna say no. But again, it's just that invitation again, is this something you'd like me to talk to you about now? You know, just to invite them and then they'll say Yeah. Ok. Can you tell me a little bit more about it once you've got to that stage, it's kind of explaining initially kind of cardiac arrest and then the DNA CPR. So you'll say you might have, um, seen it on television before where someone goes into what we call cardiac arrest. It's when their heart stops beating. Um, in this scenario, one of the things that we can do is CPR again, which is something you might have seen before. So it's where we do the chest compressions. Um There will be a whole team involved, it'll be intubation, giving them drugs and you can just kind of emphasize that it's, it's quite an invasive procedure and it's quite a lot for someone to go through. Um just so that they can appreciate that it's not, I suppose this kind of quick fix that can, it can sometimes deem to be on like television if that's where they've seen it before. So this is where you kind of wanna explain the CPR and then just again, explain how it's, it's really quite a lot for a patient to go through. So you can say that often it can result in broken ribs. Um It's only successful in about 30% of patients without other health conditions. If it was to be successful, there's often some deterioration in health that you know, some further deterioration in health and they, they'd have to be uh sent to the ICU ward for intubation and kind of assessment after it. So it's really a lot for a person to go through and you kind of want to emphasize that, you know, it's not this easy fix. It is quite a lot for someone to go through. And then I suppose you'll have to explain that in the scenario that you've been given, the consultant has decided that DNA CPR is to be put in place. And you say so, you know, we understand that, you know, Jack's been in and out of hospital recently and the consultants um put DNA CPR in place and then you're probably going to get a little bit of kickback from the patient and they're going to be saying, oh, you're giving up, you're giving up on them and this is where you can say no, no, you know, this is, you know, far from it, we're still going to be giving them antibiotics, oxygen, pain relief. We're still going to be looking after them. The only thing that's not going to happen is if their heart stopped, they won't be given CPR because it's essentially not in their best interest. Um They're not in a fit enough state to, I suppose, uh I suppose it's not gonna be effective on them due to that, I suppose, multiple comorbidities and their poor health. So it's not suitable for every patient. Um Another question you might get in this scenario is, well, I refuse, I don't want them to put DNA CPR in and you'd have to say, well, unfortunately, you know, it's, it's a medical decision made by the consultants. Um CPR is kind of a medical procedure and no one has the right to demand medical treatment. So it's the, it's the consultants in charge who deem if something's gonna be beneficial for that patient. I mean, you can, if they're still kicking back, you can say, look, I'll raise it. Um and we can ask for other consultants to review it. However, you know, it is a medical decision made by the team in the patient's best interest. So, and then you can kind of go on to discuss things like, you know, it's a really invasive and hard thing for someone to go through and when someone's reaching the end of life, we try and help them pass with dignity and it's really not a dignified thing to go through and even if they did recover from it, they're gonna have some lasting er lasting health impacts as well. Er And again, it's you, you're chunking and checking throughout. So, you know, once you explain the, the DNA CPR, am I making myself clear or can you just let me know what you understand about DNA CPR after our discussion? Have you got any further questions any further concerns? Um I suppose you used to answering them, you know, as they come back at you, it's again just following this structure on the right which is a really kind of good structure for it and just trying not to get stuck under your feet again, it's not the easiest one to do, but it's, it's just emphasizing to the patient that again, we've got the same goals here. We want, you know, your, your mum, your dad, your uncle, whatever to be comfortable. We don't want to put them through any unnecessary pain or any undignified procedures that aren't going to have any benefit to them. What we do want to do is we want to keep them comfortable, we want to keep them pain free. Um, and they'll kind of a lot of the time they'll rally with you and they'll agree and they'll come to see that. Ok. So, you know, maybe it's not the best, you know, they have been flip flopping in and out of hospital for the past six months. You know, maybe their health is deteriorating to the point where it would be best not to put them through, you know, a really drastic procedure such as CPR, which wouldn't be pleasant for the patient or the family. Um, and then I suppose you can introduce things like, you know, there are further things we can do if they wanted to be cared for at home. If you wanted to stop them from coming into hospital so that they could pass at home, that's something we could do as well. But it's just kind of, I suppose it's wrapping everything up in a nice bow so that the family member can see that you do have the same goals and it's not that you don't care for the patients. In fact, it's the opposite, you know, you only want to be doing things that are in their best interest and unfortunately, you know, CPR just isn't one isn't suitable for every patient. Um, and that pretty much comes to, er, the end of the presentation tonight guys. So, er, you know, thank you for listening. Er, hope it's been, you know, of some benefit to you if you can, um, give us a bit of feedback at the end, you know, that would be really, really helpful. Um, um, and yeah, just get stuck in with the osk practice after this. It's, it's really good to just practice now in a kind of low pressure environment. If you make a mistake, you make a mistake. It's good. Everyone learns from it. So, yeah, you should get stuck in with the teaching afterwards. Thank you. Um, Angus. Just before you go there are two new questions in the chat. So one of them is, do you need to ice in the Spike Station? Um, it's, I mean, with Manchester, it's always good to ice. So I suppose, um, when you do it, when you're gaining their perception, you're kind of asking their ideas. So it kind of comes in two in one there. So, you know, have you got Well, what do you understand so far about so and so's condition and then I suppose you could follow on with that with, you know, have you got any kind of concerns moving forward? And then when you're moving towards your kind of strategy in your plan, you can ask kind of their expectations, you know, is there anything else that you think you'd want us to be doing for your family member? Or is there anything which is still concerning you? And you should go on like concerns and concerns and concerns. If you, if they haven't got any concerns, you're probably doing something, right? Ok, great. And then the other one is for investigation. Should we only list and explain the investigation of the three differentials? Um, yeah. So I suppose you, if you're, if you've given three differentials, um, yeah, do your investigations that's gonna narrow those down. So your investigations want to help you narrow down your differentials to get to the one that's actually causing it. So, yeah, if you're gonna, if you're gonna name some, I'd focus them on your, on your, on your differentials. Ok, great. Um, well, thank you so much, Angus. Um, for everyone asking about the QR code and the slides, um, that will be emailed to you the feedback form. So if you fill that out, then you will get the slides through that. Ok. So now with the ay portion of it, um, can everyone planning on staying just pop a yes in the chat just to make things a little bit easier. Ok, great. So I'll sort you guys into breakout rooms in a minute. We've got three breakout rooms. Um, so our ay facilitators are Samia, um Patricia and Dania. Um So, 01 more thing, we also have a doctor as well. Um, layer. So if she pops into your breakout room, she is just there to give feedback. Obviously she's the doctor. So it's really useful feedback. So just so you know who she is. Um and then I'm just gonna sort you into breakout rooms, you just click on the breakout sessions and then join the breakout rooms. So gift if you want to join Danny's breakout session and then Janella, if you want to join Patricia's breakout session, and then Smoothie and Pra if you want to join Samir's breakout session, and then if anyone else wants to join sessions, just click on a breakout room. And yeah.