Tuesday 18 December 2007


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.


Elaine said...

It takes patience and skill to cope with a patient who is being seen to be disruptive or dangerous. I think what you did was excellent - with perhaps the most important aspect after giving of your time to talk to this man, being the giving of an extra nurse.

So often understaffing leads to staff being unable to cope.

Milk and Two Sugars said...

If he had been unable to converse with you and unresponsive to reorientation, reasoning, etc, would you have prescribed more drugs? (I appreciate that good psychiatrist-ing and nursing were sufficient in this situation, but surely there are occasionally patients too ill to make sense of you?)

The Shrink said...

M&2S that's a good question.

As I said, my first thought would still be, "If I'm using an antipsychotic, and they're not getting better, am I doing the right thing?"

My "cure" rate (okay, my rate of symptom reduction, resolution of distress, enabling coping, effecting change) is seen as the same as my colleagues but with substantially fewer days in hospital (I've only one inpatient this week, had none at all for a while a few weeks ago).

Audit and review means I'm confident my practice is effecting at least as good outcomes as my peers but the last time I used doses above the BNF maximum was a year ago when last December a manic patient with dementia improved on antipsychotics and galantamine but not as much as I'd have hoped. Improvement showed the medication was doing something, he'd not got any side effects so ramping up the dose worked well for him. But this year I've yet to use high dose (meaning using over the BNF limit of one drug, or using several antipsychotic drugs that collectively total more than 100% of one ontipsychotic when pooled).

So yes, I do prescribe more drugs (more meaning over BNF limits), but would need clear rationale to do so, with clear understanding of what was being achieved and under what circumstances it would subsequently be reduced or withdrawn.

Disillusioned said...

It also takes time and willingness to talk with and listen to patients. Much "easier" to drug them up.
Glad you were able to buck the trend in this case at least - and in others too, from what you have written here.

Anonymous said...

Some of my more respected psychs think similarly to yourself. Of the few that really rock my nursing world they are the ones that make me work harder. Smart bastards they are.
Making the 'team' think bigger than the pill box is a talent many psychs could/should lead the way on and not just rely on others to use their noggins sometimes. I am not sure but believe psychs expect (and rightly so) that other professionals actually know they're adjunctive jobs and aren't there purely to guard and watch over the effects of medication.
When called to assist, I appreciate the advice of the psych who promotes the consideration of alternative options; such as distracting activity, family contact, creative use of limited resources, humour. Removing the negative behaviours by empowering the postitive behaviours for challenging people is a far safer way than just upping meds but often falls down because of limited skills and resources, apathy, staff hangovers or plain belligerence.
Sometimes directing non-pharmaceutical care as part of a plan is necessary and is most effective when the team are called to evaluate the results of that care - sometimes resulting in "oh, we didn't actually do that because he got better" (usually translates to - we didn't fancy doing that so we just stopped considering his behaviour as a problem or did something else instead more interesting with him).
I don't like meds as a frontline or unilateral response; it's a back up or adjunct to other psychosocial interventions that seem to be all too ignored.

Fiona Marcella said...

Very intersting post and comments.
My main problem with treatment that seeks to avoid over medication is that, as a "carer" (hate the word, but what other will do?) I've got on much better with the psychiatrists who have prescribed, than those who haven't.

Is that because I'm a lazy cow looking for a magic pill to cure my daughter's illness rather than looking into family systems, her environment, treatment that involves work on her part and mine? Probably.

I've found those who want to demedicalise problems very difficult to get on with, at least in part because unlike those who say "lets try this pink pill or what about a blue one" they don't suggest any solutions, just sum up and say "over to you".

I'm not suggesting that this isn't the best approach, it's just that so far as a family we've failed pretty spectacularly at rising to the challenge.

The Shrink said...

Marcella, I'm not against medication, if someone's psychotic (and it's not going to pass in a couple days) then I'm all for antipsychotic medication. Life's too short to miss weeks of it through being psychotic for weeks on end, being needlessly robbed of that time and opportunities that can never be recovered.

The crux of it is that medication has a massive role to play for a small number of folk (so there's nop other compelling choice but to use it), and no role to play for a small number of folk (so there's no other compelling choice but to avoid it).

For the majority of folk it possibly has a role to play, of varying degree, so there's a choice.

There are choices then of using/not using medication and of type of medication (antipsychotic, antidepressant, anxiolytic, mood stabiliser, sedative, hypnotic), of using drugs alone or in combination and choice of dose.

I'm against thoughtless use of medication as a simple, expedient solution (that conveniently ends things, as you hand the prescription over so all's done) because it's not always the right thing to do. As mental health workers we shouldn't do what's easy, we should do what's right. Saying Person X has Diagnosis Y so just prescribe Drug Z is simplistic and usually ineffective.

I'm all for prescribing thoughtfully, using the right drug at the right dose for the right reason for the appropriate duration.