Thursday, 17 January 2008


I met with a young patient who has dementia (F00.02 Dementia in Alzheimer's disease, early onset, severe) and his wife.

They'd had a chequered course before relocating to be with family, so moving in to my patch. They've input from social services, our local Alzheimer's Society branch, myself, my nursing colleagues and a Support Time and Recovery (STAR) worker. The patient's never been to hospital, we're all pretty community focussed and see them there to give advice (no Council Tax to pay, get Attendance Allowance etc), to give emotional support, to give practical support (our STAR worker visits once a week to care for him so his wife can pop out and get a break), to offer other helpful ways to cope (they're starting day respite with us tomorrow), to answer queries (this week they were wondering why his walking up stairs was worse) and to look at medication.

His MMSE is 2/30, his dementia is severe. Donepezil is being used to treat Behavioural and Psychological Symptoms of Dementia (BPSD) not to maintain cognitive levels any more. When his MMSE dropped from moderate to severe the donepezil was withdrawn. He became upset, irritable, distraught and withdrawn, shouting and resistsing personal care. When re-introduced he became active, animated and appreciative (most of the time) of his wife's input. The donepezil is doing the man good.

Now, with so many people involved, a lot of information was gained before I met with him and his wife. What was embarassing for the senior nurse was that the medication she said our patient was taking, "Just donepezil," wasn't quite true. She and I saw them this week. When I was talking about mood swings, irritability, frustration emerging when attending to ADLs and forgetfulness, his wife chipped in that she gave him an antidepressant they still had lying around, "but only once or twice a month." He also received over the counter medication for coughs, colds, constipation and pain too. The nurse was scarlet, couldn't believe that the history I got was so different from what she's ellicited just a couple days ago after spending 2 hours with them. I'd not see it as a big thing, they spoke at length with her about practical care but spoke at length with me about symptoms, progression and medication.

I remember as a junior doctor the injustice of me taking a lengthy history then my patient saying something different to my Registrar or Consultant. People do, though. It can be that going through things once then raises more thoughts. It can be that stirring thoughts around in that direction leads on to more detail and depth when asked again.

Anyway, one outcome from me spending an hour with them talking through their dementia care was that he regularly wasn't swallowing his medication. I don't feed at the trough at all, I don't take anything from drug companies (not even biros). But credit where it's due, their orodispersible donepezil is A Good Thing. She puts it on his tongue, it instantly melts and dissolves, all is well.

Without medication, he's unwell. With it, life's better for him and his wife. The medication's formulated in a way that folk with severe dementia can take it.

Much goodness.


Anonymous said...

Just a note on the injudicious history taking; same thing happens when pt X is behaving like a donut and you ask the doc to review so he has a first hand experience of what you're talking about - and on due arrival, pt X acts like an angel.

On a similar line; but slightly off - there are those who like to use their knowledge and astute observations to appear of greater importance...
I remember barking mad patient Z - Z shook the super consultant's hand. super consultant and super nurse were then discussing the possible causalities of pt Z's cold extremeties.. hyperkalaemia perhaps? hyponatraemia? (I forget the indicated conditions.. but anyway...)
I invited pt Z into the office to join in the debate..
"Hey Z.. do you still run your hands under the icy cold water for 10 minutes to get rid of the devil?"
"Oh yes Ian. I must."
super egos deflated.

toolate said...

Much, inflated badness.

Polly said...

hehehe, on the Hx taking thing. I'm at the point where when I take the Hx and present it to a resident, then the resident takes the history again and presents to a registrar- we all get totally different things. Why can't these lovely patients just be consistent? :P

imPRESsed1 said...

Good blog. Do you see any clinical improvement with memantine in patients like this? Or only for mild/moderate sx?

The Shrink said...

Graham, thanks for stopping by and commenting. Memantine seems to have modest utility (which, I guess, is why NICE don't sanction it's use on the NHS outside of research work).

It's got the big advantage that it's not got the cardiac side effects/risks that the 3 acteylcholinesterase inhibitors all have.

It's got the big disadvantage that it doesn't seem to work so well.

I find that some folk with mild dementia do very well with it. I've some folk with early onset Alzheimer's disease and Picks disease who've proven dementia that's been stable for years on treatment (with decline prior to starting memantine). It seems to be a useful adjunct in mild dementia in younger adults, for some patients.

Too, it's useful in helping de-escalate extreme behavioural and psychological symptoms of dementia (BPSD) in severe dementia, for some patients.

So for some younger adults with mild dementia and for some folk with severe BPSD it seems useful but, really, outcomes haven't been stunning in our Trust. We've done audit and even paid a research assistant to generate detailed research in our memory clinic. With objective scrutiny, in our clinical practice, memantine's not stacking up at all favourably.

Jan said...

How nice to see a doc acknowledging that there are reasons why histories differ when given to different people. My last psych admission involved me speaking to seven different people at different times - of course I said different things to each of them. One reason for this (glossing over differing levels of trust and/or subjective distress) is that each of them asked me different questions.

Calavera said...

Oh my goodness, tell me about it!

On my first surgical firm (with a really really hardcore consultant, who made us check up on our patients twice a day) I spent the better part of an hour taking a history from an elderly gentleman.

When I presented him to the consultant on the post-take ward round, I recited a very eloquent history with all the vital details included.

At the end of it, there was a brief pause and the consultant looked at me expectantly. Then he finally said, "Did you ask about this gentleman's prostatic history at all?"

I nodded and said there was nothing of note (I had asked all the relevant questions to the patient, only to be answered with negatives.)

The consultant looked at me and then said, "Yes. Well. This gentleman has had increasing prostate symptoms for a few months now which is why he's here today for further investigations."


" why exactly did you think he was in hospital today?"

I didn't dare say 'because he had a tummy ache?'

Oh dear.