DGM Core Tools

Why

The 4AT bands are simple: 0 means delirium and cognitive impairment are both unlikely; 1 to 3 suggests possible cognitive impairment; 4 or more suggests possible delirium, with or without cognitive impairment. A score of 6 sits firmly in the top band. Add the acute onset, the fluctuation and the failed attention item and delirium is the working diagnosis until proven otherwise — which means the next step is a cause, not a label.

Why not the others

• B — That is the 1 to 3 band. Six is well past it, and the fluctuating course points to delirium rather than a stable cognitive impairment.
• C — There is no “normal for age” acute inattention. Post-operative delirium after a hip fracture is common, but common is not benign — it predicts longer stay, functional loss and mortality.
• D — The 4AT is a screening tool, not a diagnosis. A positive score should trigger assessment and a cause hunt, never end the thinking.

Why

Three features make this delirium: onset over hours to days, a fluctuating course, and impaired attention. Perceptual disturbance and a disturbed sleep-wake cycle support it. The collateral history is the diagnostic pivot — a documented change from a clear baseline one week ago cannot be a neurodegenerative dementia.

Why not the others

• A — Alzheimer’s is insidious over months to years and leads with episodic memory; attention is relatively preserved early on. It does not appear in three days.
• C — Depression can mimic cognitive impairment (“pseudodementia”) but the picture is persistently low mood, poor motivation and slowed thinking — not fluctuating conscious level and hallucinations.
• D — Lewy body dementia does bring fluctuation and vivid visual hallucinations, so it is a fair trap — but it develops over months, and you can only diagnose it once delirium has been excluded and the picture persists. Never diagnose DLB in the acute phase.

Why

Hypoactive delirium is the commonest subtype and the most missed, precisely because the patient causes no trouble. Withdrawal, drowsiness, slowed responses and reduced oral intake in someone acutely unwell with a clear premorbid baseline should trigger a 4AT and a cause hunt. It carries a worse prognosis than the hyperactive form — largely because nobody looks for it.

Why not the others

• A — Depression does not appear in three days on a background of pneumonia, and starting an antidepressant here treats the observer’s discomfort, not the patient. Exclude delirium before diagnosing a mood disorder in an acutely unwell older person.
• B — “Just tired” is the sentence under which most hypoactive delirium hides. Fatigue does not usually come with inattention and a changed conscious level.
• D — Delirium can be part of dying, but it is reversible far more often than it is terminal. Deciding she is dying without screening or a cause hunt is a diagnosis of convenience.

Why

Asymptomatic bacteriuria is present in a large minority of older people, so a positive dipstick in someone over 65 tells you very little: it cannot distinguish infection from colonisation, and treating it exposes the patient to harm while the real precipitant goes unfound. A full delirium screen means observations, a medication review, bloods (FBC, U and E, CRP, glucose, calcium, LFTs, TFTs, B12), an ECG, and a deliberate look for pain, constipation, urinary retention, alcohol withdrawal and sensory deprivation.

Why not the others

• A — This is the single commonest error in delirium care. UK guidance is explicit: do not use urine dipsticks to diagnose UTI in people over 65. Diagnose clinically, on symptoms and systemic signs — which he does not have.
• B — Imaging is for focal neurology, head injury, anticoagulation or a delirium that will not explain itself. Scanning first, before a bedside screen and a drug chart review, wastes time and finds nothing.
• C — Sedation is not a substitute for a diagnosis, and he is not described as distressed or at risk. Regular antipsychotics prolong delirium and add falls.

Why

NICE CG103 sets a high bar: drugs only if the person is distressed or a risk to themselves or others, and only after verbal and non-verbal de-escalation has failed. Then use short-term haloperidol at the lowest effective dose, usually for a week or less, titrating cautiously and reviewing daily. In Parkinson’s disease and dementia with Lewy bodies haloperidol is contraindicated (its product information lists both), because of the risk of a severe neuroleptic sensitivity reaction, and NICE CG103 asks prescribers to take account of MHRA advice on its cardiac and neurological risks, especially in these conditions. Any alternative there is a specialist decision rather than a routine antipsychotic.

Why not the others

• B — “Regular for a week” removes the daily decision. Sedation should be as-required, reviewed every day, and stopped the moment it is not needed — otherwise it follows the patient home on the discharge summary.
• C — Restraint escalates distress, causes injury, and carries clear legal implications under the Mental Capacity Act. It is a last resort of proportionate restriction, not a treatment plan.
• D — The opposite over-correction. Refusing all medication when someone is assaulting staff and endangering himself is not patient-centred care; it is abandoning both him and the team.

Why

Delirium prevention is one of the genuine successes of geriatric medicine, and it is almost entirely non-pharmacological. NICE recommends a tailored multicomponent package addressing each risk factor the person actually has — here, sensory impairment, immobility, pain, dehydration and cognitive impairment. A Cochrane review (Burton et al, 2021) found that multicomponent approaches prevent around two in five cases of delirium on hospital wards outside intensive care — a better number than any drug has produced.

Why not the others

• A — Prophylactic antipsychotics do not reliably prevent delirium and add sedation, falls and cardiac risk. NICE does not recommend them.
• C — Cholinesterase inhibitors have no role in preventing or treating delirium, and may worsen outcomes. They are a dementia treatment, not a delirium one.
• D — This is the anti-bundle. Immobility and sedative hypnotics are two of the strongest modifiable risk factors for delirium — this plan would make it more likely, not less.

Why

Her entire symptom cluster — confusion, dry mouth, constipation, falls — is the anticholinergic syndrome, and she is taking three anticholinergics at once. Burden is cumulative and dose-related, and is associated with cognitive decline and falls. Withdraw them sequentially so you can attribute the benefit: stop the chlorphenamine, review whether the amitriptyline is needed at all, and consider a bladder alternative such as mirabegron or supervised bladder training.

Why not the others

• A — This is a textbook prescribing cascade: adding a cholinesterase inhibitor to fight the drugs blocking acetylcholine. You would be prescribing the accelerator and the brake together.
• B — Another cascade — treating the side effects of a drug with more drugs, while leaving the cause in place. Two extra medicines, no cognitive benefit, ongoing falls risk.
• D — Reasonable one day, but not first. Assessing cognition while she is drowned in anticholinergics risks labelling a reversible drug effect as dementia. Clean up the drug chart, then reassess.

Why

Falls on standing in the morning are orthostatic hypotension until measured otherwise, and a sitting BP tells you nothing about it. He is on two vasodilators plus an alpha-blocker, and a Z-drug on top. STOPP flags drugs that predictably worsen falls: alpha-blockers, benzodiazepines and Z-drugs, vasodilators in known postural hypotension. Doxazosin and zopiclone give the biggest return for the least therapeutic loss, so they go first — one change at a time, with review.

Why not the others

• A — Deprescribing is a scalpel, not a bulldozer. Stopping ramipril and sertraline abruptly and simultaneously risks rebound hypertension and discontinuation symptoms, and you would never know which change helped.
• B — Equipment is part of a falls plan, never the whole of it. Hip protectors are poorly tolerated and do not stop him falling — and the medication review is the intervention with the evidence.
• C — A reassuring sitting BP is exactly how postural hypotension gets missed. The measurement that matters is the one taken standing, at 1 and 3 minutes.

Why

This is the “triple whammy”: an ACE inhibitor plus a diuretic plus an NSAID, which together dismantle the kidney’s ability to defend its own perfusion and is a leading cause of avoidable acute kidney injury. STOPP advises against NSAIDs when eGFR is below 50, and separately against NSAIDs in heart failure, where they cause fluid retention. Both criteria are breached here, and her creatinine is already climbing.

Why not the others

• B — A PPI protects the stomach, not the kidney or the failing heart. It treats one of three risks and leaves the dangerous ones untouched — while adding a drug.
• C — The renal and cardiac risks are not confined to high doses, and three months is a long time to watch a rising creatinine in someone on ramipril and furosemide.
• D — All systemic NSAIDs share the mechanism. Ibuprofen is marginally lower risk for the gut, not for the kidney. Topical NSAID, by contrast, gives useful analgesia in knee OA with minimal systemic absorption.

Why

START exists because under-prescribing harms older people just as reliably as over-prescribing. A fit 76-year-old with established coronary disease and diabetes has clear indications for a statin and an antiplatelet, and under NICE NG28 (2026) for an SGLT2 inhibitor to protect the heart and kidneys, with an ACE inhibitor and beta-blocker as standard post-MI therapy unless contraindicated. Deprescribing is not the same as nihilism: the question is always whether this person, at this stage, stands to benefit within their likely lifespan — and he does.

Why not the others

• A — Ageism dressed as caution. Secondary prevention after MI retains benefit into old age, and absolute risk is higher in older people, so the number needed to treat is often better, not worse.
• C — Anticoagulation is not the answer for coronary secondary prevention without AF or another indication — it adds bleeding risk without the right benefit. Antiplatelet is the correct class.
• D — Tight glycaemic targets in older people risk hypoglycaemia, falls and confusion for a benefit measured in decades, so a second drug just to push HbA1c below 48 is not the answer. An SGLT2 inhibitor is different: here it is for heart and kidney protection, not HbA1c (NG28, 2026).

Why

Glucocorticoid-induced bone loss is fastest in the first months of treatment, so protection given late has already lost most of its value. START explicitly flags calcium, vitamin D and a bisphosphonate in patients on long-term corticosteroids. She has multiple additional risk factors — age over 75, low body weight, smoking history, family history of hip fracture — which in most UK guidance mean treating without waiting.

Why not the others

• A — Arrange the DEXA by all means, but do not let it delay treatment in a high-risk patient already eight months into steroids. NICE NG259 (July 2026) counts systemic glucocorticoids of 5 mg or more prednisolone daily (or equivalent) for over 3 months as a trigger for fracture-risk assessment; if a DXA scan would be significantly delayed it advises considering starting antiresorptive treatment meanwhile, and it allows a shared decision to treat without a DXA when the scan would not change the decision (for example, older people living with frailty).
• B — Calcium and vitamin D are the foundation, not the treatment. They do not prevent steroid-induced fractures on their own.
• D — Waiting for the first fracture is the whole problem. Primary prevention is precisely what bone protection is for, and the fracture you prevent may be the hip.

Why

STOPP flags benzodiazepines beyond four weeks: they cause sedation, confusion, impaired balance and falls, and tolerance to the hypnotic effect develops quickly while the harms do not. But withdrawal must be gradual — typically reducing by about an eighth of the daily dose every one to two weeks, slower if she struggles, with the pace set by the patient. Her willingness is the single best predictor of success, so protect it.

Why not the others

• A — Abrupt withdrawal after six years risks rebound insomnia, severe anxiety and even seizures. It also destroys trust, and she will simply find the drug elsewhere.
• B — Z-drugs are not safer in older people — same falls, same confusion, same dependence, different marketing. Swapping one hypnotic for another is running on the spot.
• C — The harm is not “obvious”, it is two falls and daytime drowsiness. Duration of use is a reason to withdraw carefully, not a reason to continue.

Why

Capacity assessment is always two stages, and the order matters. Start with the functional stage: can he understand, retain, weigh and communicate the information for this decision now? Only if he cannot do you turn to the diagnostic stage and ask whether that inability is because of an impairment or disturbance in the functioning of the mind or brain — dementia, delirium, stroke, intoxication, learning disability. Section 2(1) is framed that way round, and starting from the diagnosis is how diagnostic override happens. Most people with moderate dementia retain capacity for many decisions.

Why not the others

• B — This is the “diagnostic override” the Act was written to abolish. A label is not an assessment, and skipping the functional test is unlawful.
• C — Outcome-based reasoning. Principle 3 of the Act is explicit: a person is not to be treated as unable to decide merely because they make an unwise decision.
• D — A relative can tell you a great deal about the person, but capacity is assessed by the clinician proposing the intervention. “Next of kin” has no decision-making status in English law.

Why

The four functional abilities are: understand the relevant information; retain it long enough to make the decision; use or weigh it in the process; and communicate the decision. A person must be able to do all four. She can understand and repeat, but she cannot weigh the consequence of refusal against the burden of treatment — a failure of the “use or weigh” limb, and the one most often missed because the person sounds coherent.

Why not the others

• A — She is communicating perfectly well; the words are not the problem. Failure of communication means an inability to convey the decision by any means, including blinking or gesture.
• C — The trap. Fluent understanding and repetition are not the same as weighing. Someone can echo the information back and still be unable to use it.
• D — She clearly can understand and communicate, so this is factually wrong — and capacity is never assumed away without assessment. It must be documented, decision by decision.

Why

Capacity is not a status a person carries around; it attaches to a specific decision at a specific moment. Managing a property portfolio is cognitively far more demanding than deciding whether to accept a flu jab, and many people who cannot do the first can easily do the second. Capacity may also fluctuate — in delirium it can change within a day — so assess when he is at his best, at the time the decision must be made.

Why not the others

• A — This is the “global incapacity” myth. It strips people of decisions they are perfectly able to make, which is exactly the harm the Act was designed to prevent.
• B — There is no expiry date on a capacity assessment, and no automatic restoration. Each decision, each time.
• D — Consent to vaccination is absolutely a medical decision requiring capacity. The right answer is right for the right reason — specificity, not triviality.

Why

She meets all four functional criteria — she understands, retains, weighs and communicates. Principle 3 of the MCA states that a person is not to be treated as unable to make a decision merely because it is an unwise one. Adults with capacity may refuse life-saving treatment for reasons that others find incomprehensible; the value the decision expresses is hers to hold. Support her, explore it, offer palliative and pain management, revisit if she wishes — but do not overrule her.

Why not the others

• A — Circular reasoning, and the most common misuse of the Act: defining incapacity by the outcome you dislike. If refusing surgery proved incapacity, no one could ever validly refuse anything.
• B — Best interests only arises once capacity is absent. She has capacity, so there is no best-interests decision to make — and operating would be an assault.
• C — Family have no legal power to consent or refuse on behalf of a capacitous adult. Their distress is real and deserves support, but it does not transfer the decision.

Why

Where there is no LPA for health and welfare and no deputy, the decision-maker is the clinician proposing the intervention. Best interests is a structured process, not a hunch: consider whether he may regain capacity, involve him as far as possible, and take into account his past and present wishes, his beliefs and values, and the views of those close to him. The daughter’s account of his settled view carries real weight as evidence of his wishes — it is not a vote, it is testimony.

Why not the others

• B — “Next of kin” has no legal decision-making status in England and Wales. Family are consulted as a source of evidence about the person, not as proxies.
• C — Not a legal test, and it systematically privileges the loudest relative over the patient’s own values. Document the reasoning and, if the disagreement persists, escalate — second opinion, ethics or, ultimately, the Court of Protection.
• D — An IMCA is instructed for serious medical treatment or a change of accommodation when there is no appropriate person to consult. Here there is family. Family conflict does not trigger an IMCA — though a second opinion or mediation may help.

Why

A valid and applicable advance decision to refuse treatment has the same legal force as a contemporaneous refusal by a person with capacity. Where it refuses life-sustaining treatment it must additionally be in writing, signed, witnessed, and contain the words that it applies even if life is at risk — all of which are satisfied here. Treating in the face of it would be unlawful. Note the asymmetry: you can refuse treatment in advance, but you cannot demand it.

Why not the others

• A — That confuses an advance decision with an advance statement of wishes. An advance statement guides best interests; an advance decision to refuse binds.
• C — Backwards. Its entire purpose is to speak for her when she cannot. It takes effect precisely because she now lacks capacity.
• D — No relative can override a valid advance decision. She may raise genuine doubt about validity or applicability — if there is real doubt, treat while it is resolved, and apply to the Court of Protection if needed — but she cannot substitute her own view.

Why

CFS 6 is defined by needing help with all outside activities and with keeping house, together with problems on stairs and needing help with bathing, and possibly minimal help with dressing. That is her exactly. The scale is scored on the person’s baseline in the two weeks before the acute illness — not on how they look on the ward today, which is why the collateral history matters.

Why not the others

• A — CFS 4 (very mild frailty) describes someone not dependent on others day-to-day, but slowed, with symptoms limiting activity and often “tired” — she is well past that.
• B — CFS 5 (mild frailty) means needing help with high-order instrumental activities only — finances, transport, heavy housework. It stops short of personal care; her need for help bathing pushes her to 6.
• D — CFS 7 (severe frailty) means completely dependent for personal care, from any cause, though stable and not at high risk of dying. She still manages most of her own personal care.

Why

CGA is the core technology of geriatric medicine, and the evidence is unusually good: patients admitted to hospital who receive CGA are more likely to be alive and living in their own home at follow-up. It has four domains — medical, functional, psychological or cognitive, and social or environmental — and two non-negotiable features: it is interdisciplinary, and it produces a plan that someone owns, delivers and reviews.

Why not the others

• A — That is a frailty screening tool such as the CFS, PRISMA-7 or an eFI. Screening identifies who might benefit from CGA; it is the doorway, not the room.
• B — The single most common misunderstanding. A brilliant solo clerking is not CGA. Without the multidisciplinary team and the coordinated plan, the outcome benefit disappears.
• C — A checklist is a paper artefact. CGA is a process of assessment, planning, intervention and review — the follow-through is where the benefit lives.

Why

NG249 (April 2025, which replaced CG161) offers a comprehensive falls assessment to people who have fallen in the last year and meet any of its criteria: living with frailty, a fall injury needing medical or surgical treatment, loss of consciousness with the fall, being unable to get up independently, or two or more falls in the year. Mr V has had two falls, so he qualifies. After a fall without those criteria, NICE advises a gait and balance assessment, then a falls-prevention exercise programme (and considering a home-hazard assessment) if a problem is found. It covers gait and balance, muscle strength, osteoporosis and fracture risk, perceived functional ability and fear of falling, visual impairment, cognition, continence, home hazards, cardiovascular examination and — always — a medication review. The single strongest intervention is strength and balance exercise, and his fear of falling is itself a treatable risk factor.

Why not the others

• B — Vitamin D matters for bone health, and correct deficiency if present, but on its own it is not an effective falls intervention. It is one line in a multifactorial plan.
• C — Hip protectors are poorly tolerated and do not prevent falls; bed rails can cause injury and are a restrictive practice. Neither addresses why he is falling.
• D — The most harmful option on the list. Reduced activity means deconditioning, more weakness, more falls, less life. Getting him back to the allotment is a clinical goal, not a risk.

Why

Orthostatic hypotension is a sustained fall of at least 20 mmHg systolic, or at least 10 mmHg diastolic, within three minutes of standing. Her systolic drops 24 mmHg and stays down, with symptoms. The practical points: lie her flat for five minutes first, measure at one and three minutes standing, and always record whether she had symptoms. Then look for the cause — drugs first, then dehydration, autonomic failure and anaemia.

Why not the others

• A — The definition is about the drop, not the absolute number. A fall from 190 to 160 counts too, and can be just as symptomatic.
• C — Either criterion is sufficient — systolic 20 or diastolic 10. They are alternatives, not a pair.
• D — A tilt table is for unexplained syncope, not for routine orthostatic hypotension. This is a bedside diagnosis, made with a cuff and three minutes of patience.

Why

Both errors are common and both can do real harm, because CFS scores get used in escalation and treatment decisions. The scale was developed and validated in older people, and is not designed for people under 65 or for those with stable long-standing disability or learning disability, where dependence does not reflect the cumulative deficits the scale is measuring. And it is a measure of usual state: score the baseline about two weeks before the acute illness, using collateral history.

Why not the others

• A — Universal application is precisely what the developers warn against. A tool used outside its validated population produces a number that looks objective and means nothing.
• B — Age matters: applying it to a 45-year-old with cerebral palsy misclassifies lifelong stable disability as frailty and may wrongly limit treatment.
• D — Scoring on today’s function during an acute illness inflates the score in exactly the patient who is most likely to recover. Delirium is not frailty.

Why

NG56 exists because single-condition guidelines, stacked up, produce a regimen no human can live with. The approach: establish what matters to the person, clarify treatment burden, review each medicine for likely benefit in his time frame and against his goals, and agree a plan he can actually follow. His goals — walking to the shop, avoiding hospital — are clinical information, and they should reorganise the whole plan.

Why not the others

• A — This is how twelve medicines happened. Guidelines are written for single diseases in trial populations that excluded people like him; applying them additively is not evidence-based, it is arithmetic.
• B — Deprescribing nihilism. Frailty is not a reason to withdraw everything — some drugs, such as those for symptom control or an anticoagulant in AF, matter more, not less. The test is benefit within his lifespan and against his goals.
• C — Six more opinions produce six more medicines and six more appointments. Multimorbidity needs a generalist to hold the whole picture, which is the job you are being asked to do.

Why

NICE NG97 (Dementia, 2018) asks for a history from the person and, where possible, from someone who knows them well, a brief validated cognitive instrument, and blood and urine tests to exclude reversible causes. It is explicit that dementia should not be ruled out solely because the person has a normal score on a cognitive instrument. Once reversible causes have been investigated and dementia is still suspected, NG97 recommends referral to a specialist dementia diagnostic service, such as a memory clinic or community old age psychiatry service. The son’s account of functional decline is the evidence here; the 6CIT is only a screen.

Why not the others

• A — NG97 says in terms: do not rule out dementia solely because of a normal score on a cognitive instrument.
• B — There is no diagnosis or subtype yet. NG97 says acetylcholinesterase inhibitors should only be started on the advice of a clinician with the necessary knowledge and skills; the first prescription can then be issued in primary care.
• D — Repeating the screen delays a diagnosis the history already points to. With reversible causes checked and dementia still suspected, the NG97 step is referral.

Why

NG97 (2018) asks for a structured assessment before any treatment for distress in dementia: explore possible reasons and check for clinical or environmental causes, for example pain, delirium or inappropriate care. A one-week change in a man with no history of aggression is a new symptom, and delirium belongs on the list. Psychosocial and environmental interventions are the initial and ongoing management. Antipsychotics are reserved for people at risk of harming themselves or others, or with agitation, hallucinations or delusions causing severe distress — after discussing benefits and harms, at the lowest effective dose, for the shortest time, with reassessment at least every 6 weeks.

Why not the others

• B — It skips the assessment, and even when an antipsychotic is justified NG97 asks for reassessment at least every 6 weeks — not once a year.
• C — NG97 says do not offer valproate to manage agitation or aggression in people living with dementia, unless it is indicated for another condition.
• D — A benzodiazepine is not an NG97 option for distress in dementia, and sedating him leaves the cause unfound. The prescribing tool on this page covers why STOPP flags benzodiazepines in older people.

Why

NICE NG71 (Parkinson’s disease in adults, 2017) recommends that if Parkinson’s disease is suspected, people are referred quickly and untreated to a specialist with expertise in its differential diagnosis. Treatment then starts after specialist assessment. When it does, NG71 offers levodopa to people in the early stages whose motor symptoms affect their quality of life; where they do not, the choice is between a dopamine agonist, levodopa or a monoamine oxidase B inhibitor.

Why not the others

• A — Starting treatment before specialist assessment is the step NG71 asks you not to take — the referral is to be made untreated.
• B — Investigation is a specialist decision, not a gate to referral. The NG71 step for suspected Parkinson’s is a quick, untreated referral.
• C — Dopamine agonists are not first line for everyone: NG71 offers levodopa where motor symptoms affect quality of life, and agonists carry a recognised risk of impulse control disorders.

Why

NG71 (2017) is explicit that antiparkinsonian medicines should not be withdrawn abruptly or allowed to fail suddenly, because of the risk of acute akinesia or neuroleptic malignant syndrome. In hospital, NICE asks that they are given at the appropriate times — which can mean allowing self-medication — and that changes are made only after discussion with the Parkinson’s specialist team. Being nil by mouth before surgery is exactly the situation in which a dose is allowed to fail, so the expected answer is to keep the medicine going and get specialist advice if the oral route is not possible.

Why not the others

• A — This is the abrupt withdrawal NG71 warns against, with the risk of acute akinesia or neuroleptic malignant syndrome.
• C — NG71 says doses in hospital are adjusted only after discussion with the Parkinson’s specialist. Postural hypotension is managed by reviewing the medicines that may be causing it, not by an arbitrary dose cut.
• D — Haloperidol is contraindicated in Parkinson’s disease (product information), and NICE NG97 warns that antipsychotics can worsen motor features and cause severe sensitivity reactions in Parkinson’s disease dementia and Lewy body dementia.

Why

Her picture is urgency incontinence (overactive bladder). NICE NG123 (Urinary incontinence and pelvic organ prolapse in women, 2019) recommends bladder training lasting a minimum of 6 weeks as first-line treatment for urgency or mixed urinary incontinence. If a bladder medicine is later considered, NG123 asks the prescriber to take account of coexisting conditions, current use of other medicines that affect total anticholinergic load, and the risk of adverse effects including cognitive impairment, and not to offer immediate-release oxybutynin to older women who may be at higher risk of sudden deterioration. NICE NG97 adds that some commonly prescribed medicines increase anticholinergic burden, and therefore cognitive impairment, and asks clinicians to consider minimising them.

Why not the others

• A — Not first line, and NG123 specifically says do not offer immediate-release oxybutynin to older women who may be at higher risk of sudden deterioration — with two anticholinergics already on board and new forgetfulness, she is the person that warning is for.
• C — Supervised pelvic floor muscle training (at least 3 months) is first line for stress or mixed incontinence. Her diary shows urgency and no stress leakage.
• D — NG123 says absorbent containment products are not a treatment for urinary incontinence; they are a coping strategy alongside or after active treatment.

Why

NICE CG49 (Faecal incontinence in adults, 2007) asks for a focused baseline assessment — history, general examination, anorectal examination and a cognitive assessment where appropriate — and lists conditions to address before routine management of faecal incontinence begins. Faecal loading is the first on that list. Where acute severe faecal loading is contributing, CG49 recommends a rectally administered treatment initially, with potent oral laxatives if that is inappropriate or does not work. It also asks clinicians to consider alternatives to medicines that might be contributing. Loose stool leaking round a loaded rectum is overflow, not diarrhoea.

Why not the others

• A — Loperamide is CG49’s first-choice antidiarrhoeal — which is what makes this the trap. Here the leakage is overflow from faecal loading, and an antidiarrhoeal would make the loading worse.
• B — Treatable causes of diarrhoea are on CG49’s list, but the rectal examination has already found the cause. Waiting leaves the loading untreated.
• C — Specialist management comes after the baseline assessment and initial management — and the treatable cause has already been found.

Why

NICE CG97 (Lower urinary tract symptoms in men: management, 2010) recommends, at initial assessment: a general medical history to identify possible causes of LUTS and associated comorbidities; a physical examination guided by urological symptoms and other conditions, including the abdomen, external genitalia and a digital rectal examination; a urine dipstick test for blood, glucose, protein, leucocytes and nitrites; a urinary frequency volume chart for men with bothersome LUTS; and information, advice and time to decide whether they wish to have a PSA test. Men considering any treatment should have their baseline symptoms assessed with a validated symptom score, such as the International Prostate Symptom Score (IPSS). Serum creatinine with eGFR is offered only if renal impairment is suspected.

Why not the others

• A — CG97 says do not routinely offer flow-rate measurement or a post-void residual volume measurement at initial assessment.
• B — PSA is not a routine add-on. CG97 asks for information, advice and time to decide whether to have the test, so it is the man’s informed choice.
• D — Creatinine and eGFR are offered only if renal impairment is suspected, and CG97 says do not routinely offer upper urinary tract imaging for uncomplicated LUTS.

Why

NICE CG97 (2010) recommends supervised bladder training, advice on fluid intake and lifestyle advice for storage LUTS suggestive of overactive bladder, and drug treatment only when conservative options have been unsuccessful or are not appropriate. It recommends an alpha blocker (alfuzosin, doxazosin, tamsulosin or terazosin) for moderate to severe LUTS, and says to consider offering an anticholinergic as well as the alpha blocker to men who still have storage symptoms after an alpha blocker alone, taking comorbidities and current treatment into account. Men on anticholinergics are reviewed every 4 to 6 weeks until symptoms are stable, then every 6 to 12 months. Local NHS prescribing guidance (Derbyshire JAPC overactive bladder guideline, 2022) advises using antimuscarinics with caution in older people who have, or are at risk of, cognitive dysfunction, and considering the anticholinergic burden of existing medicines — amitriptyline adds to his.

Why not the others

• B — CG97 says do not offer phosphodiesterase-5 inhibitors solely to treat LUTS in men, except within a randomised controlled trial.
• C — A 5-alpha reductase inhibitor is for men with a prostate estimated to be larger than 30 g or a PSA above 1.4 ng/ml at high risk of progression. His prostate is small, the 5-ARI does not target his storage symptoms, and stopping the alpha blocker would lose the voiding benefit.
• D — CG97 says consider an added anticholinergic, not always, and only after conservative measures. Given his forgetfulness and existing anticholinergic medicine, cognition and total anticholinergic load need weighing first.

Why

NICE NG31 (Care of dying adults in the last days of life, 2015) recommends an individualised approach to anticipatory prescribing: assess which medicines the person might need for symptoms likely in the last days of life — agitation, anxiety, breathlessness, nausea and vomiting, noisy respiratory secretions and pain — and ensure suitable medicines and routes are prescribed as early as possible, reviewed as needs change. NG31 asks prescribers to weigh the likelihood of each symptom, the benefits and harms of prescribing and of not prescribing, the risk of sudden deterioration, and the place of care and the time it would take to obtain medicines. A Friday afternoon at home is exactly that last point. Before any anticipatory medicine is given, NG31 asks for a review of the person’s symptoms.

Why not the others

• B — NG31 asks for medicines to be prescribed as early as possible, taking into account the time it would take to obtain them. Waiting for a symptom at a weekend at home leaves her without relief when she needs it.
• C — She is comfortable. NG31 suggests considering a syringe pump when more than 2 or 3 doses of any as-required medicine have been given in 24 hours — and a standard regimen is not individualised.
• D — NG31 says do not routinely start oxygen for breathlessness — only for known or suspected symptomatic hypoxaemia. On hydration it asks for support to drink if she wishes and a daily assessment of whether clinically assisted hydration is needed, not routine fluids.

Why

GMC guidance (Treatment and care towards the end of life) says that where CPR will not be successful, doctors are not obliged to provide it — but the decision must be sensitively discussed with the patient unless this would cause them serious harm — and serious harm means more than that the patient might become upset. If a patient still wants CPR, the GMC asks doctors to explain their reasons and the patient’s right to seek a second opinion. Both the GMC and the Resuscitation Council UK are clear that a DNACPR decision applies only to CPR; other appropriate treatment and care continue. The wider conversation belongs in advance care planning: ReSPECT (the Recommended Summary Plan for Emergency Care and Treatment) records personalised recommendations, agreed in conversation with the person and those close to them, for a future emergency in which they cannot make or express choices. It is not legally binding, unlike a valid advance decision to refuse treatment. NICE NG142 (2019) asks services to ensure advance care planning is offered to adults approaching the end of their life.

Why not the others

• A — A DNACPR decision covers CPR only. It does not imply that any other treatment will be withheld or withdrawn.
• B — A clinical judgement that CPR would fail does not remove the duty to tell him. The exception is serious harm — more than distress.
• D — A person with capacity can refuse CPR, but there is no obligation to provide CPR that will not succeed. He should be told why, and offered a second opinion if he wants one, in line with GMC guidance.