2008 will hopefully be a fine year in the blogsphere.
Although sadly Maple Leaf Medic has stopped blogging, Dr Brown has returned with patient experiences and keen insight in equal measure, Mousethinks waxes lyrical with thought provoking clinical contacts, Cal's accounts remain as stimulating and entertaining as ever, Milk & 2 Sugars is back from her soujourn after exams and thankfully continues to deliver her antipodean perspective and humour as does Polly with The Girl giving more medical student perspectives.
It's a shame that The Psychiatrist Blog remains silent since even those not enthusiastic 'bout it would say it generated stimulating and animated discussion. Shiny Happy Person continues to write 'bout psychiatry far better than I ever could, succinctly conveying what I'd spend pages waffling over, giving a pithy and somehow more real account of both postgraduate medical training and of psychiatric clinical practice that's always engaging to read.
What with retired nurses and the vibrant Mental Nurse site keeping me both pondering and entertained, there's a lot to look forward to reading through 2008.
What I'm really looking forward to is the illuminating discourse from Zarathustra (gah, the link's old, he's not still a student) 'bout the text Al Azif penned by Abdul Alhazred. A true treatise on sanity, hmmm! ;-)
Friday 28 December 2007
Wednesday 26 December 2007
Tuesday 18 December 2007
Antipsychotics
I work with older adults 'cept when I'm on call.
A couple weeks ago, when on call and covering everything, I had to deal with "a problem" that an acute admission ward was having with a chap in his 20's who was psychotic. He'd no past episodes. He was a non-smoker. Deluded, grandiose, assertive, thought disordered and at risk (having driven his van in to a neighbour's house) and drug/alcohol free, the nursing staff were perturbed that he was awake at night, shouting and resisting personal care (like a bath, earler that evening). When one nurse forced him back in to his bedroom, and the bloke swung at the nurse, they called me to review things.
When I saw him he was pretty calm with me over the hour I talked with him, and pretty reasonable and accepting of options explored.
He felt awake, he wasn't sleepy, he never went to be at 11.00pm normally even when well, he didn't want to lie down when he wasn't remotely tired.
The admitting team had him on 20mg olanzapine (the maximum dose), 4mg lorazepam (the maximum dose) and 7.5mg zopiclone (the maximum dose).
Maximum BNF doses make me ponder. Is it that the drugs are the wrong answer? Is it that drugs are the right answer but we've chosen the wrong drugs? Is it that the drugs aren't being given? Is it that the pharmacodynamics require more than one drug to be given? Is it that patient factors (how their body handles medication) means higher doses need to be given? Is it something that patient's doing (e.g. smoking cigarettes affects olanzapine's dose a lot, effectively halving it) that affects the dose?
It struck me that high dose antipsychotics didn't seem justified even though it's what the nursing staff sought. I'm not one to leave nursing staff to get battered, but I really believed that this chap could be managed with skilled nursing care and the medication he was on. We got an extra nurse on to the ward (she wanted the extra shift for cash before Christmas anyway ;-) ) and helped with reality orientation, distraction and de-escalating arousal/distress better than more antipsychotics could. There were no more assaults and no documented episodes of hostility or aggression.
A week later and the team say he's doing well. His sleep pattern is normal. His psychosis is resolving. Thank goodness he's not established on hefty doses of more drugs (since invariably that's then seen as what's cured him, so that's evidence to stay on them all for ages).
Happen it's because I'm an old age psychiatrist (and often am at BNF limits but seldom exceed BNF limits), but ramping up doses of high dose antipsychotics increasingly fills me with ill ease. When discussed at a case conference I was struck that I was in the minority, most colleagues taking a different view. It's a funny old world.
A couple weeks ago, when on call and covering everything, I had to deal with "a problem" that an acute admission ward was having with a chap in his 20's who was psychotic. He'd no past episodes. He was a non-smoker. Deluded, grandiose, assertive, thought disordered and at risk (having driven his van in to a neighbour's house) and drug/alcohol free, the nursing staff were perturbed that he was awake at night, shouting and resisting personal care (like a bath, earler that evening). When one nurse forced him back in to his bedroom, and the bloke swung at the nurse, they called me to review things.
When I saw him he was pretty calm with me over the hour I talked with him, and pretty reasonable and accepting of options explored.
He felt awake, he wasn't sleepy, he never went to be at 11.00pm normally even when well, he didn't want to lie down when he wasn't remotely tired.
The admitting team had him on 20mg olanzapine (the maximum dose), 4mg lorazepam (the maximum dose) and 7.5mg zopiclone (the maximum dose).
Maximum BNF doses make me ponder. Is it that the drugs are the wrong answer? Is it that drugs are the right answer but we've chosen the wrong drugs? Is it that the drugs aren't being given? Is it that the pharmacodynamics require more than one drug to be given? Is it that patient factors (how their body handles medication) means higher doses need to be given? Is it something that patient's doing (e.g. smoking cigarettes affects olanzapine's dose a lot, effectively halving it) that affects the dose?
It struck me that high dose antipsychotics didn't seem justified even though it's what the nursing staff sought. I'm not one to leave nursing staff to get battered, but I really believed that this chap could be managed with skilled nursing care and the medication he was on. We got an extra nurse on to the ward (she wanted the extra shift for cash before Christmas anyway ;-) ) and helped with reality orientation, distraction and de-escalating arousal/distress better than more antipsychotics could. There were no more assaults and no documented episodes of hostility or aggression.
A week later and the team say he's doing well. His sleep pattern is normal. His psychosis is resolving. Thank goodness he's not established on hefty doses of more drugs (since invariably that's then seen as what's cured him, so that's evidence to stay on them all for ages).
Happen it's because I'm an old age psychiatrist (and often am at BNF limits but seldom exceed BNF limits), but ramping up doses of high dose antipsychotics increasingly fills me with ill ease. When discussed at a case conference I was struck that I was in the minority, most colleagues taking a different view. It's a funny old world.
Thursday 13 December 2007
Social Care
It's not often that I recommend that a patient is detained under the Mental Health Act 1983, but this week I had cause to do just that. That makes 3 patients detained this year, not bad for a full time Consultant Psychiatrist and less than my colleagues, but I'm still conscious that it's loss of liberty and choice for 3 people at a distressing time in their lives.
This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.
I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.
I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.
Much badness.
This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.
I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.
I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.
Much badness.
Wednesday 12 December 2007
Care
Again I shamelessly take themes that you, gentle readers, generate yourselves rather than having creativity myself. Again I'm caught by Disillusioned's comments about differences in service provision arising within the same Trust.
So I had a rummage around the stats and, what do you know, Disillusioned is right.
Within our Trust the General Adult services are pretty hit and miss. Some folk get a decent service, many don't. I could wax lyrical about why this is, but it'd be futile and consume me with despair which really isn't in the spirit of the Christmas season!
Within my own corner, Older Adults, my sector is seen to be working well. I've had my annual appraisal last week with a Director from another hospital and he reckoned All Was Good. I've presented at conferences how our team works, since it's seen as A Good Thing. Our Trust likes it and has had me doing teaching and roped in to meetings 'bout it all. In truth, it's all about the team (not me) so it's curious that I get to say my spiel when it's the team as a whole doing the work.
But it got me comparing my team with others. And there is indeed a lack of parity. My team has less qualified and less unqualified staff than any other team. It's the smallest. Other teams, that are larger, have broadly the same amount of work to do (referral rates and sector populations being comparable). In all teams no new patient has to wait more than 10 days to be seen, in our team referrals are all usually seen within the week. Access time aside, from referral with memory problems to receiving your first prescription for a cognitive enhancer, my team gives fastest access, a couple teams are similar but somewhat longer, one team has a delay of almost 2 months longer.
Interesting to see that folk in the same patch with more staff and the same amount of work have a less responsive service.
Now how the heck is this tactfully taken forward?
So I had a rummage around the stats and, what do you know, Disillusioned is right.
Within our Trust the General Adult services are pretty hit and miss. Some folk get a decent service, many don't. I could wax lyrical about why this is, but it'd be futile and consume me with despair which really isn't in the spirit of the Christmas season!
Within my own corner, Older Adults, my sector is seen to be working well. I've had my annual appraisal last week with a Director from another hospital and he reckoned All Was Good. I've presented at conferences how our team works, since it's seen as A Good Thing. Our Trust likes it and has had me doing teaching and roped in to meetings 'bout it all. In truth, it's all about the team (not me) so it's curious that I get to say my spiel when it's the team as a whole doing the work.
But it got me comparing my team with others. And there is indeed a lack of parity. My team has less qualified and less unqualified staff than any other team. It's the smallest. Other teams, that are larger, have broadly the same amount of work to do (referral rates and sector populations being comparable). In all teams no new patient has to wait more than 10 days to be seen, in our team referrals are all usually seen within the week. Access time aside, from referral with memory problems to receiving your first prescription for a cognitive enhancer, my team gives fastest access, a couple teams are similar but somewhat longer, one team has a delay of almost 2 months longer.
Interesting to see that folk in the same patch with more staff and the same amount of work have a less responsive service.
Now how the heck is this tactfully taken forward?
Monday 10 December 2007
No work
Disillusioned kindly posted comments 'bout Day Hospital but then interestingly mentioned how staff sickness meant that the work didn't get done.
This got me thinking.
If a Consultant Psychiatrist is off sick for a short time (a few day), any routine work isn't done but any urgent work is covered by colleagues, being absorbed in to their working week. If off for any length of time, a locum is brought in to fill the post and do the work. Although I've not had a day off sick this year, nor have others I work with, I think that it's understandable that if I am off sick, 'phoning in that morning to say I'm on my death bed, then the clinic list for that day would have to be cancelled. Given that the work isn't done by anyone else then has to be done when I return to work, on top of everything else, it's usually easier to soldier on and do the work rather than take time out one week then have 2 weeks' work to do the next. But anyway, short term sickness will occasionally occur and will occasionally impact on appointments.
For nursing staff, the story's the same for short term sickness too. If colleagues are off for a short time then urgent stuff is dealt with and some it's understood that appointments for that day may need to be cancelled. Going through all activity since April 2008, we've actually not had to do this terribly often, since either other CPNs* or I have done the visits instead. Thus, we can count on one hand the number of patients who've had cancellations through sickness. We don't like to mess patients around so if we can sort it out we rather would do, then we're up to date and the patient's had the input we'd all felt was needed.
Long term sickness is different, though. I've little sympathy or understanding for why long term sickness should affect patient visits and support at all, since it's long term (so plans can be made to address this).
Disillusioned said that staff off long term do have impact on support. Needs identified and planned for within the Care Programme Approach (CPA) should, obviously, be met. The whole point of it is that you're looking at needs and planning medical, social and nursing care to address these needs.
For a service to have folk, with CPA evidencing the service provision nececssary for their health, to then fail to deliver, seems wholly inexcusable. Okay, if through short term sickness I'd concede as above that the odd visit may not happen, but for people to just do nothing is unbelievable. It's embarrassing.
In what other area could someone be off work, have patients in need of support, and still no support is given and no work gets done?
* Apologies to anyone who's a Integrated Developed Independent Outreach Team (IDIOT) nurse and not a CPN, but I can't get my head around new jargon for new jargon's sake ;-)
This got me thinking.
If a Consultant Psychiatrist is off sick for a short time (a few day), any routine work isn't done but any urgent work is covered by colleagues, being absorbed in to their working week. If off for any length of time, a locum is brought in to fill the post and do the work. Although I've not had a day off sick this year, nor have others I work with, I think that it's understandable that if I am off sick, 'phoning in that morning to say I'm on my death bed, then the clinic list for that day would have to be cancelled. Given that the work isn't done by anyone else then has to be done when I return to work, on top of everything else, it's usually easier to soldier on and do the work rather than take time out one week then have 2 weeks' work to do the next. But anyway, short term sickness will occasionally occur and will occasionally impact on appointments.
For nursing staff, the story's the same for short term sickness too. If colleagues are off for a short time then urgent stuff is dealt with and some it's understood that appointments for that day may need to be cancelled. Going through all activity since April 2008, we've actually not had to do this terribly often, since either other CPNs* or I have done the visits instead. Thus, we can count on one hand the number of patients who've had cancellations through sickness. We don't like to mess patients around so if we can sort it out we rather would do, then we're up to date and the patient's had the input we'd all felt was needed.
Long term sickness is different, though. I've little sympathy or understanding for why long term sickness should affect patient visits and support at all, since it's long term (so plans can be made to address this).
Disillusioned said that staff off long term do have impact on support. Needs identified and planned for within the Care Programme Approach (CPA) should, obviously, be met. The whole point of it is that you're looking at needs and planning medical, social and nursing care to address these needs.
For a service to have folk, with CPA evidencing the service provision nececssary for their health, to then fail to deliver, seems wholly inexcusable. Okay, if through short term sickness I'd concede as above that the odd visit may not happen, but for people to just do nothing is unbelievable. It's embarrassing.
In what other area could someone be off work, have patients in need of support, and still no support is given and no work gets done?
* Apologies to anyone who's a Integrated Developed Independent Outreach Team (IDIOT) nurse and not a CPN, but I can't get my head around new jargon for new jargon's sake ;-)
Wednesday 5 December 2007
Clinical Research
Commonly I'm asked to help manage Behavioural and Psychological Symptoms of Dementia (BPSD).
Usually this involves stopping medication that's making things worse and changing the environment to reduce ambiguity and distress then psychoeducation to guide carers on what to expect, how to de-escalate distress and what interventions can be effective to minimise disturbed behavioural repetoires without compromising personal care.
For example, a wife recently struggled to bath her dementing husband because he assertively resisted each time she tried. Removing unnecessary medication made him much more content more of the time anyway, then guidance with her meant she'd cracked it and was able to use a mix of ongoing reality orientation and reassaurance to bath him without any problems.
Still, for some folk, medication for BPSD is useful. I don't like older antipsychotics, I won't sedate anyone to "make things more manageable" and I'll only use medication as part of the process of care (rather than being seen as the solution itself). At best, medication then is something that helps the patient and carers manage behavioural disturbance better, allowing the patient to engage with the carer in the techniques they can use. Medication, then, is just a tiny part of the solution, helping the carer do the high quality dementia care we teach and advocate.
With that in mind, it's not often I find myself using olanzapine or risperidone in the treatment of BPSD. Just a couple times a year, that I can recall. But there's a snag.
The UK Medicines and Healthcare products Regulatory Agency (MHRA) said that they shouldn't be used.
Letters in the British Medical Journal criticised the authority/strength of direction, saying these drugs shouldn't be used, since they're clinically helpful and risks were low.
A more objective observational study didn't find the level of risk and concern the MHRA described concluding, "Perhaps the best we can say is that on the basis of this good observational study, the risk of increased strokes from atypical antipsychotics in dementia is less than the trials indicate."
The MHRA say that background risk of stroke is about 1% a year in this patient group. Patients on olanzapine or risperidone have an annual risk of about 3%. Many of the strokes are small (and arising in people with a degree of vascular dementia already).
The MHRA conceded that it's not likely to be a problem with these specific drugs, it's just that there's evidence about them. So alternatives aren't known to be any safer.
These patients with dementia and behavioural disturbance often can't and don't have capacity to give valid consent to treatment with a difficult risk/benefit ratio to consider. As the medics in the BMJ wrote, who is advocating that they should get the care they need and deserve?
Studies tell us about general risks and trends and effects. They don't tell us about our specific patient in front of us. Curtailing clinical freedom so the individual's care is overly influenecd by "average" statistical trial outcomes is harmful.
Much badness.
Usually this involves stopping medication that's making things worse and changing the environment to reduce ambiguity and distress then psychoeducation to guide carers on what to expect, how to de-escalate distress and what interventions can be effective to minimise disturbed behavioural repetoires without compromising personal care.
For example, a wife recently struggled to bath her dementing husband because he assertively resisted each time she tried. Removing unnecessary medication made him much more content more of the time anyway, then guidance with her meant she'd cracked it and was able to use a mix of ongoing reality orientation and reassaurance to bath him without any problems.
Still, for some folk, medication for BPSD is useful. I don't like older antipsychotics, I won't sedate anyone to "make things more manageable" and I'll only use medication as part of the process of care (rather than being seen as the solution itself). At best, medication then is something that helps the patient and carers manage behavioural disturbance better, allowing the patient to engage with the carer in the techniques they can use. Medication, then, is just a tiny part of the solution, helping the carer do the high quality dementia care we teach and advocate.
With that in mind, it's not often I find myself using olanzapine or risperidone in the treatment of BPSD. Just a couple times a year, that I can recall. But there's a snag.
The UK Medicines and Healthcare products Regulatory Agency (MHRA) said that they shouldn't be used.
Letters in the British Medical Journal criticised the authority/strength of direction, saying these drugs shouldn't be used, since they're clinically helpful and risks were low.
A more objective observational study didn't find the level of risk and concern the MHRA described concluding, "Perhaps the best we can say is that on the basis of this good observational study, the risk of increased strokes from atypical antipsychotics in dementia is less than the trials indicate."
The MHRA say that background risk of stroke is about 1% a year in this patient group. Patients on olanzapine or risperidone have an annual risk of about 3%. Many of the strokes are small (and arising in people with a degree of vascular dementia already).
The MHRA conceded that it's not likely to be a problem with these specific drugs, it's just that there's evidence about them. So alternatives aren't known to be any safer.
These patients with dementia and behavioural disturbance often can't and don't have capacity to give valid consent to treatment with a difficult risk/benefit ratio to consider. As the medics in the BMJ wrote, who is advocating that they should get the care they need and deserve?
Studies tell us about general risks and trends and effects. They don't tell us about our specific patient in front of us. Curtailing clinical freedom so the individual's care is overly influenecd by "average" statistical trial outcomes is harmful.
Much badness.
Tuesday 4 December 2007
Day Hospital
Should we have one?
The case against is compelling.
Our day hospital has oodles of staff treating very few of my patients. Not much bang for our buck. If the staff were in a Community Mental Health Team they'd be seeing about 4 to 5 times as many folk.
What does a Day Hospital do that a CMHT and social service day centres and EMI nursing homes can't do, if NHS staff visit and work within them?
The case against is compelling.
Our day hospital has oodles of staff treating very few of my patients. Not much bang for our buck. If the staff were in a Community Mental Health Team they'd be seeing about 4 to 5 times as many folk.
What does a Day Hospital do that a CMHT and social service day centres and EMI nursing homes can't do, if NHS staff visit and work within them?
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