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.