Over the last two weeks I've seen three new patients with acute confusional states (or delirium, as it seems to be called, once again). All presented with disorientation, distress, lethargy and low mood.
Having stopped their amitriptyline, which had been appropriately started by their GPs then they'd been on for ages, I've reviewed them all this week.
They've all improved. A lot. Tiredness, mood and muzzy head causing disorientation, all gone. Great to have days where folk are reviewed and have been cured. Other than use of ECT, it's rare to have those "pick up your bed and walk" cured moments in old age psychiatry, then three come at once!
Thursday, 29 May 2008
Tuesday, 27 May 2008
Songs
Milk & 2 Sugar tagged me over at Tea at Ten, to list 7 songs I've been listening to this week. As both my readers will know I don't usually go for this tagging malarky, but how can I refuse her? Without further ado :
David Bowie, Heroes
Leonard Cohen, Dance me to the end of love
Amy Winhouse, the whole album but the last track I heard was Back to black
Sting, Fields of gold
Bon Jovi, It's my life
Madeline Peyroux, Don't wait too long
Heather Small, Proud
I know, I know, I'm a mixed up kind of guy, ho hum!
David Bowie, Heroes
Leonard Cohen, Dance me to the end of love
Amy Winhouse, the whole album but the last track I heard was Back to black
Sting, Fields of gold
Bon Jovi, It's my life
Madeline Peyroux, Don't wait too long
Heather Small, Proud
I know, I know, I'm a mixed up kind of guy, ho hum!
Community Pharmacists
I work with good GPs. I have a good relationship with them. Since joining this Trust, no GP has ever referred a problem as urgent and not had it attended to within 24 hours. No urgent emergency has has to wait more than 4 hours. We're audited on this every month, so I know we're a responsive service, which GPs appreciate.
Because of this relationship we've developed, there's been a healthy dose of common sense between Primary and Secondary Care.
Say a drug dose changes and a patient needs an ECG doing in a couple weeks but it's a way to trawl to the hospital, most GPs have no issue with the ECG being done in their surgery by their Practice Nurse. It's eating up a bit of their Practice Nurse time, it's generating no income for them, they have to mail the ECG to me, the ECG can be done in the hospital, but to smooth out things for their patients they offer this choice.
I take on and manage and follow up patients who are outwith our operational policy, but if I didn't do this they'd cause chaos and difficulties for the GP.
To date it's worked well, we blur boundaries, support one another and take policies/protocols with a pinch (well, more huge great handfuls) of salt and simply crack on and do what's best.
I like this.
Recently, one group of practices has appointed a new pharmacist. She's keen. She's determined to bring prescribing costs down. She's never met me. She has written to me, prolifically. A few things concern her. Well, that's disingenuous, I assume they don't concern her since she's a pharmacist with the salient information to hand so will know that the prescribing is rational and appropriate. What concerns her is the cost. Through this, she's notionally concerned that :
Lorazepam
Some patients with dementia are on lorazepam. They were battering people and were unmanageable. Now they're on 2mg of lorazepam regularly with some prn and are cured. They're in care homes with regular nurse follow up to ensure that the care homes use the minimum dose and complete diraies/use behavioural programmes rather than focus on medication. But although none of them are on more than 4mg of lorazepam, the British National Formulary (BNF) states a dose of lorazepam of 4mg in adults, 2mg in the elderly. These folks can sometimes have more than 2mg.
Of course, it's titrated to clinical need, there are no treatment emergent adverse events and it's working. So we use medication at the minimum effective dose, but that minimum is sometimes above 2mg. It's better than using lots of drugs at low (less effective/ineffective) dose. Our Royal College and voluntary groups advocate this.
She's asking that I undertake prescribing for all these patients, removing all such prescribing from the GPs. More than asking, she's saying that she's not willing for the GPs to prescribe these.
I'm sorely tempted to write back and suggest if she wants to change their drug regimen, go ahead and good luck.
Antipsychotic medication
A number of patients are on antipsychotic medication because of their dementia, causing memory loss and changes in thought so they're less adept at reality testing and become muddled. Antipsychotics can help smooth out chaotic thoughts so they can grasp the right train of thought more successfully more of the time. Also it can help with distress, helping folk feel less distraught. In some dementias people have delusions. They lose things, through poor memory, then try and understand why and reason it's been stolen, then look around over time and are mildly disoriented which fits with intruders, then develop abberant ideation as cognition deteriorates so can become deluded, with paranoid delusions. Antipsychotics can help these. Some will hallucinate. Antipsychotics can help these, too.
The BNF does not list licenced indications of Behavioural and Psychological Symptoms of Dementia for any drugs. Dementia care, with medication, is almost all outside the listed Summary of Product Characteristics (SPC) that all drugs have. The trials needed to get this evidence base, to change their SPC, aren't easy. They're not cost effctive and they're ethically fraught. Almost all prescribing in old age psychiatry is "off label" and outwith what the SPC says. A pharmacist will know this because the BNF has few modern drugs that we use that are developed with trials in older adults.
No means no!
I have no desire to take on routine prescribing responsibility for every patient with dementia. I have no computer for repeat prescriptions, all my prescribing is thoughtful and individual. If it is routine my GPs kindly undertake it.
What to do, what to do :
- thank her for her point of view and ignore the issue?
- decline to accept all these patient and let her GPs face her harrassment?
- decline to accept and advise her to discuss changes with her GPs?
- decline to accept and suggest that the drug plans are sound and that she change them at her peril?
It's folk like this that afford me an unhealthy glimpse in to how folk like Dr Rant can become so, erm, effusively colourful, in their frustrations with what's in essence unhelpful meddling.
Because of this relationship we've developed, there's been a healthy dose of common sense between Primary and Secondary Care.
Say a drug dose changes and a patient needs an ECG doing in a couple weeks but it's a way to trawl to the hospital, most GPs have no issue with the ECG being done in their surgery by their Practice Nurse. It's eating up a bit of their Practice Nurse time, it's generating no income for them, they have to mail the ECG to me, the ECG can be done in the hospital, but to smooth out things for their patients they offer this choice.
I take on and manage and follow up patients who are outwith our operational policy, but if I didn't do this they'd cause chaos and difficulties for the GP.
To date it's worked well, we blur boundaries, support one another and take policies/protocols with a pinch (well, more huge great handfuls) of salt and simply crack on and do what's best.
I like this.
Recently, one group of practices has appointed a new pharmacist. She's keen. She's determined to bring prescribing costs down. She's never met me. She has written to me, prolifically. A few things concern her. Well, that's disingenuous, I assume they don't concern her since she's a pharmacist with the salient information to hand so will know that the prescribing is rational and appropriate. What concerns her is the cost. Through this, she's notionally concerned that :
Lorazepam
Some patients with dementia are on lorazepam. They were battering people and were unmanageable. Now they're on 2mg of lorazepam regularly with some prn and are cured. They're in care homes with regular nurse follow up to ensure that the care homes use the minimum dose and complete diraies/use behavioural programmes rather than focus on medication. But although none of them are on more than 4mg of lorazepam, the British National Formulary (BNF) states a dose of lorazepam of 4mg in adults, 2mg in the elderly. These folks can sometimes have more than 2mg.
Of course, it's titrated to clinical need, there are no treatment emergent adverse events and it's working. So we use medication at the minimum effective dose, but that minimum is sometimes above 2mg. It's better than using lots of drugs at low (less effective/ineffective) dose. Our Royal College and voluntary groups advocate this.
She's asking that I undertake prescribing for all these patients, removing all such prescribing from the GPs. More than asking, she's saying that she's not willing for the GPs to prescribe these.
I'm sorely tempted to write back and suggest if she wants to change their drug regimen, go ahead and good luck.
Antipsychotic medication
A number of patients are on antipsychotic medication because of their dementia, causing memory loss and changes in thought so they're less adept at reality testing and become muddled. Antipsychotics can help smooth out chaotic thoughts so they can grasp the right train of thought more successfully more of the time. Also it can help with distress, helping folk feel less distraught. In some dementias people have delusions. They lose things, through poor memory, then try and understand why and reason it's been stolen, then look around over time and are mildly disoriented which fits with intruders, then develop abberant ideation as cognition deteriorates so can become deluded, with paranoid delusions. Antipsychotics can help these. Some will hallucinate. Antipsychotics can help these, too.
The BNF does not list licenced indications of Behavioural and Psychological Symptoms of Dementia for any drugs. Dementia care, with medication, is almost all outside the listed Summary of Product Characteristics (SPC) that all drugs have. The trials needed to get this evidence base, to change their SPC, aren't easy. They're not cost effctive and they're ethically fraught. Almost all prescribing in old age psychiatry is "off label" and outwith what the SPC says. A pharmacist will know this because the BNF has few modern drugs that we use that are developed with trials in older adults.
No means no!
I have no desire to take on routine prescribing responsibility for every patient with dementia. I have no computer for repeat prescriptions, all my prescribing is thoughtful and individual. If it is routine my GPs kindly undertake it.
What to do, what to do :
- thank her for her point of view and ignore the issue?
- decline to accept all these patient and let her GPs face her harrassment?
- decline to accept and advise her to discuss changes with her GPs?
- decline to accept and suggest that the drug plans are sound and that she change them at her peril?
It's folk like this that afford me an unhealthy glimpse in to how folk like Dr Rant can become so, erm, effusively colourful, in their frustrations with what's in essence unhelpful meddling.
Thursday, 22 May 2008
Staffing Care Homes
I wrote about care homes and how, sometimes, they're the best place for a person to be.
Recently our Trust has been sharing experiences with an area in the USA.
This coincidentally resonated with a comment Pem made about quality of provision of community care. In the USA the best quality of care in hospitals is arguably the best in the world. It's got problems with delivering great care for chunks of the population, but what hospital care does well, it does very well.
Through funding pressures, community services (especially in mental health) are generally much less well developed in the USA than in the UK.
Both health and social welfare provision isn't brilliant in the UK, but it can be pretty good. It struck me that a gentleman of 62 with Parkinson's Disease who's developed PD dementia or Lewy Body Dementia can get very good care in the UK. There are many specialist units to look at younger adults/folk of working age with cognitive impairement. Thus his assessment, diagnosis and care planning can be generated by a dedicated Consultant Psychiatrist and a capable, motivated, enthusiastic multidisciplinary team. Ongoing community support from the team can be frequent (several times a week) with care provided by Health services in centres outside hospital environments. Any medication can be prescribed by the NHS Consultant Psychiatrist, protocols are simply guidelines and the Consultant has clinical latitude to prescribe in their patient's best interests (unlike when care's privately funded and either the hospital or the insurance company can curtail clinical freedom, meaning certain drugs may not be available).
Care can be shared across boundaries more readily in the UK, so this chap with Parkinson's Disease and dementia will be seen by a specialist early onset dementia team but also by a specialist Parkinson's Disease nurse and neurologist.
A real difference is in care homes. Within half an hour of where I'm sitting there are over 60 registered care homes. There's plenty of choice. What if a care home can't undertake the care the man needs and deserves? They've not the staffing levels, or experience? Well, resources can be put in place so they can meet his needs. A community team from the Trust can reach in to the care home, supporting their staff with ongoing training and education as well as modeling practical dementia care (e.g. getting him up and out of bed on a morning then having breakfast) so the care staff can learn good practice. If they don't have staffing levels to continue to attend to this, Continuing Care funding can ensure they do have cash for extra staff to be employed on the shifts so the gentleman can get the time needed. It may be he needs one to one care, if so, we can get it funded and he can get one to one care.
With mental health services providing continuity of his dementia care through a specialist team (which includes a dedicated Consultant Psychiatrist), social services providing funding for a 24 hour specialist care home for him, joint Continuing Care funding for extra staff, a Parkinson's Disease team providing continuity of care of his PD and mental health services having ongoing training for the care homes, the gentleman can receive exceptionally good care.
A work of fiction? An idealistic aspiration? Why, no, not at all. The scenario above describing the NHS and social provision is exactly, exactly what one of my patients (and his care home) is currently receiving.
The NHS can coordinate and deliver community care well. Sometimes we forget that.
Recently our Trust has been sharing experiences with an area in the USA.
This coincidentally resonated with a comment Pem made about quality of provision of community care. In the USA the best quality of care in hospitals is arguably the best in the world. It's got problems with delivering great care for chunks of the population, but what hospital care does well, it does very well.
Through funding pressures, community services (especially in mental health) are generally much less well developed in the USA than in the UK.
Both health and social welfare provision isn't brilliant in the UK, but it can be pretty good. It struck me that a gentleman of 62 with Parkinson's Disease who's developed PD dementia or Lewy Body Dementia can get very good care in the UK. There are many specialist units to look at younger adults/folk of working age with cognitive impairement. Thus his assessment, diagnosis and care planning can be generated by a dedicated Consultant Psychiatrist and a capable, motivated, enthusiastic multidisciplinary team. Ongoing community support from the team can be frequent (several times a week) with care provided by Health services in centres outside hospital environments. Any medication can be prescribed by the NHS Consultant Psychiatrist, protocols are simply guidelines and the Consultant has clinical latitude to prescribe in their patient's best interests (unlike when care's privately funded and either the hospital or the insurance company can curtail clinical freedom, meaning certain drugs may not be available).
Care can be shared across boundaries more readily in the UK, so this chap with Parkinson's Disease and dementia will be seen by a specialist early onset dementia team but also by a specialist Parkinson's Disease nurse and neurologist.
A real difference is in care homes. Within half an hour of where I'm sitting there are over 60 registered care homes. There's plenty of choice. What if a care home can't undertake the care the man needs and deserves? They've not the staffing levels, or experience? Well, resources can be put in place so they can meet his needs. A community team from the Trust can reach in to the care home, supporting their staff with ongoing training and education as well as modeling practical dementia care (e.g. getting him up and out of bed on a morning then having breakfast) so the care staff can learn good practice. If they don't have staffing levels to continue to attend to this, Continuing Care funding can ensure they do have cash for extra staff to be employed on the shifts so the gentleman can get the time needed. It may be he needs one to one care, if so, we can get it funded and he can get one to one care.
With mental health services providing continuity of his dementia care through a specialist team (which includes a dedicated Consultant Psychiatrist), social services providing funding for a 24 hour specialist care home for him, joint Continuing Care funding for extra staff, a Parkinson's Disease team providing continuity of care of his PD and mental health services having ongoing training for the care homes, the gentleman can receive exceptionally good care.
A work of fiction? An idealistic aspiration? Why, no, not at all. The scenario above describing the NHS and social provision is exactly, exactly what one of my patients (and his care home) is currently receiving.
The NHS can coordinate and deliver community care well. Sometimes we forget that.
Wednesday, 21 May 2008
GPs
One of my patients with memory problems (F00.02 dementia in Alzheimer's disease, early onset, severe) has finally ground his wife down so much that he's been placed in emergency respite care.
She's been managing him, essentially single handedly, for an age.
He's got a lot of Parkinsonian motor symptoms and a changeable presentation and misperceptions suggesting visual hallucinations so I think he may well have Lewy Body dementia but he'd not tolerate DAT Scanning and is too advanced for detailed neuropsych evaluation.
He has behavioural and psychological symptoms of dementia (BPSD). He wanders, a lot. In our day centre, throughout the day he'd spend 6 hours walking and only half an hour sat down. He bangs walls when he's frustrated. Left alone, he never troubles other people.
In the care home, he's wandering at night. Staff didn't like that so tried to force him in to bed. He didn't like that. He's now labelled as "aggressive" and staff want more medication. Through the day he wanted to walk outside. He didn't want to wait 'til the afternoon when the late shift would open the doors and let him walk in the enclosed garden, so he walked around inside. He's now labelled as "restless."
It's an EMI Nursing Home so has qualified mental health nurses and experienced care staff, but to support them my nursing colleagues or I have been visiting 3 days a week.
He's on galantamine (to manage BPSD rather than improve cognition, now) and lorazepam to de-escalate arousal and distress. The care home sought haloperidol 3 times this week from his GP. His GP said no.
His GP 'phoned me up. We talked through what was going on. Because this was urgent respite placement, the nursing home is outside my patch, thus the GP looking after the home isn't someone I know or have ever had contact with before. But I could have kissed her. She's seen my patient, she thought maybe he had Lewy Body dementia and haloperidol would be A Bad Thing. She saw that the wife had managed the man alone, so why did a specialist care home with oodles of staff need medication when she did not? She saw that lorazepam had worked so a touch more may well help him settle in a disorienting environment. She saw him as active but no risk to others, not warranting sedating. She'd spotted relevant physical comorbidity that I'd spent half an hour sorting out last time, she generated sensible drug strategies to manage this over the next week.
The patient's in the right sort of care home, having rich input from specialist dementia care nurses and myself, is on appropriate medication and has a GP coordinating mental health and physical health care, and advocating for care home staff to use behavioural rather than pharmacological strategies to manage BPSD.
Some days, everything's just peachy! :-)
She's been managing him, essentially single handedly, for an age.
He's got a lot of Parkinsonian motor symptoms and a changeable presentation and misperceptions suggesting visual hallucinations so I think he may well have Lewy Body dementia but he'd not tolerate DAT Scanning and is too advanced for detailed neuropsych evaluation.
He has behavioural and psychological symptoms of dementia (BPSD). He wanders, a lot. In our day centre, throughout the day he'd spend 6 hours walking and only half an hour sat down. He bangs walls when he's frustrated. Left alone, he never troubles other people.
In the care home, he's wandering at night. Staff didn't like that so tried to force him in to bed. He didn't like that. He's now labelled as "aggressive" and staff want more medication. Through the day he wanted to walk outside. He didn't want to wait 'til the afternoon when the late shift would open the doors and let him walk in the enclosed garden, so he walked around inside. He's now labelled as "restless."
It's an EMI Nursing Home so has qualified mental health nurses and experienced care staff, but to support them my nursing colleagues or I have been visiting 3 days a week.
He's on galantamine (to manage BPSD rather than improve cognition, now) and lorazepam to de-escalate arousal and distress. The care home sought haloperidol 3 times this week from his GP. His GP said no.
His GP 'phoned me up. We talked through what was going on. Because this was urgent respite placement, the nursing home is outside my patch, thus the GP looking after the home isn't someone I know or have ever had contact with before. But I could have kissed her. She's seen my patient, she thought maybe he had Lewy Body dementia and haloperidol would be A Bad Thing. She saw that the wife had managed the man alone, so why did a specialist care home with oodles of staff need medication when she did not? She saw that lorazepam had worked so a touch more may well help him settle in a disorienting environment. She saw him as active but no risk to others, not warranting sedating. She'd spotted relevant physical comorbidity that I'd spent half an hour sorting out last time, she generated sensible drug strategies to manage this over the next week.
The patient's in the right sort of care home, having rich input from specialist dementia care nurses and myself, is on appropriate medication and has a GP coordinating mental health and physical health care, and advocating for care home staff to use behavioural rather than pharmacological strategies to manage BPSD.
Some days, everything's just peachy! :-)
Tuesday, 20 May 2008
Liaison
I recently reviewed a lady who had depression. Allegedly.
She was on a orthopaedic surgical ward, recovering from an arthroplasty, when surgeons played with their meccano to fix a fractured neck of femur. They felt she was depressed so couldn't engage with the rehabilitation so was taking an age to sort out. Days in hospital cost money, the orthopaedic team wanted results.
She wasn't losing weight. She wasn't off her food. She had no initial insomnia. She had broken sleep because the ward was noisy at night. She had no early morning wakening. She had no loss of hope for the future. She had no loss of libido. She had no loss of energy. She had no loss of joy (and had never had anhedonia in the past). She had no mood problems before admission. Her mood was low because at that moment life was not great.
Her loss of interest in rehabilitation and despondent mood was understandable.
Someone had hacked a bleedin' great hole in her leg, chopped about a lot with sharp spiky bits, screwed lots of meccano in and put needles and thread through her thigh.
It hurt.
She was on weak analgesics but, after surgery, had shooting electrical pains.
I started her on duloxetine 60mg once a day. Ten days later she was up and about mobilising.
Was her mood any better? Why, yes it was. Was this because of the duloxetine? Yes, certainly. Did the antidepressant cure her depression and help her recovery? No. She was not depressed. She had suboptimally treated neuropathic pain which duloxetine addressed. She no longer had burning in her thigh or deep shooting/lancing pains on transition from sitting to standing so could work with the physioterrorists.
A good result.
She was on a orthopaedic surgical ward, recovering from an arthroplasty, when surgeons played with their meccano to fix a fractured neck of femur. They felt she was depressed so couldn't engage with the rehabilitation so was taking an age to sort out. Days in hospital cost money, the orthopaedic team wanted results.
She wasn't losing weight. She wasn't off her food. She had no initial insomnia. She had broken sleep because the ward was noisy at night. She had no early morning wakening. She had no loss of hope for the future. She had no loss of libido. She had no loss of energy. She had no loss of joy (and had never had anhedonia in the past). She had no mood problems before admission. Her mood was low because at that moment life was not great.
Her loss of interest in rehabilitation and despondent mood was understandable.
Someone had hacked a bleedin' great hole in her leg, chopped about a lot with sharp spiky bits, screwed lots of meccano in and put needles and thread through her thigh.
It hurt.
She was on weak analgesics but, after surgery, had shooting electrical pains.
I started her on duloxetine 60mg once a day. Ten days later she was up and about mobilising.
Was her mood any better? Why, yes it was. Was this because of the duloxetine? Yes, certainly. Did the antidepressant cure her depression and help her recovery? No. She was not depressed. She had suboptimally treated neuropathic pain which duloxetine addressed. She no longer had burning in her thigh or deep shooting/lancing pains on transition from sitting to standing so could work with the physioterrorists.
A good result.
Tuesday, 13 May 2008
Care Homes
Most of us, when elderly, won't end up in care. By most of us, statistics show that well over 95% aren't in permanent 24 hour care. Going in to permanent care is, therefore, a relatively uncommon consequence. Too, it is costly. Thus (before even considering patient and carer needs and wishes) it is not undertaken lightly.
Hospital Wallpaper talks good sense. It's unusual for me to find something she says which I take issue with, but I've a different take on this :
It would be wonderful if everyone was like Mark at NeeNaw who declares "no member of my family will end up in a care home".
- Hospital Wallpaper
I don't think it would be wonderful.
I'm seeing a gentleman, Alan who's unable to look after himself (F00.12, dementia in Alzheimer's disease, late onset, severe), with his wife (and sometimes with his daughter, when she can skip out of work to meet with us). I see him every 2 weeks, along with a community psychiatric nurse. The CPN and I go together so one of us can be with Alan whilst the other talks with his wife.
His wife is always in floods of tears. Alan needs supervising, all the time. He wanders at night, and fiddles, often downstairs in the kitchen. He can get out of the house and wander in their garden or on to the road. She has to wake and attend to him through the night, when he's not sleepy and trying to get him to bed is futile. He can't appreciate if it's 7.00am or 7.00pm and needs little sleep so, along with catnaps through the day, needs just a few hours sleep at night. From 9.00pm to 2.00am is quite sufficient. 5 hours sleep, often broken and always poor quality, is not sufficient for his wife. She's permanently knackered.
He can't find words for things and over the last couple months can't generate coherent speech. Often over the last few months he hasn't been able to comprehend what his wife's asking of him or saying to him. Communication is more difficult.
He's experiencing dementia so is blissfully happy most of the time, living in the moment of the here and now with no recollection of recent events. He can't recollect having arguments or resisting personal care or tears earlier, he can pace in his garden, with his wife attending to their flowerbeds, happy as anything. He hums and sings, constantly.
Sadly, his lack of recent memory means he sees his wife as his wife. He remembers her, and their relationship, as it was years ago, when they had great, fun-filled days together. He doesn't understand or identify with her being his carer, at all. She's not his nurse, his support worker, his carer, she's his wife. He knows this and believes this as a fact, it's a distant memory over time that's indelible. So why is she trying to take his clothes off him or shave him or bath him?!
He identifies with himself as a younger man, since that is what he remembers, so that's his reality. He's always known how to wash himself. He's always shaved himself. He's always bathed himself. So why should he have his wife foisting herself on him, trying to do these things for him?
He can't manage a razor or his electric shaver any more. His wife despairs, seeing her proud and tidy and clean shaven husband "go to wrack and ruin" with a scraggy beard and wild, tempestuous hair. Billy Connolly would be pleased, he does indeed look "windswept and interesting" because he is.
Alan can't go to day care. He could, until a few months ago when he caused so much chaos and unpleasantness in patient transport that the ambulance services needed 2 people to convey him and even after a few weeks of this said it was unsafe, so stopped taking him. Not to be out done, one of our team visited every Friday morning and walked him to the day centre. This worked for a month or two until he caused too much bedlam and chaos there, too. Wandering, pacing, resisting care and interventions, fiddling with other peoples' clothes and possessions, social services day care ain't an option now.
Alan hasn't had a bath for months. He has dirty finger nails. He's unshaven. But, he's fed, he's warm, he's hydrated, he's kempt, he's happy and he's loved. His wife dotes over the man, even though she's frazzled and in tears all the time and perpetually knackered.
If Alan is at home, what does he get out of this? He gets his wife splendid company and he gets the familiarity of his surroundings. He doesn't see neighbours. He doesn't go for walks in the local park, use the local library, visit the local shops, attend the local church or use any local facilities what so ever. The location is of no merit to him, it's the people around him and living in the moment that matters, now.
If Alan is in a 24 hour care home, what does he get out of this? He'd get his own room, with privacy. He'd get a lounge, with other people and company. He can sing or chatter away to folk who can sing or chatter back, interacting together. If distraught, he can have skilled staff intervene to give him one to one time and help with reality orientation and reduce his distress, or distract him, or divert him in to singing them a song from a musical or going for a walk in the garden. If the homehasn't got staff to do this, staffing levels matter, so we get Continuing Care funding to pay for the staff so that this can happen. Several folk have 1:1 care all day every day, to ensure they get the care they need and deserve.
He gets stability, security, not having to move again. He gets no stress or strain, all cooking, all cleaning, all laundry, all shopping, all practical care is sorted by someone else. He gets carers. Carers are working shifts so, unlike his wife, are bright eyed and bushy tailed. Carers can try interventions time and time again. If he won't have a bath at 9.00am it can be offered by a different carer an hour later, or by someone from a different shift after lunch, or maybe he'll respond to someone on the night shift and have one just before bed. These are carers, in uniforms, looking like nursing staff, so folks like Alan can identify that (unlike his wife) it is their job to help wash, bathe, shave and help him.
Purely through their role (not skills, knowledges, competencies) they can deliver care that his wife never can. Too, they have familiarity with dementia care so can assist him, morning, noon and night.
Most of all, he gets his wife.
His wife doesn't need to be exhausted and stressed and sleep deprived and worried, all the time. She doesn't need to be strong and cope for him and her, all the time. She doesn't need to try and be a wife, a carer, a nurse, a cleaner, a cook, feed him and every other role she plays, all the time. The care home do all the care. She can visit him every hour of every day, as his wife.
I'd revise what Hospital Wallpaper quoted. I'd rather say, "No member of my family will end up in a care home, unless it's in their best interests." Because sometimes, just sometimes, it is.
Hospital Wallpaper talks good sense. It's unusual for me to find something she says which I take issue with, but I've a different take on this :
It would be wonderful if everyone was like Mark at NeeNaw who declares "no member of my family will end up in a care home".
- Hospital Wallpaper
I don't think it would be wonderful.
I'm seeing a gentleman, Alan who's unable to look after himself (F00.12, dementia in Alzheimer's disease, late onset, severe), with his wife (and sometimes with his daughter, when she can skip out of work to meet with us). I see him every 2 weeks, along with a community psychiatric nurse. The CPN and I go together so one of us can be with Alan whilst the other talks with his wife.
His wife is always in floods of tears. Alan needs supervising, all the time. He wanders at night, and fiddles, often downstairs in the kitchen. He can get out of the house and wander in their garden or on to the road. She has to wake and attend to him through the night, when he's not sleepy and trying to get him to bed is futile. He can't appreciate if it's 7.00am or 7.00pm and needs little sleep so, along with catnaps through the day, needs just a few hours sleep at night. From 9.00pm to 2.00am is quite sufficient. 5 hours sleep, often broken and always poor quality, is not sufficient for his wife. She's permanently knackered.
He can't find words for things and over the last couple months can't generate coherent speech. Often over the last few months he hasn't been able to comprehend what his wife's asking of him or saying to him. Communication is more difficult.
He's experiencing dementia so is blissfully happy most of the time, living in the moment of the here and now with no recollection of recent events. He can't recollect having arguments or resisting personal care or tears earlier, he can pace in his garden, with his wife attending to their flowerbeds, happy as anything. He hums and sings, constantly.
Sadly, his lack of recent memory means he sees his wife as his wife. He remembers her, and their relationship, as it was years ago, when they had great, fun-filled days together. He doesn't understand or identify with her being his carer, at all. She's not his nurse, his support worker, his carer, she's his wife. He knows this and believes this as a fact, it's a distant memory over time that's indelible. So why is she trying to take his clothes off him or shave him or bath him?!
He identifies with himself as a younger man, since that is what he remembers, so that's his reality. He's always known how to wash himself. He's always shaved himself. He's always bathed himself. So why should he have his wife foisting herself on him, trying to do these things for him?
He can't manage a razor or his electric shaver any more. His wife despairs, seeing her proud and tidy and clean shaven husband "go to wrack and ruin" with a scraggy beard and wild, tempestuous hair. Billy Connolly would be pleased, he does indeed look "windswept and interesting" because he is.
Alan can't go to day care. He could, until a few months ago when he caused so much chaos and unpleasantness in patient transport that the ambulance services needed 2 people to convey him and even after a few weeks of this said it was unsafe, so stopped taking him. Not to be out done, one of our team visited every Friday morning and walked him to the day centre. This worked for a month or two until he caused too much bedlam and chaos there, too. Wandering, pacing, resisting care and interventions, fiddling with other peoples' clothes and possessions, social services day care ain't an option now.
Alan hasn't had a bath for months. He has dirty finger nails. He's unshaven. But, he's fed, he's warm, he's hydrated, he's kempt, he's happy and he's loved. His wife dotes over the man, even though she's frazzled and in tears all the time and perpetually knackered.
If Alan is at home, what does he get out of this? He gets his wife splendid company and he gets the familiarity of his surroundings. He doesn't see neighbours. He doesn't go for walks in the local park, use the local library, visit the local shops, attend the local church or use any local facilities what so ever. The location is of no merit to him, it's the people around him and living in the moment that matters, now.
If Alan is in a 24 hour care home, what does he get out of this? He'd get his own room, with privacy. He'd get a lounge, with other people and company. He can sing or chatter away to folk who can sing or chatter back, interacting together. If distraught, he can have skilled staff intervene to give him one to one time and help with reality orientation and reduce his distress, or distract him, or divert him in to singing them a song from a musical or going for a walk in the garden. If the homehasn't got staff to do this, staffing levels matter, so we get Continuing Care funding to pay for the staff so that this can happen. Several folk have 1:1 care all day every day, to ensure they get the care they need and deserve.
He gets stability, security, not having to move again. He gets no stress or strain, all cooking, all cleaning, all laundry, all shopping, all practical care is sorted by someone else. He gets carers. Carers are working shifts so, unlike his wife, are bright eyed and bushy tailed. Carers can try interventions time and time again. If he won't have a bath at 9.00am it can be offered by a different carer an hour later, or by someone from a different shift after lunch, or maybe he'll respond to someone on the night shift and have one just before bed. These are carers, in uniforms, looking like nursing staff, so folks like Alan can identify that (unlike his wife) it is their job to help wash, bathe, shave and help him.
Purely through their role (not skills, knowledges, competencies) they can deliver care that his wife never can. Too, they have familiarity with dementia care so can assist him, morning, noon and night.
Most of all, he gets his wife.
His wife doesn't need to be exhausted and stressed and sleep deprived and worried, all the time. She doesn't need to be strong and cope for him and her, all the time. She doesn't need to try and be a wife, a carer, a nurse, a cleaner, a cook, feed him and every other role she plays, all the time. The care home do all the care. She can visit him every hour of every day, as his wife.
I'd revise what Hospital Wallpaper quoted. I'd rather say, "No member of my family will end up in a care home, unless it's in their best interests." Because sometimes, just sometimes, it is.
Friday, 9 May 2008
Alcohol
I can't say someone's a drunk, or someone has "a drink problem." That could be a perjorative and unjust opinion. As a medic, pronouncing such a formulation or diagnosis has consequences (with driving, insurance, all sorts). As such, as with all good diagnosis, a combination of clinical acumen and a diagnostic framework guides formulation. The bottom line : I have to go by what our diagnostic bible, ICD-10, says.
This means that instead of "alcoholic" I end up with the less than catchy diagnosis of "F10.241 Mental and behavioural disorders due to use of alcohol, dependence syndrome, currently using the substance (active dependence), with physical features".
Or I can opt for "F10.1 Mental and behavioural disorders due to use of alcohol, harmful use." At least that's shorter to write.
Thus, it's not common for me to make such a diagnosis partly 'cause such folk go to drug and alcohol services and partly because the diagnostic framework means I've quite a high threshold before someone can attract such a diagnosis.
I was helping a gentleman who's almost 90. He was up before 7.00am today and went shopping at 8.00am. Does all the cooking, cleaning, washes all the crockery, pays all the bills, sorts all the post, does the laundry, vacuums and tidies up, does everything. He's knackered. At almost 90, although in decent physical health, he's unable to manage the volume and intensity of activity he's undertaking. It's not tenable over the long term.
He's not my patient, he's never been referred to me. It's his son, who's almost 70. His GP didn't think he was depressed but very sensible sought an opinion since it's all so grim, so he came to my corner. His son sits in bed most of the day, drinks vast amounts of alcohol and is dependent on his frail elderly father for everything. Not because he's physically unwell, or disabled, or has deficits. But because the son likes it this way, it means he can kick back and drink. Stress free, eschewing all life's responsibilities.
I really feel for his proud father, who's struggling but can't and won't thrust responsibility back to his son or accept social care/anyone doing things for them.
I can't cure this.
This means that instead of "alcoholic" I end up with the less than catchy diagnosis of "F10.241 Mental and behavioural disorders due to use of alcohol, dependence syndrome, currently using the substance (active dependence), with physical features".
Or I can opt for "F10.1 Mental and behavioural disorders due to use of alcohol, harmful use." At least that's shorter to write.
Thus, it's not common for me to make such a diagnosis partly 'cause such folk go to drug and alcohol services and partly because the diagnostic framework means I've quite a high threshold before someone can attract such a diagnosis.
I was helping a gentleman who's almost 90. He was up before 7.00am today and went shopping at 8.00am. Does all the cooking, cleaning, washes all the crockery, pays all the bills, sorts all the post, does the laundry, vacuums and tidies up, does everything. He's knackered. At almost 90, although in decent physical health, he's unable to manage the volume and intensity of activity he's undertaking. It's not tenable over the long term.
He's not my patient, he's never been referred to me. It's his son, who's almost 70. His GP didn't think he was depressed but very sensible sought an opinion since it's all so grim, so he came to my corner. His son sits in bed most of the day, drinks vast amounts of alcohol and is dependent on his frail elderly father for everything. Not because he's physically unwell, or disabled, or has deficits. But because the son likes it this way, it means he can kick back and drink. Stress free, eschewing all life's responsibilities.
I really feel for his proud father, who's struggling but can't and won't thrust responsibility back to his son or accept social care/anyone doing things for them.
I can't cure this.
Wednesday, 7 May 2008
Hospital grounds
Walking to lunch, walking to management meetings, walking to case conferences, walking to my wards, I cross grass. I like walking across grass, espcially when it's just been cut. We've pleasing grounds, with established ancient trees and new colourful flowers. At the moment, the trees are a riot of colour and the grounds are carpeted in blossom.
Have a look here.
Thus, my world is a better place.
Have a look here.
Thus, my world is a better place.
NICE Drugs
The National Institute of Health and Clinical Excellence (NICE) guides on clinical practice through Technology Appraisals (does this drug/gadget/procedure work) and Clinical Guidelines (what does the evidence base from all research suggest should be done) which commissioners (some practices occasionally and Primary Care Trusts in particular) then accept as How It Shall Be.
As such, what NICE says matters. If NICE say a drug or treatment should be available, a Primary Care Trust better have good reasons why it isn't, if they don't fund it. To date, when challenged, I don't believe there have ever been good enough reasons (and patients have been supported in accessing whatever NICE suggest).
NICE isn't wholly independent, it's an arms-length government body. So it's kind of independent, but it can't bite the hand that feeds it. Naieve though I may be, I do see it as pretty independent (rather than peddling government policy) because the decisions and rationale given has shown this to be the case.
There have been a lot of discussions about the recent court ruling. The Times says the courts uphold limiting the drugs, with comment siding more with NICE. The Telegraph says the courts recognised NICE was flawed, with comment siding more with the drug companies. The Guardian gave a balanced view, the ruling upheld NICE guidance but the process was weak. The BBC comment was about a drug appeal victory that bemused me.
NICE have issued their own response here.
What is all this about?
Well, NICE look at evidence. If we just make it up as we go along, experienced clinicians could do that themselves. NICE exists to cut through that and guide us on what the best evidence at present suggests. NICE balance this with some opinion (from patients, carers, health and social care professionals, charities, support groups, drug companies, anyone with an interest). This then informs implementation guidelines they generate.
The evidence for Alzheimer's disease drugs is clear. They work. NICE acknowledged this in their first appraisal and in the subsequent review.
Drugs cost money. NICE work out quality life years and benefits that drugs can give, making a decision (that's the same on all appraisals, not specific to dementia care) on whether the bang for the buck is good enough. If quality of life is only modestly improved or if it costs squillions to achieve benefit, the cash in the NHS could be better used elsewhere and NICE won't recommend wholesale use of the drug.
The contentious bit is when to start and when to stop the drugs. You get good benefit in the middle stages of the disease. You sometimes get some benefit at the later stages, but not in cognitive domains (i.e. it can treat behavioural symptoms, it doesn't improve cognition).
Peterson's work in 1999 showed that mild cognitive impairment will often get better. In any given year, if you've mild cognitive problems (memory, orientation, concentration, sequencing, whatever), many get better, many stay the same and only 12% (1 in 8) go on to develop dementia. So 7 out of 8 don't, even 12 months on.
Ritchie in 2001 found conversion rates from mild cognitive impairment to dementia of 11% to 12% with a huge proportion recovering to normal. So, again, only 1 in 8 got worse, most got better.
NICE reckon if you're found to have mild cognitive impairement you shouldn't be on medication. I guess we'd all agree with that.
NICE reckon if you're found to have mild dementia you shouldn't be on medication. I disagree with this, I think once a diagnosis of dementia (not mild cognitive impairement) has been made, treatment should be started. In my corner we do, the PCT and GPs are happy with this, so all is well. Nationally this isn't the case and in many areas patients need to deteriorate to moderate dementia before drugs are offered. Therein lies the contention. In what other illness do you have to irreversibly and needlessly deteriorate before a helpful medication is started?
NICE say in dementia care (like most other guidance) that their guidance should apply to about 2 out of 3 patients. Thus, a lot of the time it won't apply. Given this latitude, if commissioners accepted and funded this too, all would be well.
Overall, the ruling isn't that relevant, to my mind. The courts said, don't change any guidance but do be more open about how you made your decisions.
This concerns me far, far, far more.
What NICE have had to do is give Big Pharma their algorithms for quality life measures and outcomes for whether a drug is cost effective or not. With this, a drug company can now have research and costing that, owning the algorithm, they can generate a result just below the line so NICE will recommend it. If it was well below the line, heck, they can charge more. If above the line, pay for "better" research. Effectively, drug companies can now generate answers for NICE that they know NICE will have to accept. As I started saying, what NICE says matters and is adopted as policy. Now, with this algorithm, Big Pharma can know that their product will have to be recommended by NICE. If Big Pharma can tell NICE that, using their own processes, their drug comes up as meriting widespread NHS use, drug companies now have a mechanism to indirectly affect national prescribing policy.
This concerns me much more than wrangles over MMSE and dementia cut off guidelines that any half savvy medic has been getting around, anyway.
As such, what NICE says matters. If NICE say a drug or treatment should be available, a Primary Care Trust better have good reasons why it isn't, if they don't fund it. To date, when challenged, I don't believe there have ever been good enough reasons (and patients have been supported in accessing whatever NICE suggest).
NICE isn't wholly independent, it's an arms-length government body. So it's kind of independent, but it can't bite the hand that feeds it. Naieve though I may be, I do see it as pretty independent (rather than peddling government policy) because the decisions and rationale given has shown this to be the case.
There have been a lot of discussions about the recent court ruling. The Times says the courts uphold limiting the drugs, with comment siding more with NICE. The Telegraph says the courts recognised NICE was flawed, with comment siding more with the drug companies. The Guardian gave a balanced view, the ruling upheld NICE guidance but the process was weak. The BBC comment was about a drug appeal victory that bemused me.
NICE have issued their own response here.
What is all this about?
Well, NICE look at evidence. If we just make it up as we go along, experienced clinicians could do that themselves. NICE exists to cut through that and guide us on what the best evidence at present suggests. NICE balance this with some opinion (from patients, carers, health and social care professionals, charities, support groups, drug companies, anyone with an interest). This then informs implementation guidelines they generate.
The evidence for Alzheimer's disease drugs is clear. They work. NICE acknowledged this in their first appraisal and in the subsequent review.
Drugs cost money. NICE work out quality life years and benefits that drugs can give, making a decision (that's the same on all appraisals, not specific to dementia care) on whether the bang for the buck is good enough. If quality of life is only modestly improved or if it costs squillions to achieve benefit, the cash in the NHS could be better used elsewhere and NICE won't recommend wholesale use of the drug.
The contentious bit is when to start and when to stop the drugs. You get good benefit in the middle stages of the disease. You sometimes get some benefit at the later stages, but not in cognitive domains (i.e. it can treat behavioural symptoms, it doesn't improve cognition).
Peterson's work in 1999 showed that mild cognitive impairment will often get better. In any given year, if you've mild cognitive problems (memory, orientation, concentration, sequencing, whatever), many get better, many stay the same and only 12% (1 in 8) go on to develop dementia. So 7 out of 8 don't, even 12 months on.
Ritchie in 2001 found conversion rates from mild cognitive impairment to dementia of 11% to 12% with a huge proportion recovering to normal. So, again, only 1 in 8 got worse, most got better.
NICE reckon if you're found to have mild cognitive impairement you shouldn't be on medication. I guess we'd all agree with that.
NICE reckon if you're found to have mild dementia you shouldn't be on medication. I disagree with this, I think once a diagnosis of dementia (not mild cognitive impairement) has been made, treatment should be started. In my corner we do, the PCT and GPs are happy with this, so all is well. Nationally this isn't the case and in many areas patients need to deteriorate to moderate dementia before drugs are offered. Therein lies the contention. In what other illness do you have to irreversibly and needlessly deteriorate before a helpful medication is started?
NICE say in dementia care (like most other guidance) that their guidance should apply to about 2 out of 3 patients. Thus, a lot of the time it won't apply. Given this latitude, if commissioners accepted and funded this too, all would be well.
Overall, the ruling isn't that relevant, to my mind. The courts said, don't change any guidance but do be more open about how you made your decisions.
This concerns me far, far, far more.
What NICE have had to do is give Big Pharma their algorithms for quality life measures and outcomes for whether a drug is cost effective or not. With this, a drug company can now have research and costing that, owning the algorithm, they can generate a result just below the line so NICE will recommend it. If it was well below the line, heck, they can charge more. If above the line, pay for "better" research. Effectively, drug companies can now generate answers for NICE that they know NICE will have to accept. As I started saying, what NICE says matters and is adopted as policy. Now, with this algorithm, Big Pharma can know that their product will have to be recommended by NICE. If Big Pharma can tell NICE that, using their own processes, their drug comes up as meriting widespread NHS use, drug companies now have a mechanism to indirectly affect national prescribing policy.
This concerns me much more than wrangles over MMSE and dementia cut off guidelines that any half savvy medic has been getting around, anyway.
Tuesday, 6 May 2008
Colour
Dr Shock asked what colour is your mind? I had to know.
Your Mind is Purple |
 Of all the mind types, yours is the most idealistic. You tend to think wild, amazing thoughts. Your dreams and fantasies are intense. Your thoughts are creative, inventive, and without boundaries. You tend to spend a lot of time thinking of fictional people and places - or a very different life for yourself. |
Lithium
Since being appointed as a Consultant, I think there's only one patient I've ever initiated lithium with.
But I've inherited many, so today reviewed a lady (as I am wont to do, every 3 months). All was well, it always is, but she still likes to come to see me. She's always beaming. For a lady who's on lithium as augmentation for the treatment of depression, rather than lithium treating mood swings or bipolar disorder, this is pleasing to see. Much goodness. She's no mood problems, no change in activities, no side effects, no new physical health symptoms or problems, no changes in other medication, all is well.
Lithium levels are perfect, renal and thyroid function are normal, calcium's fine.
I think the only useful thing I did with her today was comment on the splendid weather and glorious sunshine. "It's getting hot, you're on lithium, remember to drink plenty of fluids!"
Some days, my work really isn't too, too taxing.
But I've inherited many, so today reviewed a lady (as I am wont to do, every 3 months). All was well, it always is, but she still likes to come to see me. She's always beaming. For a lady who's on lithium as augmentation for the treatment of depression, rather than lithium treating mood swings or bipolar disorder, this is pleasing to see. Much goodness. She's no mood problems, no change in activities, no side effects, no new physical health symptoms or problems, no changes in other medication, all is well.
Lithium levels are perfect, renal and thyroid function are normal, calcium's fine.
I think the only useful thing I did with her today was comment on the splendid weather and glorious sunshine. "It's getting hot, you're on lithium, remember to drink plenty of fluids!"
Some days, my work really isn't too, too taxing.
Thursday, 1 May 2008
Clinical Research
I didn't read the paper 'cause I couldn't get past the first picture. What can I say, I'm weak. But how ever you look at it, it did get me thinking, why do I never get asked to participate in this kind of research?
Memantine
I don't use a lot of memantine because NICE tell us not to, saying "Memantine is not recommended as an option for people with moderately severe to severe Alzheimer’s disease unless it is being used as part of a clinical trial (research)."
This means our commissioners don't pay us cash for this drug. Our GPs have it "red lighted" so if they entertain prescribing it wailing alarms and flashing lights go off, then stern Area Prescribing Committee pharmacists frog march in and rant at the GP until they stop having such ludicrous ideas, like prescribing memantine for their patients.
Still, I've a few patients on memantine, for good reasons. Well, I think they're good reasons. Anyway, the outcome is that the patients have stable cognitive function now, so there's been no progression of symptoms of dementia on memantine (but before memantine they were getting worse month on month). So, I continue to use it, a bit, because for a small number of folk it makes a meaningful difference.
It's just a small number of folk, partly because it's not funded (so I can never pass them back to the GP, so our hospital has to bear the cost of the drugs forever). The costs are not trivial. If I've a dozen patients on memantine then that'll cost as much as a secretary. Two dozen would pay for a nurse. Since we've no money for it, that's what it really means . . . if I want 24 folk on memantine, which nurse post do we lose to fund that?
But the other reason I've very few on memantine is, does it really work that well? I'm biased since over the years I've not used it on squillions of folk, but of those I have prescribed it form, for the vast majority it's done nothing. I'm sure it's not snake oil linement to cure all ills but it really does seem striking less efficacious than donepezil, galantamine and rivastigmine. Or is it just me?
This means our commissioners don't pay us cash for this drug. Our GPs have it "red lighted" so if they entertain prescribing it wailing alarms and flashing lights go off, then stern Area Prescribing Committee pharmacists frog march in and rant at the GP until they stop having such ludicrous ideas, like prescribing memantine for their patients.
Still, I've a few patients on memantine, for good reasons. Well, I think they're good reasons. Anyway, the outcome is that the patients have stable cognitive function now, so there's been no progression of symptoms of dementia on memantine (but before memantine they were getting worse month on month). So, I continue to use it, a bit, because for a small number of folk it makes a meaningful difference.
It's just a small number of folk, partly because it's not funded (so I can never pass them back to the GP, so our hospital has to bear the cost of the drugs forever). The costs are not trivial. If I've a dozen patients on memantine then that'll cost as much as a secretary. Two dozen would pay for a nurse. Since we've no money for it, that's what it really means . . . if I want 24 folk on memantine, which nurse post do we lose to fund that?
But the other reason I've very few on memantine is, does it really work that well? I'm biased since over the years I've not used it on squillions of folk, but of those I have prescribed it form, for the vast majority it's done nothing. I'm sure it's not snake oil linement to cure all ills but it really does seem striking less efficacious than donepezil, galantamine and rivastigmine. Or is it just me?
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