Download Title: CPR preference of older in

Scientific Meeting
British Geriatrics Society, SE Thames Region
15 September 2005
Host: University
Hospital Lewisham, Lewisham High Street, SE13 6LH
Present:
Dr R Lewis (Chairman)
Dr A Abdulla (Hon Secretary)
Dr K Rhodes
Dr J Potter
Dr M Patel
Dr W Hildick-Smith
Dr B Bora
Dr K Dey
Dr N Aftab
Dr W Fitzpatrick
Dr R Rangasamy
Dr C Thom
Dr K Rudra
Dr K Singhal
Dr P Brighton
Dr D Mukhopadhyay
Dr N Hayes
Dr F Martin
Dr S Jones
Dr S Panagiotakis
Dr A Van Heuven
Dr P Tsang
Dr J Burch
Dr S Roe
Dr R Pathansali
Dr J Dennison
Dr Smithard
Dr J Evans
Dr B Al-Saffar
Dr Roger Lewis, the Chairman, commenced the meeting after welcoming all attendants,
with a programme of five presentations four of which were of interesting clinical cases
and one was an audit on Admissions to King’s College Hospital from surrounding Care
Homes.
The presentations were:
1)
Myasthenia Gravis – A Rare Presentation with Tongue Atrophy and
Fasciculation – Dr Jessica Burch and Dr M Patel, Lewisham Hospital
2)
Neuroleptic Malignant Like Syndrome without Rigidity in a Patient with
Parkinson’s Disease – Dr Nawaid Ahmad and Dr Belinda Kessel, Princess
Royal University Hospital
3)
CPR Preference of Older In-patients: A Case Controlled Study – Dr D
Mukhopadhyay and Dr F Martin, St Thomas’/Guy’s Hospital
4)
Intravenous Pamidronate for Intractable Metastatic Bone Pain – Dr K Conway
and Dr A Abdulla, Princess Royal University Hospital
5)
Audit of admissions of Care Home residents in Hospital – Nicky Hayes,
King’s College Hospital
The abstracts for these presentations are attached and a summary of the PowerPoint
presentations are available from the secretary, Dr A Abdulla.
After a short coffee break, the meeting reconvened for its second half and commenced
with a lecture by Dr Daya Gunawardena on “The Role of Geriatricians in the
management of dementia”. This was followed by an update on Parkinson’s Disease by
Dr K Chaudhari, Consultant Neurologist at UHL & KCH. A good amount of discussion
followed each of the lectures and the meeting as a whole was well attended.
It was agreed that Dr Jessica Burch, SpR at Lewisham Hospital, be awarded the SpR
presentation prize for the best presentation.
ABSTRACT (1)
Ref: BGS.call for papers
July 2005
BRITISH GERIATRICS SOCIETY MEETING
15 September, 2005
University Hospital Lewisham
Lewisham High Street, London SE13 6LH
Name DR JESSICA BURCH
Address UNIVERSITY HOSPITAL LEWISHAM, LEWISHAM HIGH ST, LONDON
Tel.No. BLEEP 552 / 07870 650052
I feel this is a very interesting case which has a number of learning points with regards to the diagnosis
and more specifically to the course and treatment of this patients illness.
CASE REPORT Myasthenia Gravis – A Rare Presentation with Tongue Atrophy and Fasciculation
Dr J Burch, Dr M Patel
A 76 year old man presented with a three week history of progressive dysarthria and dysphagia,
describing extended mastication with difficulty in food bolus manipulation. He had evidence of tongue
atrophy and fasciculation. In the absence of any other clinical features, the differential included
amytrophic lateral sclerosis and paraneoplastic disease.
After a number of tests and a significant deterioration, it was noted that his acetylcholine receptor
antibodies were elevated. He was transferred to Kings Hospital for further confirmatory tests. His
disease was unusually aggressive in its course with multiple complications related to the disease as
well as its treatment.
Bulbar presenations are recognised in myasthenia, but tongue atrophy is rare and usually late in the
disease. We found no previous published cases of fasciculation. Myasthenia needs to be considered,
even in the absence of classical symptoms and in all age groups, in order to be diagnosed early and
treated appropriately.
ABSTRACT (2)
Neuroleptic malignant like syndrome without
rigidity in a patient with Parkinson’s disease
Dr. Nawaid Ahmad, Dr. Belinda Kessel,
Princess Royal University Hospital, Farnborough, Kent, UK
ABSTRACT
Objective: To describe a case of Neuroleptic Malignant Syndrome without rigidity, due
to withdrawal of anti-parkinsonian medications, in a patient with Parkinson’s disease.
Case: A 72 year old male with 12 year history of Parkinson’s disease on maintenance
treatment (Sinemet Plus 1tab/2hrly, Sinemet CR 1 tab. nocte, apomorphine pump,
Amantadine 100mg BD, cabergoline 4mg BD and Madopar dispersible prn ), was
admitted to hospital with inability to eat and drink and dyskinesia. On admission he was
found to be very dyskinetic and this made his swallowing ability very poor. He was able
to swallow only thin fluids. As his swallowing was considered to be unsafe he did not
receive his regular medications for forty eight hours. Also during this time he had an
Endoscopy which meant being nil by mouth and missing the regular doses of his drugs.
On the fourth day of admission he developed symptoms of Neuroleptic malignant
syndrome and became confused, febrile (38 degrees), hypotensive (BP: 40/20) with high
CK levels (9381 IU/l) associated with further derangement of renal function and
metabolic acidosis. However he did not develop any rigidity, instead he was found to be
still very dyskinetic. He was admitted to ITU and required intubation and ventilatory
support with sedation. Soon after he was restarted on his anti-parkinsonian medications
and his confusion & fever subsided, he became more alert and was successfully weaned
off from the ventilator. His kidney function also continued to improve. Unfortunately he
developed several complications including pneumonia, sepsis and needed haemodialysis
at a tertiary hospital where he ultimately died.
Conclusion: This case demonstrates that Neuroleptic malignant like syndrome can
present without rigidity on withdrawal of anti-parkisonian medications.
We will review the literature on NMS in association with Parkinsonism.
Discussion: This case opens up an interesting discussion on how to manage NMS
Parkinsonian patients with Dyskinesia. Whereas you would like to continue with the antiparkinsonian medications for NMS, dyskinesia would mean reducing or stopping any one
or more of these medications.
ABSTRACT (3)
The use of iv pamidronate in acute intractable metastatic bone pain - Case
Presentation
Katie Conway, Aza Abdulla, Princess royal University Hospital
A 93 year old gentleman presented to his GP with pain in his left arm and
shoulder, reduced power in his left hand and episodes of his hand becoming very
cold and pale – relieved by warming. He was suspected to have Raynaud’s
phenomenon and thoracic outlet syndrome and imaging confirmed this. He was
diagnosed to have metastatic prostate cancer which with T1 root compression.
He was seen by the urology team and started hormone therapy with local
radiotherapy.
His primary problem became his severe inadequately controlled pain affecting his
pelvis, back and arms. He was admitted for a course of pamidronate infusion
over three days which had a dramatic effect on his pain, and rendered him
virtually pain free for a number of weeks after which his pain relapsed slightly but
was controlled on co-proxamol.
Pamidronate is well recognised in the management of hypercalcaemia in
malignancy, and used to reduce the number of skeletal related events in certain
forms of cancer and myeloma, and in the long term management of pain in
patients with bone pain secondary to metastases. There are a number of studies
to support these effects. The mechanism of action is thought to be due to the
potent inhibition of osteoclast-mediated bone resorption.
The role of pamidronate for the acute management of metastatic bone pain is
less well defined. There are reports of using pamidronate with good success in
patients with acute pain secondary to osteoporotic vertebral fractures and the
suggested theory is that the mechanism of action is different to that mentioned
above. It may be related to the modualtion of neuropeptides such as substance
P.
In conclusion this case demonstrates the dramatic effect pamidronate can have
in the management of acute pain secondary to bony metastases, and certainly
warrants further research to see if this effect can be demonstrated in larger
patient groups, via randomised blind studies.
ABSTRACT (4)
BRITISH GERIATRICS SOCIETY MEETING
15 September, 2005
University Hospital Lewisham
Lewisham High Street, London SE13 6LH
Name_______Nicky Hayes________________________________________________________
Address Medical Care Group, 4th Floor, Hambledon Wing, Kings College Hospital, Denmark Hill
London SE5 9RS______________________________________________________________
Tel.No.____020 7346 6056________________________________________________________________
Summary of your paper in no more than 200 words
Audit of admissions of care homes residents to hospital
The hospital admissions of residents of care homes in Lambeth, Southwark and Lewisham were audited for the period
October – December 2004. Data were collected at GSTT and KCH for all admissions during this period. Limited comparison
is possible with data collected from a previous period at UHL.
Key findings included:

The number of admissions per month is probably about 50 per hospital, the majority being from care homes with
nursing (nursing rather than residential homes).

In most cases the decision to admit was made by care home staff without involving GPs. The commonest
diagnoses were related to infection, particularly chest and urine.

Care home residents have the same average length of stay as general medical patients

Underlying factors are not well recorded on EPR or discharge summaries. Dementia was recorded in 20% of cases.

Mortality rates of care homes residents in hospital is up to 34%

Readmission rates within 28 days from care homes are comparable with general readmission rates
Implications for future service development include improvement of two-way communication between care homes and
hospital, regular review of residents of care homes, which includes consideration of health care choices and end of life
management planning. The role of the Care Homes Support Team in facilitating this process will be presented.
ABSTRACT (5)
Title: CPR preference of older in-patients: a case control
study
D Mukhopadhyay, F C Martin. Department of Ageing and Health, Guy’s and St Thomas’ NHS
Foundation Trust
ABSTRACT
Method: Fifty consenting in-patients of age > 65 years with Abbreviated Mental Test Score
(AMTS) > 7 were interviewed face-to-face two days pre-discharge from an urban teaching
hospital about their knowledge of, preference to undergo, and estimate of survival from
CPR. Data on their concurrent condition were collected from case records or with
standardised assessment scales: AMTS, Barthel Index (BI), GDS-15, Cumulative Illness
Rating Scale (CIRS), SF-12 Health Survey, Pre Arrest Morbidity (PAM) and Prognosis
After Resuscitation (PAR) scores.
Results: CPR was wanted by 72% of patients. Using logistic regression analyses there was no
significant associations between preference for CPR and age (mean 82 years), gender (52%
women), place of residence (86% from own/rented home), ADL-dependency (median BI 15),
cognitive function (median AMTS 8), mood, general health perception, co-morbidity and
predictive scores for unsuccessful CPR. Patients’ own estimate of survival chance was
significantly associated with their preference for CPR (p<0.001); all 24 patients who offered
an estimate of their survival chance opted for CPR, compared to 12 of 26 (46%) who did not.
Conclusion: Most elderly in-patients surviving to discharge opted for CPR. CPR prognoses
and multi-dimensional assessments did not predict patients’ preferences.
BUSINESS MEETING
MINUTES
Present
Dr Roger Lewis – (Chair)
Dr Aza Abdulla – (Secretary)
Dr Ken Rhodes
Dr Finbar Martin
Dr Methool Patel
Dr David Black
Dr James Dennison
Dr David Smithard
Dr W Fitzpatrick
Dr Jonathon Potter,
Dr S Jones,
Dr R Pathansali,
Dr S Panagiotakis
Apologies
Dr Stewart Bruce
Dr Ian Sturgess
Dr G Batty
Dr Iain Carpenter
Dr Catherine Bryant
Dr Michael Jenkinson
Dr M Kinirons
Dr I Starke
Dr M Bayliss
Dr H Alexander
Dr P Reynolds
Dr Roger Lewis started the meeting by welcoming Dr Panagiogaiks, who was on Clinical
Attachment with Dr Finbarr Martin.
1
Minutes of previous business meeting
The Minutes of the last meeting held on the 17th March 05 at the Princess Royal
University Hospital at Farnborough, Orpington, were approved and signed by Dr
Roger Lewis
2
New members/Appointments/Awards
Two recent appointments were made at Guy’s and St Thomas’s Hospital; Dr
Jugdeep Dhesi appointed with particular interest in POPs surgical liaison work
and Rebekcah Schiff with particular responsibility for IC work in Lambeth.
Dr Adam Harper was appointed at Brighton replacing Dr H O’Neill who moved
to Worthing.
A Personal chair has been awarded to Ian Carpenter (University of Canterbury)
3
4
Matters Arising
(a)
Appointment of Father Figures:
Dr Roger Lewis commented that SE Thames Region was the first Region to
appoint 2 Father Figures and that both Drs Jonathon Potter and Roger Lewis
have been confirmed in this post.
(b)
RCP report on SpR posts:
Roger Lewis fed back on the report received following the College visit
inspecting the SpR posts in the Region. The conclusion was that the report
was complementary in general though there were some concerns mostly
around achieving a balance between General Medicine and Geriatrics. The
assessors have commented that in two particular centres this balance has
notably shifted in favour of General Medicine and that adjustments will have
to be made. There was also a comment that where the SpRs timetable is
particularly busy then the individual SpR need not be present on all consultant
ward rounds.
It was reported that although the quality of teaching was very good, some
topics, such as non medical professional teaching, were not adequately
undertaken. It was also noted that the SpR attendance for the training days
was not always satisfactory mainly because of the new rota and shift system
and at times our training day coinciding with that of GIM.
The College Committee suggested trying to direct SpRs more towards
research. The Committee did comment though that our Region was doing
well in this aspect as there were a number of trainees who had obtained an
MD or PhD.
The Committee also highlighted various areas of good practice in the Region
and commented that the programme was well organised that it was well
organized with a wide availability of sub-specialty training and opportunities
for flexibility for staff; it also remarked on the success of the MSc course
(c)
Training Days/Adjustment to Trainees Curriculum
Roger Lewis commented on the current training curriculum and remarked that
in essence all the sub-specialties are covered each two years. He commented
on the possibility of having additional competencies for subspecialties..
This view has not been supported by many of the trainees who wish to keep
their options open rather than going down the narrow path of subspecialisation within geriatrics medicine as a trainee. Roger Lewis invited
any other views on this subject. Finbarr Martin supported the view of the
trainees and maintained that there may not be adequate time in training period
to cover additional competencies. However, the trainee can use his/her own
academic session to gain increased experience in an area of his/her choice.
(d)
Modernising Medical Careers
Dr David Black, who was congratulated by Roger Lewis on his Professorship,
updated the meeting on the subject of Modernising Medical Careers. He stated the
intention for Trusts creating post CCST training posts which are essentially junior/sub
consultant posts. He also remarked that these posts may be welcomed by some
juniors. Further discussion took place around Modernising Medical Careers, the
future of acute medicine and also General Medicine, and setting “knowledge exams”
for trainees as well as, in the future, consultants. David Black reported that there was
a lot of work that needed to be done in the near future before finalising the best way
to assess compentency and a development tree for trainees/graduates.
4. BGS Regional Administration
Nil to report
5
English Council Nomination
Roger Lewis expressed the Region’s gratitude towards Jonathon Potter’s service
on the Council of England and remarked that we had not received any
nominations for replacement. Dr Mehool Patel from Lewisham was proposed by
Jonathon Potter and after being seconded was voted as replacement representing
the SE Thames Region.
Aza Abdulla and Gwen Battie were formally appointed on the Clinical Practice
and Effectiveness Committee Group on the England Council.
6
Any Other Business
Nil to report.
7
Date and Time of Next Meeting
16th March 06 at Queen Mary’s Hospital, Sidcup.
CME points awarded 5.5