PBL 9 About depression-disclaimer: Information are obtained from various sources

over the internet and are not owned by me.

1) Depression (history and examination) Kai Yang
Questions to ask the patient who may have depression
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Have you been feeling sad, down or blue?

Have you felt depressed or lost interest in things daily for 2 or more weeks in the past?
Have you ever felt like taing your own life? - Risk of self-harm.
Do you find yourself waking up very early in the morning?
Has your appetite been poor recently?
Have you lost weight recently?
How do you feel about the future?
Have you had trouble concentrating on things?
Have you had guilty thoughts?
Have you lost interest in things you usually enjoy?

Characteristic features of depressive illness

Characteristic
Mood
Talk
Energy
Ideas
Cognition
Physical
Behaviour
Hallucinations

Clinical Features
Depressed, irritable, miserable
slow, monotone
Reduced, lack motivation
Guilt, unworthiness, suicidal thoughts
Impaired learning, pseudodementia in elderly patients
Insomnia ( esp early waking), poor appetite, weight loss
Retardation, agitation
Auditory-often hostile

In major depression, as defined by the American Psychiatric Association, fourth edition, patients will manifest a
depressed mood or loss of interest or pleasure in all or most activates most of the day plus at least four of the
following symptoms for a period of at least two weeks:

loss of interest in usual activities

either increase or decrease in appetite and weight
increased or decreased sleep
agitation or retardation
appropriate guilt or worthlessness
diminished concentration
suicidal ideation.

Watch for standard symptoms of depression, as well as these symptoms common among the elderly suffering from
depression:

Complaints of aches and pains (back, stomach, arms, legs, head, chest), fatigue, slowed movements and speech,
loss of appetite, inability to sleep, weight increase or decrease, blurred vision, dizziness, heart racing, anxiety.

Inability to concentrate, remember or think straight (sometimes mistaken for dementia). An overall sadness or
apathy, withdrawn; unable to find pleasure in anything.

Irritability, mood swings or constant complaining; nothing seems to make the person happy.

Talk of worthlessness, not being needed anymore, excessive and unwarranted guilt.

Frequent doctor visits without relief in symptoms; all tests come out negative.

Alcoholism can mask an underlying depression.

How to differentiate pseudodementia and true dementia?

The history of disturbance in pseudodementia is often short and abrupt onset, while dementia is more often insidious.
Clinically, people with pseudodementia differ from those with true dementia when their memory is tested. They will
often answer that they don't know the answer to a question, and their attention and concentration are often intact, and
they may appear upset or distressed. Those with true dementia will often give wrong answers, have poor attention and
concentration, and appear indifferent or unconcerned.

2) Treatment for depression Kabhisha

3) Biopsychosocial for depression -Albert
4) Pathophysiology of Parkinsons Jing Yi
Cardinal signs of Parkinson disease resting tremor, rigidity, bradykinesia, postural instability (balance impairment
late phenomenon)
- predominantly a disorder of basal ganglia
-one of the most common neurologic disorders
- affecting approximately 1% of individuals older than 60 years
Anatomy
The striatum (caudate and putamen)
largest nuclear complex of basal ganglia
receive excitatory input from several areas of cerebral cortex
receive inhibitory and excitatory input from dopaminergic cells of substantia nigra pars compacta
these inputs are received by the spiny projection neurons
there are two types of spiny projection neurons:
those that projects directly to the internal segment of globuspallidus (GPi) major output site
those that projects directly to the external segment of globuspallidus (GPe) - indirect pathway to GPi via
subthalamic nucleus
the actions of direct and indirect pathway regulate the neuronal output from GPi, which provides tonic inhibitory
input to the thalamic nucleithat project to the primary and supplementary motor areas

Pathophysiology
There are 2 major neuropathologic findings in Parkinson disease:

Loss of pigemented dopaminergic neurons of substantia nigra pars

compacta
(most prominently in the ventral lateral SN loss of neurons before the
motor signs emerge)

Presence of Lewy bodies and Lewyneurites

Lewy bodies increases with age, not specific to Parkinson disease,
represent the presymptomatic phase
Dopamine is released from nigrostriatal (substantia nigra pars compacta
[SNpc]) neurons to activate the direct pathway and inhibit the indirect
pathway. In Parkinson disease, decreased striatal dopamine causes
increased inhibitory output from the GPi/SNr via both the direct and indirect
pathways. The increased inhibition of the thalamocortical pathway
suppresses movement. Via the direct pathway, decreased dopamine
stimulation causes decreased inhibition of the GPi/SNr. Via the indirect
pathway, decreased dopamine inhibition causes increased inhibition of the
GPe, resulting in disinhibition of the STN. Increased STN output increases
GPi/SNr inhibitory output to the thalamus.

Initial clinical symptoms of Parkinson disease include the following:

Tremor
Subtle decrease in dexterity
Decreased arm swing on the first-involved side
Soft voice
Decreased facial expression
Sleep disturbances
Rapid eye movement (REM) behavior disorder (a loss of normal atonia during REM sleep)
Decreased sense of smell

Symptoms of autonomic dysfunction (eg, constipation, sweating abnormalities, sexual dysfunction, seborrheic
dermatitis)
A general feeling of weakness, malaise, or lassitude
Depression or anhedonia
Slowness in thinking
Onset of motor signs include the following:
Typically asymmetric
The most common initial finding is a resting tremor in an upper extremity
Over time, patients experience progressive bradykinesia, rigidity, and gait difficulty
Axial posture becomes progressively flexed and strides become shorter
Postural instability (balance impairment) is a late phenomenon

5) Parkinsons (history and examination)- Ying Yi

History
Particular things to look out for:
General lethargy and tiredness
Problems using tools
*General problems with dexterity
*Freezing often whilst walking the patient may suddenly stop. This is particularly apparent at times when
hesitation is normal, e.g. when turning, or when going through a doorway
Difficulty rolling over in bed
*Ask them about their handwriting - Typically it becomes smaller, and more spidery. You may want to ask them
to write their name and address to show you their writing.
*Anosmia start by asking if they have noticed any changes in their sense of smell.
Violent dreams patients with PD may act out their dreams whilst laid in bed particularly violent ones. This
may involve arm swinging and legs kicking. Often their partner will sleep in a different bed
Visual hallucinations usually these are not distressing, and many patients find them intriguing. For example,
may involve seeing animals walking around the room, or seeing a hat stand, and thinking it is a person.
*Also being checked during examination.
Examination
General inspection
Masklike face
Speech monotonous and hypophonic (reduced volume)
Anosmia - only recently recognized as a feature. Ask basic questions e.g. can smell when cooking?
Posture and gait

Posture and Gait

Parkinsons is often a spot diagnosis you may be
able to give a Dx just by seeing a Pt walking into the
room
Stooped posture
Difficulty to initiate walking
Reduced length of steps
Slow shuffling gait
Accelerated gait
May stop abruptly
Turning may be difficult and slow
Reduced arm swing; often associated with tremors
http://www.youtube.com/watch?v=j86omOwx0Hk

Rombergs test
Ask patient to stand unaided with their eyes closed.
If the patient sways or loses balance then this test is
positive.
Stand near the patient in case they fall.

Pull test
To perform this test correctly, should not tell
the patient what you are going to do, but this
might be dangerous.
Ask the patient to stand, at ease.
Stand behind the patient, and put your hand
on his shoulder.
Then quickly and firmly, pull back on the
shoulder.
In normal individuals, they might take 1 or 2
steps backwards to stop themselves falling.
In PD, it may take 4-5 steps before they come
to rest again righting reflex

Resting tremor
Check for a resting tremor in the hands by placing a piece of paper on the patients outstretched hands.
Look specifically for pill-rolling tremor http://www.youtube.com/watch?v=0-t4RTQ0EsM
Tone

Test tone in shoulder, elbow, wrist.

Increased tone
Rigidity characteristic features in PD
Occurs due to increased tone in both protagonists and antagonist muscles.
Mainly large proximal group of muscles of limbs e.g. biceps and knee flexors are affected.
Lead-pipe rigidity occurs uniform resistance to flexion giving a feeling as if lead pipe is being bent
Cogwheel rigidity a series of catches during passive motion of the limbs
Due to rigidity, posture becomes that of flexion attitude in which: back is flexed, arms are abducted and
flexed and the knees are bent
**NB: rigidity differs from spasticity seen in lesions of pyramidal tracts.
Why rigidity occurs? In Pt with PD, lack of dopaminergic activity due to degeneration of neurons in
substantia nigra shifts the balance towards excitatory cholinergic fibers as a result, hyperkinetic
features of PD appear
http://www.medclip.com/index.php?page=videos&section=view&vid_id=108737

Check dexterity
Another good test to elicit PD.
Ask the patient to oppose their thumb and forefinger.
Ask them to repeat this action, perhaps for up to 1 minute.
As the patient repeats the action, it may become more and more difficult, and the size of the movement
becomes gradually reducing.
You may repeat the test, recruiting each finger in turn.

Check handwriting
Particularly useful if you have previous examples of the handwriting, but you can also ask the patient if
they think their handwiritng has changed.
It is likely to become smaller, and more spidery.

Coordination
Test for dysdiadochokinesis
Show Pt how to clap by alternating the palmar and dorsal surfaces of hand.
Ask them to do this as fast as possible.
Repeat the test with the other hand.

Finger-to-nose test
Place your index finer about 2 feet from the Pt face.
Ask them to touch the tip of the nose with their index finger then tip of your finger.
Ask them to do this as fast as possible while you slowly move your finger.

 Repeat the test with the other hand.

Heel-to-shin test
Have the Pt lying down for this and get them to run the heel of one foot down the shin of the other leg.
And then bring the heel back up to the knee and start again.
Repeat the test with other leg.

Thank Pt. Wash hands.

Cerebellar examination for PD WHY?
Increasing evidence suggests that cerebellum may have certain roles in pathophysiology of PD.
Functional or morphological modulations in cerebellum were detected related to akinesia or rigidity, tremor,
gait disturbance, dyskinesia and some non-motor symptoms.
Pathological changes in the cerebellum might be induced by dopaminergic degeneration, abnormal drives from
the basal ganglia and dopaminergic treatment, and may account for some clinical symptoms in Parkinson's
disease.
Investigations
No laboratory biomarkers exist for the condition.
Findings on routine magnetic resonance imaging (MRI) and computed tomography (CT) scan are unremarkable.
No laboratory or imaging study is required in patients with a typical presentation.
Diagnostic testing may be indicated to exclude other disorders in DDx.
E.g. Pt who do not have tremor should generally be considered for MRI evaluation to exclude brain
lesions e.g. stroke, tumor, demyelination.
http://www.osceskills.com/e-learning/subjects/cerebellar-examination/
http://almostadoctor.co.uk/content/osces/examinations/neurology-exams/focussed-exam-parkinsons-disease
**Difference between spasticity and rigidity
Features
Spasticity
Rigidity
Lesion
Occurs in pyramidal tract lesions, commonest
Occurs in basal ganglia lesion, therefore, called
site being internal capsule
the extrapyramidal rigidity.
Muscles involved

One group of muscles either agonist or

antagonist (usually antigravity muscles) are
involved

Both agonist and antagonist muscles are

involved producing a uniform hypertonia often
resulting in general attitude of flexion of the
limbs and trunk.

Characteristics of
hypertonia

Clasp-knife type of hypertonia is seen in muscles

involved i.e. on passive flexion initially there is
marked resistance but then there is sudden
completion of movement without much
resistance (similar to closure of a pocket knife)

Usually there occurs a uniform resistance to

flexion giving a feeling as if lead pipe is bent
(lead-pipe) or sometimes there is a series of
catches during passive motion of the limb
(cogwheel rigidity).

Relation of
hypertonia to
stretch

Spasticity is stretch sensitive i.e. degree of

hypertonia developed during any passive stretch
is proportional to the speed of stretch applied.

Rigidity is not stretch sensitive.

http://books.google.com.my/books?id=M6vviWpZ0LsC&pg=PA963&lpg=PA963&dq=lead+pipe+rigidity+Parkinson+and+
cogwheel+rigidity+clasp+knife+rigidity&source=bl&ots=IqekWf4EfT&sig=387UQ2Ot-

cGXfnBDpeWJORt5YVg&hl=en&sa=X&ei=1so3VLrnMIyHuATUgoGwBw&ved=0CD0Q6AEwBQ#v=onepage&q=lead%20pip
e%20rigidity%20Parkinson%20and%20cogwheel%20rigidity%20clasp%20knife%20rigidity&f=false

6) Treatment for Parkinsons Thishak

7) Macular degeneration treatment Bianca
8) Causes of frequent falls En Yin

Aging related changes-poor eyesight and hearing

Other vision problems-poor depth perception, cataracts, glaucoma and macular degeneration
Sensory problems- less aware of environment, e.g. numbness in feet
Labyrinthistis-affect balance
Muscle weakness, especially in the legs-strength, flexibility and endurance
Balance and gait-poor balance or difficulty walking (arthritis)
Postural hypotension-Parkinsons Dx, dehydration, medications (for hypertension-diuretics, beta
blockers, CCB and ACE-i)
Slower reflexes- increased amount of time to react when fall
Foot problems-painful feet, unsafe footwear (slippers, high-heeled shoes, shoes with smooth leather
soles)
Medications (side effects like dizziness or confusion)- antidepressants
Environment-loose rugs, poorly lit stairway, not having stair railings, not having grab bars in the
bathroom, wet floors
Reference: http://nihseniorhealth.gov/falls/causesandriskfactors/01.html

9) Management polypharmacy Su Yi
Introduction

Polypharmacy: the concurrent use of multiple medication items by one individual

The term has been used both positively and negatively. In the past polypharmacy has been considered something
to be avoided. It is now accepted that in many circumstances polypharmacy can be therapeutically beneficial.
In this report Polypharmacy and Medicines Optimisation, it proposed the terms appropriate polypharmacy and
problematic polypharmacy. This recognises that polypharmacy has the potential to be beneficial for some
patients, but also harmful if poorly managed.
Appropriate polypharmacy is defined as prescribing for an individual for complex conditions or for multiple
conditions in circumstances where medicines use has been optimised and where the medicines are prescribed
according to best evidence
Problematic polypharmacy is defined as the prescribing of multiple medications inappropriately, or where the
intended benefit of the medication is not realised.
Polypharmacy may be harmful in that it can increase the risk of drug interactions and adverse drug reactions,
together with impairing medication adherence and quality of life for patients.
On the other hand, employing many appropriate treatments can theoretically improve outcomes for patients,
especially given that there is an increasing evidence base for many drug interventions. However, the evidence base
for multiple interventions for several conditions in an individual patient is poor.
Polypharmacy is widespread and increasingly common, occurring in primary and secondary care, and in care
homes for older people. It has become a global issue, particularly, although not exclusively, in Western countries.

It is driven by the growth of an ageing (and increasingly frail) population and by the increasing prevalence of multimorbidity (where patients may be living with several long-term conditions, often compounded by disability and/or
frailty).

Challenges in Polypharmacy

Compliance:
o No medication regimen has any hope of being effective if the medications themselves are not actually
ingested. It is not sufficient that a certain combination of medications is effective.
o It is just as important that it is possible for the patient to take the medications as prescribed. Combinations
that are so complicated that the patient cannot keep track of them will not treat patients' symptoms
regardless of how wonderful the medications may work individually or together.
o Patients, for the most part, have a complicated psychological relationship with their medications. If
patients feel intellectually defeated by the medications that have been prescribed -- that is, if they do not
feel smart enough to manage the medications as prescribed, then they will disengage from treatment and
not take some or all of their medication
o Sometimes if a patient doesnt have their glucose controlled they are given yet another drug when it may
be because they are actually prescribed too many drugs and are not taking them properly. Its important to
extract from a patient how much of a burden it is taking the drugs
o There is a simple way to maximize compliance with a multiple medication regimen. Patients struggle with
multiple doses, not multiple medications. It is relatively easy to keep track of a bunch of different pills if
you can take them all at the same time. It is also important for the psychopharmacologist to make sure
that the patient's schedule and routine are relatively easy to understand and follow, and that means
limiting the number of doses much more than it means limiting the number of medications.
Cost
o In this day and age where medical decision making is often influenced and sometimes determined by
financial considerations, it is common for practitioners to become frustrated and often resentful when cost
becomes an issue in determining the appropriate treatment for a patient.
o In spite of this, however, cost must be considered as an issue for determining the treatment plan. Once
again, if the cost of a particular combination of medications makes it impossible for patients to get the
medications, they will not take them, and as such the medication regimen will be ineffective. Even the
most generous insurance plans have limitations or copays on medications. It is important when
considering polypharmacy to consider the financial impact at least on the patient, if not on the healthcare
system as a whole. The more medications prescribed, the higher the cost, and the more complications are
created as a result.
Side effects
o In an ideal world, we would start each medication 1 at a time, determine the side effects of each
medication as it is initiated, and then be able to say with some certainty what side effects were caused by
which medication.
o Unfortunately, in the real world, often acutely ill patients and time constraints preclude being able to
leisurely begin polypharmacy. Too often, we start more than 1 medication at once and then we are left
with the task of trying to figure out how to deal with side effects that may come from multiple medications
or multiple combinations of medications.
o The complex diagnosis and management of side effects from multiple medications present 2 different sets
of problems: short-term and long-term side effects.
o The crucial issue is to make sure that your patient is telling you all of the medications he or she is taking,
not just the ones that are prescribed by you or even just the ones that are prescribed, because many
patients are taking over-the-counter and health food store preparations. If attention is paid to these
factors, drug interactions are an easily managed issue.

Evidence-based treatment and guidelines

Where there is no evidence of benefit from the drugs being prescribed, polypharmacy should be avoided.
The evidence for choosing treatment where there is polypharmacy should ideally be clearly stated. Prescribers
should record the rationale for non-evidence-based prescriptions, for example, through patient choice.

Implications for clinical practice

Prescribers may not recognise that symptoms could be iatrogenic and unwittingly prescribe new medication to
counter the adverse effects of other drugs. This is known as incremental prescribing or the prescribing cascade
and should be avoided.
Prescribers should consider whether interactions between drugs where medication is combined will undermine
therapeutic benefit.
Many people stay on medicines beyond the point where they are deriving optimal benefit from an intervention.
When reviewing medications, health care professionals should consider if treatment can be stopped and recognise
that end-of-life considerations apply to many chronic diseases as well as cancer-related conditions
People often do not take medicines in the way that prescribers intend and there is considerable evidence that
many dispensed medicines remain unused or are wasted.
These problems increase as drug regimens become more complex.
The patient perspective on medicine-taking needs to be determined. Compromise may be needed between the
view of the prescriber and the patients informed choice.

Patient involvement

Patient involvement in decisions on drug use is fundamental in prescribing and particularly in polypharmacy.
Patients may not want to take multiple medicines, or prefer one treatment over another. Advice should be given
on which interventions may be most likely to minimise side effects, reduce symptoms and improve outcomes.

Pharmacokinetics

Absorption of Oral Medications

The aging process can reduce GI motility and GI blood flow.

Gastric acid secretion is reduced in older adults and this can result in an elevation in gastric pH.
Increased gastric pH and reduced gastric blood flow may cause reduced drug absorption
Reduced GI motility may result in more of the drug(s) being absorbed.
Age-related absorptive changes can alter significantly a drug's absorption as well as its onset of action.
The absorption of drugs that undergo first-pass metabolism also may be increased in older people. This action is
seen with nitrates and the lipophilic [beta]-adrenergic blockers (eg, propranolol).
The net effect of these changes is difficult to predict and may vary depending on the nature of the drug being
prescribed. Age-related changes affecting drug absorption are, by themselves, generally considered minimal, but
elderly patients are at high risk for developing other problems that can affect absorption. These problems, which
are common in older adults, include swallowing difficulties, poor nutrition, and dependence on feeding tubes.

Distribution

As the body ages, muscle mass declines and the proportion of body fat increases; therefore, drugs that are fat
soluble will, in general, have a greater volume of distribution in an older person compared with a young person,
but for drugs distributed in muscle tissue, the volume of distribution may be reduced. This effect is observed

with diazepam, which is highly fat soluble, and this may necessitate dosing changes until the desired effect is
observed.
The aging process also is associated with a theoretical reduction in total body water, which can affect the
volume of distribution of water-soluble drugs. Older adults in general produce less albumin, which binds drugs in
the bloodstream. Reduction in protein binding can result in an increase in free drug concentration. As the free
drug concentration increases (compared with bound drug), more drug becomes available to reach receptors,
thus increasing the pharmacologic effect in an elderly individual.
All of these effects taken together can greatly influence how a drug is distributed, and this ultimately determines
the dose that is necessary to produce a desired pharmacologic effect or unwanted adverse effects. If the
distribution volume of a drug is reduced in an elderly patient, then the loading dose that is necessary to achieve
a desired concentration is reduced and the half-life of the drug (the time it takes for the blood concentration to
decline by 50%) may be altered. Failure to take these changes into consideration can result in drug toxicity.
Changes in the half-life of a particular drug also will determine the specific dosing regimen for a patient. If a
drug's distribution volume is increased, then the opposite effects occur.
Consideration of how a drug's volume of distribution may be altered in an elderly patient is an important
component that helps determine the proper drug dose for an individual. Drugs that have undergone sufficient
study in elderly patients to determine how the volume of distribution will change because of aging can be dosed
more precisely in this population. For drugs lacking such information, the dose should be reduced and titrated to
a specific effect.

Possible Drug Interactions

1. Many elderly patients are prescribed:
a. Warfarin concurrently with a nonsteroidal anti-inflammatory drug (NSAID), a selective serotonin
reuptake inhibitor, or a lipid-lowering agent. This combination may increase the risk of bleeding (already
increased by use of warfarin alone). But be aware that although elderly patients are at increased risk for
ADRs, experts don't know what roles normal aging, comorbidities, and polypharmacy play in ADR
incidence
2. Pharmacodynamic interaction: What drug does to the body.
a. Pt take over the counter acetylsalicylic acid (ASA) for his rheumatism that increases bleeding time. He
also take Ginkgo biloba for his memory. He develops atrial fibrillation and is prescribed warfarin by his
cardiologist. In this case, ASA blocks platelets and warfarin affects clotting factors. Both increase risk of
bleeding hence interaction is bleeding. Ginkgo biloba at high doses also increases bleeding
3. Pharmacokinetic interaction: What body does to drug
a. Many elderly PTs take bisphosphonates for OP
b. They also take calcium supplements. Calcium binds onto bisphosphonates and thereby reduces the
absorption of bisphosphonates.
c. As a result, PT does not get full benefit of their bisphosphonate treatment.
4. Cytochrome P450
a. St Johns Wort induces CYP 3A4 through which some CCB are metabolized. The addition of St Johns
Wort speeds up metabolism of such CCBs. Hence BP control of CCBs may be adversely affected.
b. Drugs metabolized the same enzyme may compete. Warfarin is an example. Any other drug that goes
through the same pathway will displace warfarin and the warfarin will not be processed, resulting in
higher levels of warfarin and associated side effects.

References
http://www.stacommunications.com/customcomm/Back-issue_pages/AD_Review/adPDFs/september2003/10.pdf
Medscape
http://www.medscape.com/viewarticle/758855_4

10)

Ethical and legal, clinical decision making Kean Heng

PRINICPLES OF WITHDRAWAL OR WITHHOLDING LIFE SUPPORT

The principles of withholding or withdrawal of life-support should be based on the six basic principles of medical ethics.
These are:
1. Preservation of life which is frequently tempered by the second principle.
2. Relief of suffering - This covers distressing symptoms such as pain, distress caused by anxiety

etc.
3. First do no harm- Non maleficence
4. Respect the autonomy of patients - Patients have the right to inform choices in treatment and

have the right to refuse or accept a given mode of treatment.

5. Concept of a just allocation of medical resources - This is a concept that it must be good for

the majority in society. Allocation of scarce and expensive resources for potentially nonsalvageable patients limits the amount that can be utilised on potential survivors. Allocating scarce
and expensive resources like intensive care for potentially non-salvageable patients limits the
amount that can be spent on potential survivors. Increasing medical costs also make some form of
rationing inevitable. Intensive care is extremely expensive and economic considerations form part
of the consideration in ethical discussion regarding intensive care management.
6. To be truthful to the patients and family or surrogates as to the prognosis of their loved ones.

CATEGORIES OF PATIENTS TO BE CONSIDERED FOR WITHDRAWAL OR WITHHOLDING OF LIFE

SUPPORT
1.

A patient with imminent death

A patient with acute illness which is unlikely to cure and will certainly lead to death within hours or days,
without a period of intervening improvement. This is a patient who is clearly not responding to therapy, and is
reasonably unlikely to survive with continued therapy. Futility will be determined by prolonged multiple organ
system failure. Further intensive care management with four or more organ systems failure for over 3 days is
futile as shown.
2.

A patient with terminal condition

A patient with a terminal condition has a progressive, unrelenting terminal disease incompatible with survival
longer than 3 - 6 months. Life support treatment should be provided to treat superimposed, reversible condition
only with clear and achievable goals in mind. Cardiopulmonary resuscitation should not be instituted in a patient
with terminal, irreversible illness whose death is expected and in whom resuscitation represents a violation of
the right to die with dignity.

3. A patient with severe and irreversible condition impairing cognition and consciousness

but
death
may
not
occur
for
many
months
This category includes patients with persistent vegetative state or severe dementia. In many of
these cases who are nursed in wards, the decision is often not to initiate CPR or other resuscitative

measures in the event of a downturn in the patients condition. Although these patients are not
recipients of intensive care the treatment decision by caregivers should include one not to initiate
resuscitation i.e. Do not resuscitate or DNR orders.
4. A competent patient who has stated his/her wish not to initiate or who has stated

his/her
wish
to
have
life
support
withdrawn
This will include patients who when competent have given clear wishes before the present episode
of illness or those who have given do not rescustitateorders (DNR). The principle of patient
autonomy requires that physicians respect the decision to forego life-sustaining treatment of a
patient who possesses decision-making capacity. The medical team however has to be very certain
that this is indeed the case and in the case of doubt should disregard previous wishes.
5.

A patient who is brain dead

Brain death as death is now recognised as death in many countries including Malaysia and it is perfectly
legitimate and legal to withdraw all forms of life support from such patients once a diagnosis is made. Life
support is only continued in the event where consent for organ procurement is needed.
OTHER DECISION MAKING AIDS IN WITHDRAWAL OR WITHHOLDING
Scoring systems

Recently various scoring systems have gained increasing importance as decision making aids. Among the multitude of
predictors available the best known is perhaps the APACHE (Acute Physiological and Chronic Health Evaluation) which is
now available in version III. There are also others such as SAPS (Severe acute Physiological Score), TISS (to indicate the
number of interventions), Trauma scores and many more. Regardless of the accuracy of these predictors of outcome
these can only aid in decision making. They should not replace conscientious medical decision making taking other
factors into account.

MANAGEMENT PLAN FOR WITHDRAWAL OF LIFE SUPPORT

While the medical team puts its plan for withdrawal into operation the exact mechanics of this need not be told to the
family or patient. It is however important to emphasise that the patient will be comfortable and will not be in distress or
pain etc during the process. There should be great sensitivity to cultural norms and dignity to the dying patient. There
should be five main objectives for ensuring a good end of life care;
a.
b.
c.
d.
e.

Receiving adequate pain relief and relief of any other distressing symptom such as dyspnea
Avoidance of prolongation of dying
Active sense of control over events
Strengthen relationship among loved ones
Relief of burdenamongst caregivers and the loved one

DISCONTINUATION OF MECHANICAL VENTILATION

Withdrawal of mechanical ventilation is probably viewed as more problematic than withdrawal of other
interventions. Discontinuing mechanical ventilation does not differ morally from forgoing dialysis or
cardiopulmonary resuscitation. There are two strategies for the withdrawal of mechanical ventilation
1. Terminal weaning i.e. gradually reducing the ventilator rate, positive end-expiratory pressure,

oxygen levels or tidal volume while leaving the endotracheal tube in place
2. Extubation after appropriate suctioning

There is no significant difference in patient comfort between the two methods. However, the endotracheal tube should
generally be left in place while ventilatory support is reduced for the patients with difficulty in clearing their secretions
or protecting their airways. Regardless of the method, frequent assessment of the patients comfort during and after

withdrawal of the ventilator is most important. Intravenous opioids and benzodiazepines should be used liberally to
relief dyspnoea and other discomfort.
The alarms on the monitors should be disabled. The family should be allowed to be with the patient if they choose to.
The physician should be present to ensure the patients and familys comfort during withdrawal of mechanical
ventilation.

MEDICO-LEGAL IMPLICATIONS
Withdrawal of life support is lawful at the patients request at common law and in a few countries by legal statute. It is
more common to withdraw life support because the therapy is perceived to be of little benefit or not in the patients
best interests or the therapy is futile. In Malaysia, there is very little case law and no legislation to direct the decision
of whether to withdraw life sustaining therapy on grounds of futility or the patients best interests although these are
available in the UK and in the US. The decision to withdraw therapy, usually places responsibility on the
doctor/doctors in charge of the patient. Much weight is, however, placed on the wishes of the family or legal guardians.
Clinical decision making

Clinical decision making is the process by which we determine who needs what, when. While not exactly arbitrary, this
exercise can be quite subjective. Each clinician compiles their own data (hence the emphasis on learning to perform an
accurate H&P) and then constructs an argument for a particular disease state based on their interpretation of the
"facts."
STEPS IN DECISION MAKING TO WITHDRAW OR WITHHOLD LIFE SUPPORT
1. Medical consensus - It is essential that the primary physician and the intensive care team have

agreed on a consensus before any decision is taken. In certain cases more than one primary team
may be involved and it is essential to have the consensus of all the caregivers. In the event of
absence of medical consensus, active treatment is continued. A further time period of active
treatment is set and subsequent review of management plan. The primary physician in our context
refers to the specialist or consultant under whose department the patient is admitted.
2. Nursing consensuses - Nurses play a key role in intensive care and are in continuous contact with

patients and relatives. They sense of sympathy for the patient is often stronger and it is essential
that they also are in support of the decision to withhold or withdraw therapy.
3. Communication - In the unfortunately rare event that the patient is fully rational, awake and

competent the communication should be with the patient. More often in the intensive care setting
the discussion is with the relatives. A clear and honest medical opinion should always be given the
family. To avoid any seeming conflict of opinion, it is best that a single resource person deal with
the family, while the others can be present. The physician orchestrating discussion with either the
family or patient must be someone who is involved in the active care of the patient. This key
person must be someone who has been frequently communicating with the family and has a
rapport with them. This task should be done by a senior medical staff and should never be left to
the most junior doctor in the unit.
4. The family should be given time to come to terms with the impending loss of the their loved ones.

They should be allowed to ventilate their feelings and be as often as possible with the patient.
5. Time limited goals should be established by the clinical team and this must be based on clinical

judgement and best medical evidence. Families will usually agree to discontinuation of life support
systems after a reasonable trial of therapy has demonstrated failure. In the event of disagreement
between the physician and the patient or family, the assistance of an individual consultant and a
patient representative is often helpful to reach resolution amongst all parties. An institutional
committee such as an ethics committee may be involved if disagreements are not resolvable.

6. In dealing with the family they should not be rushed as the mental shift from hope and cure to

accepting the inevitable will not occur quickly. All explanations should be kept as simple as possible
(in a manner easily understood by lay persons). Facilities for discussion such as a private
counselling room must be made available and the designated staff should help them with any
clarifications if needed. If cadaveric organ donation is being planned these discussions should also
be approached with great degree of sensitivity.
7. Decisions must not be conflict with the laws of the country. Although active termination of life i.e

euthanasia or assisted suicide may be acceptable legally in some countries it is unlawful here.

Resource
http://www.msa.net.my/newsmaster.cfm?&menuid=21&action=view&retrieveid=23#ConsensusOnWithdrawalAndWith
holdingOfLifeSupportIntheCriticallyIll

Depression in elderly
Older individuals do not present with the typical symptoms of depression, such as depressed mood or sadness.
They may, however, respond to focused questions about whether or not they feel depressed. Once identified,
depression is often not treated due to concerns about drug side effects associated with antidepressants and
polypharmacy and beliefs that psychotherapy and other nonpharmacological interventions will not be effective for
older individuals.
The prevalence of major depression among older adults actually decreases with age, with this rate being
approximately 5% to 10% of older person living in the community and presenting to primary care practices have
diagnosable depression. Although an additional 2% of older individuals experience dysthymia (a chronic depressive
disorder characterized by functional impairment and at least 2 years of depressive symptoms), this disorder also
decreases with age.

Physical appearance of a depressed elderly

The physical appearance of older patients suspected of being depressed should be interpreted cautiously. Normal
age changes such as pale, thin, wrinkled skin; loss of teeth; kyphosis; and a wide-based slow gait, alone or in
addition to the presence of diseases such as anemia or Parkinson disease, may make the older individual look
depressed. Parkinson disease, which manifests by masked facies, bradykinesia, and stooped posture, can be
misinterpreted as depression. Patients with sensory changes resulting in impaired vision and hearing may appear
withdrawn and disinterested simply because they cannot see or hear you or others and, therefore, withdraw from
social interactions. The psychomotor retardation of hypothyroidism may offer the physical appearance of depression.
Systemic illnesses such as malignancy, dehydration, malnutrition, or chronic obstructive pulmonary disease can
produce a depressed appearance with a flat affect or decreased energy. It is possible that the older individual will
present with both medical problems and associated depression. In this scenario, it is critical that the medical
management be optimized for each of the underlying problems and the depression treated so that quality of life and
symptom management of the medical problems are optimized.

Table 77. Some Differences in the Presentation of Depression in the Older Population, as Compared with
the Younger Population
1.
2.
3.
4.
5.
6.

Somatic complaints, rather than psychological symptoms, often predominate in the clinical picture.
Older patients often deny having a dysphoric mood.
Apathy and withdrawal are common.
Feelings of guilt are less common.
Loss of self-esteem is prominent.
Inability to concentrate with resultant impairment of memory and other cognitive functions is common

Factors Predisposing Older People to Depression

Biological
Family history (genetic predisposition)

Prior episode(s) of depression

Aging changes in neurotransmission
Physical
Specific diseases
Chronic medical conditions (especially with pain or loss of function)
Exposure to drugs
Sensory deprivation (loss of vision or hearing)
Loss of physical function
Psychological
Unresolved conflicts (eg, anger, guilt)
Memory loss and dementia
Personality disorders
Social
Losses of family and friends (bereavement)
Isolation
Loss of job
Loss of income

Management of depression in the elderly

Citalopram, escitalopram, and sertraline are the safest with regard to drugdrug interactions and impact on the
cytochrome P450 enzymes. Although SSRIs are generally free of severe side effects, a small proportion of elderly
patients develop hyponatremia because of the syndrome of inappropriate antidiuretic hormone secretion, and some
experience anxiety, sleep disturbance, or agitation. Sexual side effects and weight gain or loss occur commonly with
all SSRIs and may be a reason for poor treatment adherence. (Westerners)
Serotonin syndrome is a potentially life-threatening adverse reaction to use of SSRIs. Symptoms include mental
status changes, agitation, myoclonus, hyperreflexia, tachycardia, sweating, shivering, tremor, diarrhea, lack of
coordination, fever, and even death. The risk of serotonin syndrome is increased in individuals with deficits in
peripheral 5-hydroxytryptamine (5-HT) metabolism from cardiovascular, liver, or pulmonary diseases; with tobacco
use; or when SSRIs are used with nefazodone, venlafaxine, mirtazapine, and MAOIs, TCAs, SSRIs, meperidine,
opioids, St. John's wort, or tramadol.

Table 714. Characteristics of Selected Antidepressants for Geriatric Patients

Drug*

Recommended starting daily dosage

Daily dosage range

Level of sedation

Elimination h

Selective serotonin reuptake inhibitors

Citalopram (Celexa)

10-20 mg

20-30 mg

Very low

Very long

Escitalopram (Lexapro)

10 mg

10 mg

Very low

Very long

Fluoxetine (Prozac)

5-10 mg

20-60 mg

Very low

Very long

Paroxetine (Paxil)

10 mg

10-50 mg

Very low

Long

Sertraline (Zoloft)

25 mg

50-200 mg

Very low

Very long

25 mg

75-225 mg

Very low

Intermediate

10-30 mg

25-150 mg

Mild

Long

Bupropion (Wellbutrin)

50-100 mg

150-450 mg

Mild

Intermediate

Mirtazapine (Remeron)

15 mg

15-45 mg

Mild

Long

Nefazodone (Serzone)

100 mg

200-400 mg

Mild

Short

Trazodone (Desyrel)

25-50 mg

75-400 mg

Moderatehigh

Short

Serotoninnorepinephrine reuptake blockers

Venlafaxine (Effexor)

Tricyclic antidepressants
Nortriptyline (Pamelor, others)
Other agents

*Other less commonly used antidepressants are discussed in the text.

Short = <8 h; intermediate = 8-20 h; long = 20-30 h; very long = >30 h. Half-lives may vary in older patients, and some drugs
have active metabolites.

See text for drug interactions.

See text for anticholinergic side effects.