30 June 2017

Clinical pearl: Should you initiate medicines for primary prevention in

those with limited life expectancy?
Medicines for frail, elderly patients generally exhibit a worse benefit-risk ratio than in younger
people. Adverse effects increase, and estimates of benefit often rely on clinical trials that exclude
elderly patients with multiple conditions. Prescription of potentially inappropriate medications for
older patients costs the Pharmaceutical Benefit Schedule (PBS) $250450 million annually.

Medicines aimed at preventing a condition or event may not be consistent with a patients life
expectancy and their goals of care particularly medicines where the typical benefit is only seen
after some time on continuous treatment.

Proactive deprescribing of medicines that no longer provide enough benefit to patients is integral to
end-of-life care and advance care planning. Patients or their carers should be involved in the decision
to review the ongoing need for each medicine.

Visit the Choosing Wisely Australia website for evidence supporting this recommendation.

23 June 2017
Clinical pearl: How can GPs use e-mental health as part of a stepped care
model?
A GP Mental Health Treatment Plan (GPMHTP) can be used to recommend that a patient engage in
an online psychological (e-mental health) intervention. In this way, the GPMHTP is an important tool
in a stepped care approach, where patients with a mild to moderate mental illness are commenced
on a low-intensity treatment like e-mental health and step up to a higher intensity treatment if
needed.

The RACGP is running two free webinars on Tuesday 27 June at 1.00 pm (AEST) and Wednesday 28
June at 7.00 pm (AEST) to assist GPs find out more about how e-mental health can be used in general
practice as part of a stepped care model. Register your interest to attend on the RACGP website.

Visit the RACGP website for more information on e-mental health or to download a GP Mental
Health Treatment Plan template.

16 June 2017

Clinical Pearl: Bowel cancer awareness

Many patients who are at high risk of bowel cancer are unaware of their risk. A strong family history
is an important predictor of being at high risk of bowel cancer.

GPs can ask their patients to complete the family history screening questionnaire (FHSQ) to help
identify who those who may require a more detailed assessment. It will also prompt patients to think
and learn more about their family history.

A patient who has a positive response to any question of the FHSQ will require follow-up with a more
detailed assessment of their family history. This includes determining the number of relatives
affected by colorectal cancer (CRC), their age at diagnosis and the side of the family affected. You
should also ask about the prevalence of other cancers within the family which may be associated
with Lynch syndrome. One method GPs may find useful to remember cancers associated with Lynch
syndrome is to use the acronym BOUGE:

B - brain

O - ovarian

U - urothelial

G - gastric

E - endometrial

Visit the RACGP Red Book for more information on identifying patients with increased risk of CRC or
to download the FHSQ.

9 June 2017

Clinical Pearl: Mens Health Week

Mens Health Week (MondaySunday 1218 June) is a reminder of the important role GPs play in
addressing the specific physical and emotional health needs of men.

Men see GPs less frequently than women and are less likely than women to discuss their health
problems. Such reluctance can benefit by adopting an opportunistic approach to treatment. When a
patient presents for a routine consultation, such as a certificate for work, build in a preventive activity
to engage them around risk factors such as diet, physical activity and weight gain.

Health checks in middle age are a crucial intervention point to reduce chronic illness later in life. A
significant issue that can occur in men in middle age is weight gain, a risk factor for cardiovascular
disease, diabetes and stroke. When it comes to weight gain, men may focus on action-oriented
solutions of physical activity, while diet, a key contribution to optimum health, is far less likely to
receive their attention.

The RACGPs Guidelines for preventive activities in general practice (the Red book) book includes
recommendations on preventive activities in middle age.

Read the June edition of Good Practice to find out more about tackling mens health.

2 June 2017

Clinical Pearl: Screening for chronic kidney disease

Aboriginal and Torres Strait Islander people have a significantly increased prevalence of chronic
kidney disease (CKD)1 and are approximately 10 times more likely than non-Indigenous Australians to
develop end-stage kidney failure2. Rates of CKD correlate strongly with socioeconomic
disadvantage 3. Screening requires clinical staff members to identify their Aboriginal and Torres Strait
Islander patients.
Evidence supports screening Aboriginal and Torres Strait Islander adults aged 1829 for CKD risk
factors (overweight or obesity, diabetes, elevated blood pressure, smoking, family history of kidney
disease) as part of an annual health assessment.

Once detected, interventions for CKD should address the determinants of behavioural risk factors
that arise from social disadvantage. Patients should be assisted to quit smoking, reduce excess
weight, take part in regular exercise and limit dietary sodium intake.

For more information, visit the RACGPs National guide to a preventative assessment for Aboriginal
and Torres Strait Islander people (2nd edition)*.

*The third edition of the National Guide to a preventative assessment for Aboriginal and Torres Strait
Islander people will be released in early 2018.

26 May 2017

Clinical Pearl: Prostate cancer therapy significantly increases fracture risk

Recently published osteoporosis guidelines recognise the increasing problem of fragility fracture in
men on androgen deprivation therapy (ADT). Large studies have shown that ADT increases fracture
risk by 3060% relative to untreated men of the same age.

Low bone-mineral density (BMD) is a common but under-recognised problem in men, even prior to
commencement of ADT.

A study of Australian men commencing ADT showed that, at baseline, 11 % had osteoporosis and
40% osteopenia, and 60% of the men with osteoporosis were unaware of the poor state of their bone
health.

The new guideline recommends that BMD is measured by dual-energy X-ray absorptiometry scan in
all men at the commencement of ADT. Antiresorptive therapy is recommended for men with a T-
score below -2.5, and is strongly recommended for men on ADT who have a history of fragility
fracture.

Visit the RACGP website to read the osteoporosis guideline.

19 May 2017

Clinical Pearl: Egg allergy prevention

Allergy to hens eggs is the second most common food allergy in infants and children. Studies have
shown that the introduction of egg to the diet of infants aged 46 months of age reduces the risk of
egg allergy compared with children who started egg later in life.

Before introducing egg, infants should be able to tolerate some solid foods (eg cereals, fruits and
vegetables). Infants should be given a taste of egg with an oral antihistamine available. If there is no
apparent reaction, egg can be introduced in gradually increasing amounts.
Consumption, not avoidance, reduces the risk of developing egg allergy.

Visit the RACGPs Handbook of non-drug interventions (HANDI) for more information, including
examples of egg protein sources.

12 May 2017
Clinical Pearl: Mindfulness and cognitive behavioural therapy for chronic
low back pain
Low back pain (LBP) is a leading cause of disability. Mindfulness-based stress reduction (MBSR) and
cognitive behavioural therapy (CBT) have been shown to produce small but clinically meaningful
improvements in adults with chronic low back pain and functional limitations.

The MBSR intervention includes didactic content and mindfulness practice including attention to
thoughts, meditation and breathing. The CBT program includes techniques most commonly applied
and studied for chronic LBP such as psychoeducation about chronic pain, setting and working toward
behavioural goals, relaxation skills and pain coping strategies.

GPs can provide the appropriate psychoeducation about chronic pain, even if they do not use all of
the CBT and MBRS techniques recommended for management of chronic LBP.

Visit the Handbook of non-drug interventions at the RACGP website for more information.

5 May 2017

Clinical Pearl: Prevention of type 2 diabetes

The World Health Organization (WHO) predicts that diabetes will be the seventh leading cause of
death worldwide by 2030. The 201415 Australian Health Survey (AHS) reported an estimated 5.1%
of the Australian population having some type of diabetes, an increase from 4.5% in 20112012. Of
these, approximately 85% have type 2 diabetes.

Clinical trials have shown that a healthy lifestyle, including maintaining a normal body weight,
engaging in regular physical activity and eating a healthy diet, can reduce the risk of developing type
2 diabetes. In addition, early type 2 diabetes may be managed through lifestyle modifications as diet
and exercise play an important role in glycaemic control and, in more advanced stages of the disease,
assist in the management of cardiovascular risks.

Read the 2016-2018 RACGP Diabetes Handbook for more information on changing lifestyle to
prevent or manage type 2 diabetes, including targeting modifiable risk factors such as smoking
cessation and alcohol consumption.

28 April 2017
Clinical Pearl: Strategies to improve immunisation in general practice
World Immunisation Week (2430 April 2017) is a timely reminder of the important role GPs play in
the provision of vaccines for all patients, from birth and at particular ages throughout life.

Populations with lower levels of age-appropriate immunisation rates include people who are:

of Aboriginal or Torres Strait Islander descent

born overseas
 without private health insurance
in the highest or lowest socioeconomic quintile
of low birth weight and singleton birth.

Evidence supports a number of strategies for improving immunisation such as adult immunisation
coverage of at-risk groups in the practice; use of recall-and-reminder systems and catch-up plans;
and integrating vaccination status checks into routine health assessments for target population
groups.

for more information, visit RACGP Red Book (9th edition).

21 April 2017

Clinical Pearl: Do not recommend the regular use of oral non-steroidal

anti-inflammatory medicines (NSAIDs) in older people
Non-steroidal anti-inflammatory medicines (NSAIDs), including COX inhibitors, are not usually
required for longer than short-term relief of acute pain. Treatment should be reassessed if the acute
pain has not resolved within two weeks.

Oral NSAIDs have considerable risks for cardiovascular, gastrointestinal and kidney function. They
should not be recommended without consideration of the patients additional diseases or conditions;
in particular, for older people and people with kidney disease, a history of peptic ulcer disease,
hypertension or heart failure.

Older people should use the lowest possible dose of an oral NSAID for the shortest possible duration.
If they are on long-term NSAIDs, the effectiveness of the NSAIDs should be regularly assessed
against risk, with a view to reducing the dose or ceasing. If cessation is not possible, a shorter half-life
NSAID (eg ibuprofen) may be preferable. Multiple NSAIDs should not be taken at the same time.

Visit the Choosing Wisely Australia website for more information, including exceptions and
supporting evidence.

13 April 2017

Clinical Pearl: Subsidised continuous glucose monitoring products for

young Australians with Type 1 diabetes the role of GPs
The Federal Government is providing fully-subsidised continuous glucose monitoring (CGM)
products to eligible children and young people aged under 21 years with type 1 diabetes.

This increases access to supportive technology for some younger patients with type 1 diabetes, but
may also assist GPs to review their patients diabetes management plans and facilitate access to this
technology for eligible patients. To gain access, a patient needs to be assessed by an authorised
health professional such as an endocrinologist or credentialled diabetes educator.
Management is optimal in a specialist-supported, team-based program. GPs have an important role
to ensure team based approaches are addressed with enhanced primary care planning and
coordination.

For further information about access to CGM products through the National Diabetes Services
Scheme (NDSS), visit the Australian Department of Health website or call the NDSS Helpline on 1300
136 588.

7 April 2017

Clinical Pearl: Single most easily recognised risk factor for osteoporosis
Osteoporosis is known as a silent disease because the deterioration of skeletal tissue proceeds with
no outward symptoms until a symptomatic fracture occurs.

In individuals over the age of 50, the single most easily recognised risk factor for osteoporosis is the
presence of any spinal or non-spinal minimal trauma fracture (such as a fall from standing height or
less). This also applies to vertebral fractures that are coincidentally detected on radiographs.

It should be noted that not all vertebral deformities result from minimal trauma. A review of trauma
history may guide interpretation of vertebral deformities. Dual-energy X-ray absorptiometry (DXA)
may be useful to determine if the patient has reduced bone mineral density with a higher likelihood
of sustaining an osteoporotic vertebral fracture.

Visit the RACGP website for more information on the diagnosis of osteoporosis.

31 March 2017

Clinical Pearl: Do not perform serum tumour marker tests except for
monitoring of a cancer known to produce these markers
Numerous systematic reviews for a broad range of cancer biomarkers have found no support for
testing in patients with non-specific symptoms (or no symptoms at all), in the hope of finding an
undetected cancer. Examples include CEA, CA125, AFP, hCG, PSA, fPSA and breast cancer markers.

No single tumour marker in current use is specific for malignancy, and tumour markers are rarely
elevated in early malignancy. Prostate specific antigen testing (PSA) is the only tumour marker that
is relatively specific for a single organ, although it is not specific for cancer of that organ. Tumour
markers should not be used in the initial diagnostic pathway, except in rare circumstances where
there is a strong known underlying predisposition, such as screening for liver cancer in patients with
chronic hepatitis C and cirrhosis.

Even for metastases of an unknown primary, requesting multiple markers is rarely of use in
identifying the primary cancer.

Visit the Choosing Wisely Australia website for further information.

24 March 2017
Clinical pearl: Exercise programs for chronic lower back pain
Exercise is recommended for episodes of non-specific lower back pain (LBP) that have persisted
beyond 12 weeks. Exercise is considered a safe intervention with patients reporting better function
and pain relief in the short term (6 weeks), intermediate (12 months) and long term (more than 12
months).

Current evidence suggests there is no ideal exercise, with many forms of activities showing similar
benefits. However, effective exercise programs include one of more of the following elements: core
or trunk strengthening; flexibility and stretching; aerobic and functional restoration activities; and
patient education incorporating psychological principles (e.g. pacing or goal setting).

Exercise programs shown to be effective for chronic LBP include yoga, pilates and home-based
exercise programs.

Visit the RACGP website for more information.

17 March 2017

Clinical pearl: Recognising the signs of intimate partner violence

With one in four women in Australia having experienced abuse or violence from a partner,
International Womens Day is a timely reminder of the pivotal role of GPs in recognising the signs of
Intimate Partner Violence (IPV).

IPV has serious impacts for womens health, contributing to poorer mental health, substance abuse,
injuries and suicide.

GPs are often the first health professional seen by women experiencing violence, and it is important
to assess these womens risk and safety issues.

Although victims may disclose abuse, GPs need to be alert to the signs of IPV. Clinical indicators
include emotional health issues such as feeling isolated and overwhelmed, fear, anxiety, depression
and sadness, and emotional numbing. Other common reactions to abuse include sleep issues,
nausea, chronic aches and pain, appetite disturbance and social withdrawal.

For guidance on how to recognise and respond to the signs of IPV, including best practice
recommendations, webinars and resources, visit the RACGP White Book and 1800RESPECT.

6 March 2017

Clinical pearl: Dont prescribe testosterone therapy unless there is

evidence of proven testosterone deficiency
Many of the symptoms attributed to male hypogonadism (mood changes, fatigue, reduced muscle
strength) are also commonly seen in the normal ageing male, or in the presence of comorbid
conditions. Testosterone therapy has the potential for serious adverse effects and represents a
significant expense. It is therefore essential to confirm the clinical suspicion of hypogonadism with
appropriate biochemical testing before commencement of testosterone therapy.

The initial diagnostic test in suspected male hypogonadism is measurement of fasting morning total
testosterone. As testosterone release is diurnal, with the highest levels in the early morning, blood
samples should be taken close to 8.00 am as possible. Food intake can significantly reduce total
testosterone, hence the necessity of fasting. Also, there is marked variability in testosterone levels
within an individual, so repeated measurements are necessary to establish a diagnosis.

Visit Choosing Wisely Australia for more information.

24 February 2017

Clinical Pearl: Blood ketones preferred over urinalysis for suspected

diabetic ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency with serious consequences such as
delirium/coma and/or dehydration causing pre-renal failure and death.

In patients with type 1 diabetes, DKA may occur at diagnosis or subsequently arise as a result of
surgery, trauma, infections, high dose steroids or cardiovascular ischaemia. For patients with type 2
diabetes, these causes need to combine with significantly impaired insulin secretion, typically in a
setting of insulin use.

When DKA is suspected, an immediate finger prick capillary blood glucose with blood ketones is the
preferred investigation for initial emergency assessment (Klocker et al 2013). Urinalysis for ketones
may be performed, however this may be difficult if your patient is dehydrated.

Patients with suspected DKA with any combination of the following require emergency hospital
assessment:

Abnormal ketones are 0.5 mmol/L (severe ketosis is >3.0 mmol/L)

Capillary or venous BGL >11 mmol/L
Venous Ph <7.3

Refer to the RACGPs Diabetes Handbook (2016-2018) Appendix J for more information on DKA.

17 February 2017

Clinical Pearl: Harms of homeopathy

Homeopathic products and services are ineffective, expensive and potentially harmful, and should be
avoided by GPs and patients.

In addition to wasting money on ineffective products, individuals may be exposed to other harms in
using homeopathy. They may delay or avoid medical opinion or treatment while trying homeopathic
products. Some forego conventional immunisation in place of homeopathic vaccines, which not
only poses a risk to individual health, but also others as a result of the threat to herd immunity.
There is also a small chance that individuals will experience adverse effects as a result of the misuse
of homeopathic products, including allergic reactions, drug interactions, and complications related
to the ingestion of a toxic substance.

For more information, view the RACGPs Position statement on homeopathy, which followed a 2015
National Health and Medical Research Council reviewthat concluded homeopathy has no effect
beyond that of a placebo in the treatment of a variety of condition

10 February 2017

Clinical pearl: Do not take a swab or use antibiotics to manage a leg ulcer
without clinical infection
Lower leg ulcers are most commonly venous and are often treated with antibiotics. However, in the
absence of evidence of clinical infection there is no evidence to support antibiotic treatment.

A 2014 Cochrane systematic review found no change in healing rates for antibiotics (with or without
swabs) versus placebo or usual care. Clinical infection usually implies cellulitis with pain and swelling,
although even those randomised controlled trials which did not exclude infected ulcers did not
demonstrate that antibiotics improved healing.

In the absence of clinical infection, taking a swab for microscopy and culture is not recommended.
One study of 58 such ulcers found that all 58 grew microorganism species (including staph in 88%,
enterococcus 74%, anaerobes 41%, fungi 11%). No association was found between the type of
species grown and whether the ulcer size increased, decreased or healed entirely.

Unnecessary swabbing and antibiotics adds to healthcare costs, antimicrobial resistance and patient
allergy.

Visit Choosing Wisely Australia for more information.

3 February 2017

Clinical pearl: Imaging following abnormal thyroid function tests

Don't routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is
no palpable abnormality of the thyroid gland.

Thyroid ultrasound is not part of the routine evaluation of abnormal thyroid function tests (over-
active or under-active thyroid function), unless the patient also has a palpably large goitre or a
nodular thyroid. Inappropriate use of ultrasound will frequently identify incidental thyroid nodules
which are unrelated to the abnormal thyroid function, and may lead to further unnecessary
investigation, unwarranted patient anxiety and increased costs. As a result of over-testing, the
incidence of small and indolent thyroid cancer is increasing, exposing patients to treatments
inconsistent with their prognosis.

Imaging may be indicated in thyrotoxic patients. When needed, a radionuclide thyroid scan, not an
ultrasound, should be requested to assess the aetiology of the thyrotoxicosis and the possibility of a
hyper-functioning thyroid nodule.
Visit Choosing Wisely Australia for more information.

27 January 2017

Clinical Pearl: Be sun smart this summer

Primary prevention of skin cancer is being sun smart. Everyone, particularly children, should be
advised to adopt protective measures when UV levels are three or above. These measures include
use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and
sunscreens with a sun protection factor (SPF) of 30 or higher.

Sunscreen must be applied properly to provide skin protection. About two teaspoons of sunscreen
are needed for the head, neck and arms. Ideally, it should be applied about 1520 minutes before
going outdoors. It should be reapplied every two hours and after heavy sweating, bathing or long sun
exposure, especially if outdoors when the UV Index is three or above.

Encourage patients to become familiar with their skin, and be alert for new or changing skin lesions.

For daily information about UV levels visit the SunSmart widget. For more information about
primary prevention of skin cancer, visit the RACGP Red Book.

16 December 2016
9 December 2016

Clinical Pearl: The great Aussie BBQ is under fire

During the festive season it is easy to forget about moderate eating and drinking habits. Australian
waistlines are now rivalling Santas, with more than two thirds of the population overweight.

The new edition of the RACGP Red Book: Guidelines for preventive activities in general practice (the
Red Book) recommends reducing red meat to three to four servings per week, limiting or avoiding
processed meats, and limiting alcohol consumption to two drinks per day. The evidence suggests a
weak association between red meat intake and colorectal cancer. Diets high in red meat are also
higher in fat and sodium, which are risk factors for cardiovascular disease and obesity.

GPs are reminded of the importance of assessing body mass index (BMI) and waist circumference in
adults, and taking an approach consistent with the 5As framework (Ask, Assess, Advise and agree,
Assist, Arrange follow-up). Agespecific BMI charts should be used for children two years and older.

Visit the RACGP Red Book online for more information.

5 December 2016

Clinical Pearl: Diagnosis of ankle injuries

Dont initiate plain X-ray for foot and ankle trauma unless criteria of the Ottawa Ankle Rules are met.
Ankle injuries are a common presentation in general practice and can be associated with fracture and
osteochondral injuries. However, history and examination has been demonstrated to be as effective
as imaging for diagnosis of ankle injuries. In particular, the Ottawa Ankle Rules have almost 100%
sensitivity for ruling out fractures in acute ankle injuries in both adult and paediatric patients.

NPS MedicineWise have a visiting education program on imaging in acute knee and ankle injuries
over the next few months go to NPS MedicineWise to book a visit.

Visit Choosing Wisely Australia for more information on this clinical pearl.

Ankle X-ray is only required if:

There is any pain in the malleolar zone; and,

Any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of
the tibia or tip of the medial malleolus, OR
Bone tenderness along the distal 6 cm of the posterior edge of
the fibula or tip of the lateral malleolus, OR
An inability to bear weight both immediately and in the
emergency department for four steps.
Foot X-ray series[edit]
Additionally, the Ottawa ankle rules indicate whether a foot X-ray series
is required. It states that it is indicated if:

There is any pain in the midfoot zone; and,

Any one of the following:
Bone tenderness at the base of the fifth metatarsal (for foot
injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to bear weight both immediately and in the
emergency department for four steps.
25 November 2016

Clinical Pearl Intimate partner violence: highest health risk to Australian

women
White Ribbon Day is a timely reminder of the pivotal role of GPs in the recognition, assessment and
management of intimate partner violence (IPV). IPV is prevalent in our communities, and has been
experienced by one in three Australian women aged 15 and above.

GPs are often the first health professional seen by women experiencing violence, and it is important
to assess these womens risk and safety issues. Although some victims may disclose abuse, GPs also
need to be alerted to clinical indicators such as depressive symptoms, drug and alcohol abuse,
physical injuries or chronic pain. Additionally, GPs should consider factors relevant to a womans
immediate safety, such as whether she feels safe to go home, the safety of her children and if there
are weapons in the home.
Visit the RACGP White Book for more information and examples of how to conduct a safety and risk
assessment.

Those experiencing IPV can use 1800RESPECT (1800 737 732) a national 24/7 service for support,
information and referral.

18 November 2016

Clinical Pearl: Avoid prescribing antibiotics for upper respiratory tract

infections
Most uncomplicated upper respiratory tract infections (URTIs) do not require antibiotic therapy.
Most are viral in aetiology, and URTI is usually a clinical, rather than a microbiological, diagnosis.

A 2013 Cochrane systematic review found no benefit (cure or duration of symptoms) in using
antibiotics in children or adults diagnosed clinically with URTI or purulent rhinitis. Conversely, it
found an increase in adverse effects for those randomised to receive antibiotics.

In febrile young infants, oral antibiotic therapy of presumed URTI is not only low value but can be
actively dangerous; it can delay presentation to hospital, provide inappropriate reassurance for
parents and confound investigations of sepsis.

Patient education is an important component of management, together with symptomatic

treatment advice. Streptococcus pyogenes and Bordetella pertussis, if detected, are exceptions that
do require antibiotics.

Visit Choosing Wisely Australia for more information.

11 November 2016

Clinical Pearl: Do not use antibiotics in asymptomatic bacteriuria

Antibiotic treatment of patients with asymptomatic bacteriuria does not decrease the incidence of
symptomatic urinary tract infection. This remains true even in those with indwelling urinary
catheters. Exceptions to this are pregnant women (risk of pyelonephritis causing preterm birth and
low birth weight babies) and those undergoing urological procedures.

Asymptomatic bacteriuria is a common finding in settings where urine is screened, and frequently
resolves without treatment. Although it does have an increased association with subsequent
symptomatic urine infections, prophylactic treatment prior to symptoms does not improve
outcomes.

This has been confirmed for subgroups including nursing home residents, postmenopausal women,
men with increased post-void residual volumes, and people with diabetes or spinal injury. Studies in
older adults show not only no benefit from treatment, but an increase in adverse effects due to the
antibiotic.

Visit NPS MedicineWise resource or Choosing Wisely Australia for more information.
4 November 2016

Clinical Pearl: Non-drug approaches to dementia

Clinical guidelines recommend that people who develop behavioural and psychological symptoms of
dementia (BPSD) should be treated with non-pharmacological approaches in the first instance. This
involves an assessment of the patient to see if pain or some other cause is contributing and is
managed appropriately.

Pharmacological intervention should usually only be offered first if the person, their carer(s) or family
is severely distressed, pain is the suspected cause, or there is an immediate risk of harm to the person
with dementia or others (ie, very severe symptoms). If pharmacological management is used, this
should complement, not replace, non-pharmacological approaches.

Non-pharmacological care can include music, massage, reminiscence therapy or other patient-
specific intervention, delivered either to the individual or in a group. To access help with non-
pharmacological treatment, GPs and carers can contact the 24-hour Dementia Behavioural
Management Advisory Service on 1800 699 799.

Visit the RACGP-endorsed Clinical Practice Guidelines and Principles of Care for People with
Dementia for more information.

28 October 2016

Clinical Pearl: Investigating fatigue

In a patient with fatigue, avoid performing multiple serological investigations, without a clinical
indication or relevant epidemiology.

Fatigue is a very common presentation to the GP. Presentations of fatigue lead to high rates of test
ordering, but serious somatic disease is uncommon. One Australian study found that only 16% of
tests returned abnormal results, leading to a significant clinical diagnosis in only 4% of patients.

In 2011, Australian guidelines for the investigation of fatigue were published by the Therapeutic
Guidelines. These recommend a comprehensive history and examination, consideration of the pre-
test probability, a period of watchful waiting in the absence of red flags, and the judicious use of tests
if the decision to investigate is made. The importance of appropriate follow-up was also highlighted.

In patients with unexplained or persisting fatigue, the guidelines recommend a limited number of
tests (urinalysis, FBC, BGL, TSH, EUC, LFT, ESR/CRP). Over-testing is not only unhelpful, but it can
lead to false positive results and subsequent unnecessary further investigations and treatments.

For more information, visit Choosing Wisely Australia.

21 October 2016
Clinical Pearl: Encourage your patients to do the test - the National Bowel
Cancer Screening Program
Australia has one of the highest rates of bowel cancer in the world, with around 17,000 people
diagnosed each year. The National Health and Medical Research Council (NHMRC) recommends
faecal occult blood test (FOBT) screening at least every two years for people over the age of 50 who
are at, or slightly above, average risk for bowel cancer (about 98% of the population).

If found early, nine out of 10 cases of bowel cancer can be successfully treated. Current participation
in the National Bowel Cancer Screening Program (NBCSP) is low at 37%.

Research consistently demonstrates that a recommendation from a GP to screen for bowel cancer is
an important motivator for participation. Evidence shows that if fully implemented, the NBCSP could
save 500 lives each year. You can help participation by displaying information and short videos in the
practice, sending letters and talking directly to patients about the program.

To learn about the eligible ages for screening each year, see the online calculator available on
the Cancer Screening website or visit the NBCSP website.

17 October 2016

Clinical Pearl: Blood pressure targets in type 2 diabetes

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes, and the
assessment of CVD risk is a vital part of diabetes care.

Lowering blood pressure (BP) reduces cardiovascular events and all-cause mortality in people with
type 2 diabetes in the same manner as for the general population. However, the target level for
optimum BP is controversial.

In line with findings from a number of different studies, it would be reasonable for GPs to shift the BP
target to <140/90 mmHg for people with diabetes, with lower targets considered for younger people
and those at high risk of stroke (secondary prevention), as long as the treatment burden is not high.
The target BP for people with diabetes and microalbuminuria or proteinuria remains <130/80 mmHg.
Treatment targets should be individualised and people with diabetes monitored for side effects from
the use of medications to achieve lower targets.

Visit the updated RACGP General practice management of type 2 diabetes 2016-18for more
information on blood pressure targets in diabetes

7 October 2016

Clinical Pearl - Detecting depression in adults

World Mental Health Day occurs each year on 10 October and serves as a reminder of the role GPs
play in identifying mental health issues such as depression. GPs should be alert to depressive
symptoms in patients at an increased risk for depression, and consider depression when patients
present with low mood, insomnia, anhedonia and/or suicidal thoughts.
A simple two-question test can be used to detect depression in adults:

Over the past two weeks, have you felt down, depressed or hopeless?

Over the past two weeks, have you felt little interest or pleasure in doing things?

A third question about whether help is required may improve the specificity of a GP diagnosis of
depression. For more information, see the RACGPs recently released 9th edition of the Guidelines for
preventive activities in general practice.

23 September 2016

Clinical Pearl Painless, progressive weakness Could this be motor

neurone disease?
Motor neurone disease (MND), a progressive and ultimately fatal neurodegenerative disease, is often
difficult to clinically diagnose. There is no single investigation specific to MND and no sensitive
disease-specific biomarker. Diagnosis is based on symptoms, clinical findings and the results of
electrodiagnostic, neuroimaging and laboratory studies. Rapid and accurate diagnosis is crucial to
ensuring the needs of people living with MND are met from the earliest possible stage.

GPs now have access to a new diagnostic tool developed by MND Australia that highlights the
diseases red flags. Adapted from the MND Association of England, Wales and Northern
Ireland, Painless, progressive weakness Could this be motor neurone disease? aims to assist Australian
GPs in recognising MND, expediting accurate diagnosis by a neurologist.

Delegates attending GP16 will have a copy of Painless, progressive weakness Could this be motor
neurone disease? in their conference satchel. This resource was recently approved by the RACGP as
an Accepted Clinical Resource and can be downloaded from the MND Australia website.

16 September 2016

Clinical Pearl Functional decline can be delayed

Although functional decline is a core feature of dementia, there are interventions that can help delay
it. Regular exercise is an effective approach to maintaining independence in everyday activities.
Occupational therapy can delay decline in everyday activities, and improve quality of life for the
person with dementia. People with dementia living in the community should be offered referral to an
occupational therapist. Maintaining nutrition levels through a healthy diet is also important and
weight should be monitored to detect unintentional weight loss.

Acetylcholinesterase inhibitors can also delay functional decline. Prescription should take costs and
side effects into account. Acetylcholinesterase inhibitors are commonly used to treat Alzheimers
disease. Recent evidence suggests their use for Dementia with Lewy Bodies, Parkinsons disease
dementia, vascular dementia or mixed dementia.
For more information, visit the National Clinical Practice Guidelines for Dementia in Australia. These
clinical practice guidelines were recently endorsed by the RACGP.

9 September 2016
Clinical Pearl Psychiatric side effects of montelukast

On 5 September, the ABCs 7.30 program aired a story raising concerns with the psychiatric side
effects of the asthma medication montelukast (available as brand name Singulair).

Possible psychiatric side effects include suicidal ideation, depression, agitation, aggressive
behaviour, hallucinations, insomnia, somnambulism and tremor, as well as others. However, it is
important to note that these are highly rare side effects of an effective medication that has improved
the lives of many children.

GPs are reminded to tell patients that there can be side effects with montelukast in rare
circumstances, and they should come back to discuss ceasing the medication if they experience any
issues.

For more information, visit the Therapeutic Goods Administration website and the
medications online product information leaflet.

2 September 2016

Clinical Pearl Bariatric surgery for weight management in patients with

type 2 diabetes
The causes of overweight and obesity are complex. While diet and physical activity are central to the
energy balance equation, a wide range of social, environmental, behavioural, genetic and
physiological factors have direct and indirect influences on each individuals risks of weight
management issues.

One key issue for weight management is educating and assisting patients to eat a range of foods in
amounts appropriate for energy requirements. Sources of hidden energy need to be identified and
minimised (eg alcohol, cakes and sweet beverages), especially those with added fat.

Medical management of overweight and obese patients with type 2 diabetes may not always achieve
metabolic goals, and thus bariatric surgery may be a consideration for people with a body mass index
>35 kg/m2 who have suboptimal blood glucose levels and are at increased risk of cardiovascular
disease. However, GPs should assess the appropriateness of surgery for each individual patient and
make them aware of the risks, benefits and appropriateness of the procedure.

Visit the RACGPs clinical guidelines for general practice management of type 2 diabetes for more
information.

26 August 2016

Clinical pearl: A basic dementia screen in general practice

Dementia is diagnosed on the basis of clinical criteria following a comprehensive clinical assessment,
including: history; cognitive and mental state assessment; physical examination; and medication
review. The following blood tests should be included at the time of assessment: routine
haematology; biochemistry tests including electrolytes, calcium, glucose, and renal and liver
function; thyroid function tests; serum vitamin B12; and folate levels.

The dementia screen may help identify an alternative reason for presenting symptoms. People with a
possible diagnosis of dementia should be offered referral to memory assessment specialists or
services for a comprehensive assessment. As specialist assessment services are not always available
in rural and remote areas, the Clinical practice guidelines and principles of care for people with
dementia state that strategies to ensure access should be implemented.

Visit the National Clinical Practice Guidelines for Dementia in Australia for more information. These
clinical practice guidelines were recently endorsed by the RACGP.

19 August 2016

Clinical pearl: Walking canes for knee osteoarthritis

People with knee osteoarthritis (knee OA) experience pain and decreased ability to move. Daily use
of a walking cane or stick can reduce the load transmitted through the affected knee(s), improving
pain and function.

Patients should be trained in the use of a cane or stick on the contralateral side to ensure optimal
outcomes. It is important to inform patients that they may walk more slowly during the adaption
process, but after one to two months of regular use, they will become more confident and walking
with a cane will be easier and quicker.

For more information about the use of canes for knee OA, including a walking stick training video,
refer to the RACGPs Handbook of non-drug interventions (HANDI)

12 August 2016

Clinical pearl 1: Symptoms of possible dementia should be explored when

first raised and should not be dismissed as part of ageing
Clinical cognitive assessment in those with suspected dementia should include an examination using
a questionnaire with established reliability, validity and with consideration of the particular patient
demographic, such as age, literacy, and culture.

A number of cognitive assessment tools are suitable for use in general practice:

The Mini Mental State Exam (MMSE) is the most commonly used.
The General Practitioner Assessment of Cognition (GPCOG) was developed in
Australia specifically for use with older people visiting their GP.
The Rowland Universal Dementia Assessment Scale (RUDAS) was also
developed in Australia and is suitable for use with culturally and linguistically
diverse populations.
The Kimberley Indigenous Cognitive Assessment (KICA) is a culturally
appropriate tool for use with remote-living Aboriginal and Torres Strait Islander
peoples.
Visit the National Clinical Practice Guidelines for Dementia in Australia for more information. These
guidelines were recently approved by the RACGP as an Accepted Clinical Resource.

5 August 2016

Clinical Pearl - Patients at risk of hereditary haemochromatosis

Today is Jeans for Genes Day, a fundraiser for Childrens Medical Research Institute to support
genetic research. This weeks clinical pearl focuses on a common genetic condition, hereditary
haemochromatosis (HHC).

In addition to patients who have a first-degree relative with HHC, this condition should also be
considered in adult patients with:

conditions that could be a complication of haemochromatosis (eg arthritis,

chronic fatigue, erectile dysfunction, early menopause, cirrhosis)
liver disease of unknown cause, including suspected alcoholic liver disease
a family history of haemochromatosis, liver cancer, or unexplained early death
from liver failure/heart failure
porphyria cutanea tarda and chondrocalcinosis (pseudogout).

Patients with repeated test results for fasting transferrin saturation >45% and serum ferritin >250
g/L should be followed up with HFE mutation testing (MBS item no. 73317).

The RACGP is currently updating Genetics in Family Medicine: The Australian Handbook for General
Practitioners. Visit the Guidelines on the RACGP website for more information about HHC.

29 July 2016

Clinical Pearl Oral hygiene and a healthy diet for dental health
Dental Health Week (17 August) is a timely reminder of GPs role in identifying the risk of dental
decay and periodontal (gum) disease in patients. Children and adults should be encouraged to brush
their teeth regularly to prevent tooth decay and gum disease. In addition, only moderate amounts of
sugars and foods containing added sugars should be consumed. The World Health Organization
(WHO) recommends reducing the intake of free sugars (monosaccharides and disaccharides) to less
than 10% of total energy intake in adults and children. Good oral hygiene, a healthy diet and access
to fluoridated drinking water all contribute to improving dental health.

Visit the RACGP Red book Guidelines for oral hygiene or the WHOs recommendation on sugar
intake for adults and children for more information.

22 July 2016

Clinical Pearl Protecting patients from unnecessary radiation exposure

Patients rely on their GP for education about the risks and benefits of tests, including medical
imaging. The risk associated with any single imaging procedure is likely very small, however, the
cumulative effect of frequent, repeated or potentially inappropriate imaging on the risk of radiation-
induced cancer represents a public health concern.

When considering whether a test utilising ionising radiation is justified, it can be helpful for GPs to
ask themselves: Will imaging change my diagnosis or affect my management plan for this person? Is
a test that does not employ ionising radiation a feasible option?

To increase awareness about the radiation exposure associated with medical imaging and how to
discuss the benefits and risks of imaging with patients, the Australian Radiation Protection and
Nuclear Safety Agency and the RACGP have developed the educational activity Radiation protection
of the patient, which is now available on gplearning.

15 July 2016

Clinical Pearl e-mental health for mild to moderate anxiety and

depression
Many patients are unaware of the vast array of e-mental health interventions available to them for
the management of mental health issues such as mild to moderate anxiety and depression. Online
portals Beacon and mindhealthconnect can be used to locate suitable e-mental health options and
discover more about their purpose, format, and cost. Many e-mental health interventions are free of
charge to patients and some are available in several languages.

Visit e-Mental health: A guide for GPs for more information, an RACGP resource designed to help
practitioners who are curious about using online interventions with their patients.