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At the heart of general practice since 1960

Five-minute Practitioner: January 2009

Only got five minutes? Then just read these key points on: physical activity, Alzheimer's disease and shoulder pain

Only got five minutes? Then just read these key points on: physical activity, Alzheimer's disease and shoulder pain

Physical activity

Disability is not necessarily inevitable in old age and may be postponed or avoided by positive lifestyle choices. Participation in regular, moderate-intensity physical activity in old age, such as walking, can double the likelihood of dying free from disability.

Regular physical activity can significantly reduce blood pressure and has been shown to confer some protection against CHD, diabetes, osteoporosis, and breast and colon cancer.

Long-term follow-up studies have also shown that older people who exercise three or more times a week are less likely to develop dementia.

The psychological benefits of regular physical exercise should not be underestimated. It improves self-esteem and wellbeing, and may reduce mild depression.

Deterrents to physical activity include lack of interest, physical symptoms, reluctance to join a group and mistaken beliefs about the lack of benefit.

For the vast majority of the population the risk associated with sedentary behaviour substantially outweighs any risk from physical activity. Patients can be reassured that if they are engaged in an activity that is not causing symptoms of distress, they are very unlikely to be doing themselves any harm.

GP support can be a powerful impetus for adopting and maintaining an active lifestyle.

The key message for older patients is that ‘doing something is better than doing nothing'. For many patients, walking is the ideal activity.

Public health recommendations suggest that most adults should be doing around 30 minutes of moderate-intensity activity on most days of the week.

Alzheimer's disease
Advancing age is an incremental risk factor for Alzheimer's disease (AD). The risk doubles every five years after the age of 65, increasing from 3 to as high as 69 per 1,000 person-years. Women, particularly those over the age of 85, have an increased risk of developing the condition.

Medical problems need to be actively identified and a plan of treatment developed with ongoing patient monitoring. FBC, electrolytes, glucose, B12, folate, TFTs, LFTs, and VDRL should be measured. BP should be checked and a short neurological examination performed. Ideally, a structural scan (CT or MRI) should be arranged to exclude organic treatable processes. The MMSE is a useful screening test for dementia.

The pharmacological treatment of behavioural symptoms of dementia, including depression, should be initiated by specialists. AChEI are recommended in the management of patients with AD of moderate severity only. Cognitive stimulation improves quality of life and cognitive function and adds to the effects of donepezil in mild and moderate AD.

GPs should refer patients eligible for treatment with AChEI, patients whose diagnosis is unclear and who may need more specific investigations such as brain scans or neurological and neuropsychological examinations and those who may benefit from a combined approach with psychotropic drugs and behavioural support from a mental health team in the community.

Shoulder pain

Common causes of shoulder pain in primary care include impingement/rotator cuff pathology, glenohumeral disorders such as frozen shoulder and arthritis, ACJ arthritis and referred pain.

When making a diagnosis consider the character and onset of the pain, the site and how it has changed over time, precipitating and relieving factors and also target questions to exclude cervical, neurological or chest wall problems.

It is important to remember and assess the functional aspects of the shoulder problem and how the pain is impacting on the patient's life.

Examination should include the cervical spine. Shoulder examination should be conducted from the rear and involve looking for muscle wasting, ‘squaring' or swelling. Feel for tenderness, warmth and crepitus at all the shoulder joints.

Specific X-ray views should be requested depending on suspected diagnosis but the shoulder MRI is the investigation of choice and will provide the information necessary for surgical decisions.

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