Clinical challenge

Case 1 – Lorraine

Lorraine, 84 years of age, is a resident of the supported living accommodation centre attached to the residential aged care facility (RACF) that you visit each week. Lorraine is concerned about her gradual decline in cognitive function and wants her preferences for end-of-life care to be considered. You agree to assist in preparing an advance care directive (ACD).

Question 1

Which one of the following is part of the Code of Ethical Practice for ACDs?

1. ACDs are focused on the family of the person.
2. Quality of life is defined in the ACD legislation.
3. The substitute decision maker has the same authority as the person when competent.
4. The substitute decision maker is not required to honour residual decision-making capacity.
5. An ACD can be relied on only if its validity is independently proven.

Question 2

Which one of the following is the most important step for the general practitioner (GP) in arranging an ACD?

1. Involving the family in the discussion
2. Involving a substitute decision maker
3. Communicating the ACD to relevant healthcare providers
4. Initiating the discussion to prepare an ACD
5. 5.     Checking the latest resource guides for writing an ACD

Further information

Some of your GP colleagues are reluctant to provide care to their patients when they transition from home to RACFs, as they feel those GPs working in this field are better equipped to provide high-quality care.

Question 3

Changing GPs in this circumstance could result in which one of the following disadvantages for patients?

1. Lack of information regarding prior healthcare
2. Totally new assessment by the new GP
3. Being one of many RACF patients of the new GP at this facility
4. New RACF GP specialises in this area and may have less generalist expertise

Case 2 – Mary

Mary, another of your patients at the RACF, has severe dementia and progressive cardiac failure following a recent acute coronary event. Fortunately she has an ACD in place.

Question 4

Which one of the following is part of the decision-making pathway for Mary?

1. All aspects of the ACD carry equal weight.
2. If no specific relevant preferences are stated, choose the one closest to guide you.
3. Mary’s religious preferences are not a consideration.
4. If several treatment options satisfy the decision-making criteria, choose the most restrictive.
5. If there is no evidence of what Mary would have decided, make the decision that best protects her personal best interests.

Further information

A new RACF is opening in your area and you are considering their offer to provide care for their residents. An important consideration for you is whether their model of care matches your preferred approach, the Continuity Model.

Question 5

Which one of the following best describes how GPs work within this model?

1. Care for many patients across several nearby RACFs
2. Regularly scheduled services to larger groups of patients
3. Team-based care
4. In-reach services to patients in RACFs during episodes of acute illness
5. Follow long-term patients

Case 3 – Robert

Robert, aged 69 years, is an RACF resident with Alzheimer’s dementia. He has developed behavioural and psychological symptoms of dementia (BPSD) and his behaviour has become erratic and difficult to manage.

Question 6

Which one of the following most accurately describes the aetiology of BPSD?

1. Temporal lobe dysfunction accentuates responses to environmental provocation.
2. The aetiology is multifactorial.
3. Cingulate gyrus dysfunction leads to psychotic symptoms.
4. Atrophy in the frontal lobe is associated with apathy.
5. Atrophy in the parietal lobe leads to psychotic symptoms.

Question 7

Which one of the following BPSD is reported more frequently in the early stages of the illness?

1. Anxiety
2. Misidentification
3. Wandering
4. Apathy
5. Sexually inappropriate behaviour

Question 8

Which one of the following is NOT a helpful question when assessing BPSD?

1. What behaviours are unchanged?
2. Has there been a recent change of staff?
3. Is shower time a trigger?
4. What are the risks to the resident, staff and other residents?
5. What do the family/carers think about the new behaviours?

Question 9

You are reluctant to use medication to manage BPSD because of concerns about side effects. Which one of the following is rated as a high-quality, non-pharmacological intervention for BPSD?

1. Stimulated family presence
2. Bed baths
3. Carer psycho-education
4. Cognitive stimulation
5. Pet therapy

Question 10

Use of pharmacological agents in the management of BPSD should be limited to which one of the following situations?

1. Failure of pet therapy
2. To simplify nursing care
3. Family insistence
4. Difficult access to GPs after hours
5. High risk of personal self-harm

Case 4 – Joanne

The nurse at the RACF asks you to see Joanne, as a routine urine dipstick suggests she might have a urinary tract infection. Joanne is otherwise stable, although her dementia is quite debilitating.

Question 11

What is the next appropriate step in Joanne’s management?

1. Send the urine to the lab and wait for the report before prescribing an antibiotic.
2. Carefully consider whether this is asymptomatic bacteruria.
3. Prescribe an antibiotic on the basis of her last urine lab report.
4. Prescribe an antibiotic as per Therapeutic Guidelines and adjust after receiving the lab report.
5. Prescribe an antibiotic on the basis of the common sensitivities seen across all patients’ lab reports at this RACF and adjust after receiving the lab report.

Question 12

Which one of the following symptoms is LEAST likely to raise suspicion of a new infection requiring antibiotics?

1. Delirium
2. Falls
3. Functional decline
4. Behavioural changes
5. Bacteria on urine microscopy

Case 5 – Matthew

Matthew, aged 74 years, has had considerable back pain from multiple osteoporotic crush fractures in his lumbar spine. 

Question 13

When compared with younger patients, the elderly:

1. do not view persistent pain as a normal part of ageing
2. have high expectations for the effectiveness of analgesics
3. do not fear addiction to analgesics
4. are more cautious about labelling sensations as ‘painful’
5. are less reluctant to seek help for fear of an acknowledgement of disease progression.

Question 14

Pain assessment tools are important when planning an analgesic program. Which one of the following is the gold standard in pain assessment?

1. Facial expressions
2. Body language
3. Self report
4. Negative vocalisations
5. Pin prick tests

Question 15

Which one of the following is the most appropriate first-line pain management therapy for persistent pain, particularly musculoskeletal pain?

1. Pregabalin
2. Amitriptyline
3. Oxycodone
4. Ibuprofen
5. Paracetamol

Question 16

You choose to prescribe paracetamol with amitriptyline as an adjuvant medication. Which one of the following is a common side effect of amitriptyline in elderly patients?

1. Hypernatraemia
2. Constipation
3. Peripheral oedema
4. Urinary retention
5. Abdominal pain