Wednesday 21 May 2008


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! :-)


BenefitScroungingScum said...

He sounds very much like the gentleman I found wandering (Chuck) who, thanks to an expensive new door, is no longer able to escape his, very lovely nursing home. BG

Hospital Wallpaper said...

Its wonderful to hear a story which shows how well GPs and secondary care doctors can work together. There's so much sniping between the two, it made me so happy to hear this story. Hopefully with the GPs support things will be a bit better for this man and his wife.

Fiona Marcella said...

The "sniping" between different professions can be really upsetting to those of us who witness it and perhaps take it too seriously. In my experience (as a minor admin bod in the NHS and a patient and carer) most professionals do really TRY to work together for the benefit of the patient - but the structure (or lack of it) of the NHS, the high emotions that often come along with illness, and perhaps, the nature of medical education itself which encourages decisiveness and clear thinking, sometimes at the expense of collaboration and compromise, can often hinder this.

As he has been placed some way away from home, will it be possible or even desirable for him to stay at this home with this GP, or will he be transferred to the care of another home and another GP. If so, lets hope he has as much luck with the next one.

Cockroach Catcher said...

Before my retirement, running a regional psychiatric in-patient unit for children and adolescents meant that I had to work with Child Psychiatrists within the region and I can say that apart from one or perhaps two all are very similar to the GP you wanted to kiss. They did not want to jump in and use different medications and preferred in-depth assessments. In-patient for these youngsters is to me the best approach. Alas, units after units are being closed and we will go the way of Adult Mental Health service. But the government reckoned that doctors cannot be good managers: most still have a heart.

The Cockroach Catcher

Pem said...

My husband is diagnosed as in the early stages of Lewy Body Dementia (he is 62 and I am 52). Living in a rural area in the southern United States, I'm worried whether there is any nursing home within 100 miles that could handle LBD issues. Your EMI nursing home sounds better staffed than our nursing homes with dementia units, and the closest good one of those is 30 miles away. I don't want to retire from my job as a college professor.

Thank you for your caring--it is good to know it is out there.