Friday 27 June 2008

GP Prescribing

5 years ago I had a disagreement with a local GP. Usually I'm pretty easy going and can tolerate the numerous foibles and idiosyncrasies that Consultant and GP colleagues may possess. 5 years ago a GP didn't want to prescribe galantamine for a patient with dementia. The patient had been on it for ages, was gaining benefit, was stable with no side effects and had moderate dementia . . . our shared care protocol (largely written by the APC) directs that the GP should then, ". . . reply to the request for shared care as soon as practicable," and add the drug to the patient's list of repeat prescriptions. This GP didn't want any truck with this shared care malarky, and as independant practitioners it's quite within their gift for them to do what so ever they wish. But with that latitude comes some responsibility. I wrote back to the GP conveying my disappointment that she sought to act outwith the district-wide agreed protocol but, if she had good clinical grounds to do so, she was perfectly at liberty to allow the galantamine to be stopped and explain to her patient why she was doing so. I'm normally hugely reasonable and go to inordinate lengths to support GPs but when I'm messed about I'm very Consultoid. Fortunate it only happens once every 5 years or so, then.

Sadly, it's happened again.

The problem is that a GP isn't wanting to prescribe any medication for any of her patients with dementia. This puts us all in a difficult position. The general public now perceive antipsychotics as dangerous and bad and speak of the, "urgent message" to GPs, "warning them of the danger." Tim Kendall (who really, really should know better) has said that GPs need reporting to the General Medical Council for such prescribing and saying clearly, "I think the doctors should be disciplined."
The Americans have said antipsychotics shouldn't be used in dementia care.
Our MHRA have said 2 antipsychotics should not be used in dementia care.

The GP is uneasy about prescribing. I'm happy to accept responsibility in the decision, initiation, titration and review of such prescribing. But at some point I need to discharge patients or I'll end up with squillions of patients and won't be able to be effective in addressing clinical need promptly. Other GPs are happy that if I get the patient sorted and stable and ask them to then prescribe, that's fine. Common sense gets a look in, hurrah.

After doing the work and getting things sorted then asking the GP to pick up the ongoing care, I guess I could just discharge the patient back to the GP to do with as they so wish, if having consulted a Consultant for an opinion they don't want to accept or action such an opinion.

What makes this a slightly thornier issue is that I was at a meeting with Anna Walker this week who's the Chief Executive of the Healthcare Commission. They're the body who regulate health, so are a pretty scary crowd. Her agenda for the near future now includes review and improving and rationalising prescribing in Primary Care.

Tempestuous times ahead, eh?

Thursday 26 June 2008

Bioresonance Therapy

One of my patients, who's elderly and frail, is being exploited by family and has financial hardship and has had difficulties with young drunk neighbours moving in and has had physical illnesses (fractured hip, heart attack) so, overall, has had a pretty chequered course throught this year.

I was asked to see him ostensibly because his concentration's not great.

I could see reasons why, but assessed cognition anyway. It was normal. Ropy in some areas, but understandably so, he's certainly not having problems that are sufficient to attract a diagnosis of mild cognitive impairment (MCI) or dementia.

What was of interest to me was the impact his GP had. An inquisitive soul, I always like to ask why the patient thinks they're seeing me, what they and their GP thought I could help with. It's a perk of having an hour with new patients, especially when the mental health is straightforwrd and swiftly addressed, patients can share more peripheral details that are stirring within their thoughts. This lead on to conversation 'bout the GP consultation and how helpful it had been. His GP, on chatting through with the patient what was going on and suggesting I meet up with him, also undertook some opportunistic health promotion. He's had a heart attack this year, isn't it about time to think about the cigarettes he smokes? The GP's words struck home. My patient did indeed stop smoking.

How did he do this?

He went to a private consultation where his pockets were picked. £300, if you're interested. For this, he got the most exceptional treatment I've heard someone be flannelled with for years.

The cigarettes had toxins. These were in his system. These had affected his system, which is why he wanted cigarettes. Thus, these toxins needed removing.
First, the specific packet of cigarettes he usually smokes was taken off him and taken out of the room "to be analysed." Then uninsulated wire was wrapped around each wrist and connected to a machine. Buttons were pressed. "Ooooh, you need an hour and a half on this to cleanse the toxins." Time passed. Then the explanation that, with toxins coming out, he may well smell tobacco when having a shower because, "that's the toxins coming out."

He's not smoked, it's worked for him. But I'll wager good coin it ain't the pseudoscience technobabble and spangly machine with wires and lights and buttons that's done it . . .

Tuesday 24 June 2008


Increasingly there's pressure to manage Behavioural and Psychological Symptoms of Dementia (BPSD) in ways other than just through antipsychotics. This is a good thing. I still maintain that antipsychotics can be part of the answer for some patients some of the time, but they're not a cure when used alone.

I'm blessed to be working with nursing staff who are exceptionally good at what they do. Which isn't diagnosis or medical stuff, it's nursing care. I've a lady in permanent care, through progression of her dementia. She has become increasingly vocal (shouting out) and wandersome. We have no antishouting pill. We have no antimoving pill.

I looked at her medication and stopped some of it, which made things better. Two months on, things have progressed and again the home's struggling to cope with her. My nursing colleague visited and tried to understand why this lady was shouting and moving. Hip pain from arthritis after nonunion of a fracture could be one factor. Constipation could be another. Disorientation, through diminished insight and a lack of appreciation of what's going on, could be a factor. Thirst sometimes seems to be.

As well as spending time divining why the behaviour unfolds and what it means, the nurse also undertook some interventions at frequent intervals within the care home. Aromatherapy. Hand massage. Doll therapy.

It's all worked.


Friday 20 June 2008


I posted previously 'bout the FDA in America banning antipsychotics in dementia related psychosis.

After this, it was great to chance upon this. Absolute genius.

Thursday 19 June 2008


If you've Behavioural and Psychological Symptoms of Demetia (BPSD) then how should these be managed?

The National Institute of Health and Clinical Excellence (NICE) have a view on non-drug approaches which they explain in their Clinical Guideline, CG 42, on page 28 :
"Approaches that may be considered, depending on availability, include:
● aromatherapy
● multi-sensory stimulation
● therapeutic use of music and/or dancing
● animal-assisted therapy
● massage"

I'm not opposed to these. NICE continue to say that this is, ". . . because there is some evidence of their clinical effectiveness."
NICE is correct. They can work. Of course, the truth of it is in divining what works. Is it that essential oils in aromatherapy works, or is it that having a staff member spend half an hour to an hour giving one to one time, reassauring physical contact, continuous dialogue and eye contact, all is useful? I would imagine so. I am not sold on lavender as a panacea for all ills, helping sleep and relaxing one and all. Yet the evidence is sound, for many folks it can help. We do it in our service and, for some folk, it really is useful.

What perturbs me is the vogue to move wholly away from medication.

If you've dementia and your memory is poor, your concentration is poor, your language and organisation of words is poor, your sequencing is poor, your information processing is poor, how do you think the flow of your thoughts fairs? Unsurprisingly, focussing on thoughts, generating notions and words and structuring these, following a train of thought, communicating it all is harder as the dementia progresses.

Misperceptions, misinterpretations, flawed cognitions all mean that someones thoughts aren't as clear and lucid and flowing as once they were.

Can't find your glasses? Can't find your wallet? No idea where your bank book is? Ak, someone must have broken in to your home and nicked off with them, why else aren't they where (you believe) you left them? Paranoid thoughts increase. Sometimes they become delusional and distressing. You live in a world where you're uncertain, unable to recall details of what's been happening, it's bewildering, and now it seems you've someone nicking or moving stuff in your own home. Much badness.

Can this be improved upon? Why, yes it can. You've abberant ideation through thoughts being more jumbled up than they should be. But, huzzah, we've medication that can help improve the flow of thoughts, we've antipsychotics. They can help damp down paranoid and delusional beliefs too. Splendid, a patient has unpleasant symptoms but we've medication to help so all's good. But, sadly not.

Although the benefit of antipsychotics in dementia care for some patients is widely accepted, they have risks. They increase the risk of disability and death. If you have dementia and you're on olanzapine or risperidone for a year your chance of a stroke is about 3% (compared to folk off the drugs, where the chance is about 1%). That's the problem. They're not placebo, they're proper drugs, they have real effects, so can cause serious adverse events as they change how your body ticks. As clinicians we know this and discuss it with our patients (or, more frequently, with their carers too). Carers say they can't cope, we look at interventions that can help, but the changed thoughts and psychotic symptoms persist. There're a lot of retired miners in my corner. Many are used to getting up in the early hours of the morning and when dementing know with absolute conviction that they need to be getting up for work in the wee hours. To have a man getting up and wandering the streets at 4.00am each and every night is not the easiest thing to manage. Medication isn't a solution on its own but it can mean that he can understand and appreciate reassaurance and reality orientation that carers proffer. It can help. It can mean that my patient is less distraught and their carer can cope.

I agree, totally, that antipsychotics should only ever be used as part of a package of care and the drug should not be seen as a cure or solution to problems on its own. I agree that they can be over prescribed. I agree that acetylcholinesterase inhibitors have a greater role in the treatment of BPSD in Alzheimer's disease than antipsychotics do. I agree that other classes of drugs, such as benzodiazepines, can be more useful for some patients some of the time. I agree that antipsychotics have a risk (but an additional 2% chance a year of a stroke means there's a 98% chance that it won't cause one, which for many carers having intolerable situations are odds they'll go with each and every day).

It worries me that the MHRA said that olanzapine and risperidone shouldn't be used in dementia, but to give them their dues it has been clinical advice and not an edict written in tablets of stone. Clinical freedom's curtailed but still there's room for me to prescribe them if I really believe it's in my patient's best interests.

In the USA the risks of morbidity and death that antipsychotics cause scares clinicians so much (they then get sued a lot) that they're not commonly used in BPSD. Other techniques like physical restraint are used instead. Wandering? We can cure that, let's just handcuff both wrists of the patient to either side of the bed. Happened this month. Acceptable practice, to de-escalate risks with no serious chance of strokes that nasty drugs cause. As well as not giving drugs for BPSD, they're shy about drugs in frank barn door psychosis when paranoid delusions and the consequent disturbed behaviour are present.

This week, on Monday 16th June, in America the FDA said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

If you have dementia, and have psychosis, you don't get an antipsychotic. They work, but since there's some risk, they're banned across the continent of North America.

Handcuffs or medication. I really, really hope folk in the UK take a more balanced view.

Wednesday 18 June 2008


Timing of topics, it's all a bit peculiar. Maybe it's the GP training in me, but I'm drawn back to thinking why do folk choose to present what they wish to say, now? Why not last month? Or next week?

I blogged about benefits of good care homes on the 13th of May, then about provision of appropriate staffing levels with the right skills on the 22nd of May.

The Jobbing Doctor blogged about dementia care and care homes on the 18th of June, Dr Crippen raised many issues of dementia care on the 17th of June with a follow up on the 18th of June.

This is not the first time this has happened. It just strikes me as peculiar that a theme can capture different peoples interests, working in different locations and in different disciplines, at the same time. It shouldn't, but it does!

Wednesday 11 June 2008


Oliver Smith asked here for comment on the view, "Why would you want to go into psychiatry? It is a dying bread. They've lost a lot of credibility"

I quite like the typo. There's something very pastoral about bread, what with priests and vicars gifting it as the Host, restaurants benevolently tossing it out for free whilst you await your starters, families sharing it around a table.
But anyway, why would anyone opt for psychiatry?

A post in two parts. To answer the question, it's easiest for me to be shamelessly self indulgent and share some of why I am a psychiatrist. This at least gives a context and one account of why one person chose psychiatry. Thoughts on why others have opted for psychiatry are the musings of another post since it's more contentious.

Since the question's about psychiatry, I'll not wax lyrical about medicine, as a profession. Motives for being a medic usually are laudable and enduring. Friends who didn't do medicine earn more than I do, starting to do so whilst I was still a student; money's better gained elsewhere. You're part of a huge system with the Department of Health, numerous Institutes and Colleges and "expert bodies" having influence over how you can work. Specifically, commissioners and the hospital management structure can influence details of how you work, who you work with, when you work and what you do at work. You don't go in to medicine to be your own boss.
Suffice to say, most medics I know are in it to do good, which is why they stay on evenings and work extra hours and do work that's outside their contract, because they're keen to do what's best for their patients.

So from this viewpoint, why opt in to psychiatry?

Every individual will have their own motivations and ideas and desires, but I think a few themes emerge.

For me, I knew it was something I was interested in. I finished medical school and was fortunate, passing all exams throughout university clearly, never needing a viva or resits or anything stressful. I believe this was because I was simply lucky, I saw peers who studied as hard and were cleverer failing bits. But the process of endless exams that had to be passed left me weary, so on starting out as a doctor I didn't want more arduous exams right now, thank you kindly. This left me General Practice, a career choice that (at that time) didn't need Membership examination. So I trained as a GP. I loved the medicine. The scope of what came through, the continuity of care as you see someone over time, the exploring of issues together (that shift from issues to symptoms to resolution or to problems or to diagnosis) was great - little was straightforward, it was all challenging and engaging and immersive work. People generated symptom lists, medical knowledge was applied to sift through the significance of these, cluster relevant information together, consider pathological processes and illness that can generate such symptoms, formulate diagnosis, generate and effect management, supporting physical and occupational and relationship and social and practical dimensions of peoples' lives.
And it really was broad, with stuff to do on whether folk could have a shotgun, or drive, or had capacity to get married, or was fit to stand trial, or could fly on one last holiday to Australia, or had disability and couldn't work. Not just physical medicine, General Practice was a vibrant and stimulating and diverse environment that lived and breathed biopsychosocial medicine (rather than pure medical models of health/illness).

Through this I knew GP land was great medicine, but wasn't for me. I loved the work. I found the time constraints unacceptable. So, being pragmatic, this constraint was unacceptable so I chose not to accept it and left GP land.
I got in at 8.00am, started surgey at 8.30am, over ran 'til 11.30am. I then spent half and hour sorting all referrals and paper work and letters to the hospital or whoever and all Item of Service fee stuff and went through all the letters I'd get from the hospital. From there we're up to midday, when I'd do my home visits. Usually 3 or 4, with 10 minutes to drive there, 15 minutes with the patient and family to do the history/examination/diagnosis/treatment/safety netting, document it and on to the next. Often I'd go to nursing homes too since I loved reviewing elderly folks in care (so much is found that can be improved upon when it's looked for). So we're up to about 1.30pm and I'm back in the surgery to do my Child Health Surveillance clinic or minor ops clinic or Diabetes clinic or Asthma clinic or whatever. Two and a half hours on, 4.00pm to 6.30pm and it's evening surgey. Say someone comes in with something easy that I'm really, really shit hot at and well trained in like chest pain; I take a history to see if the pain's likely to arise from stomach, oesophagus, bone/costochondritis, lung/pleura, nerves, heart, mediastinum or is referred from elsewhere then I'd examine then I'd discuss formulation/diagnosis then we'd plan investigations and treatment (and detail risks and benefits and side effects) then safety net in case there were serious cardiac events then plan follow up then document all this, all in 10 minutes. I just couldn't do it. If someone came in with something complex there are times you could just weep. Usually over ran, usually had paper work, investigation requests, referalls and Item of Service stuff to do for half an hour after the last person was seen. 7.00pm now.

Hmmm, I've been working from 8.00am to 7.00pm and, heck, I've not had any lunch yet, have I? Oh, or had any 'phone calls from a District Nurse to sort, or Health Visitor, or Midwife, or Community Psychiatric Nurse, or any of the patient problems that crop up that others bring to a GPs attention. Eeek, I've not yet fitted in any urgent calls or visits either. Thus, days often over ran beyond 7.00pm and were very very stressful.

This left me with a problem. I loved the medicine, I loved the work, I loved the patient consultations, I just couldn't do consultations in 10 minutes and have no latitude in the day to do what needed to be done in a way that was "good enough" so General Practice wasn't for me. Liked the job, couldn't live with the system. But being fair on entering GP training I knew I wasn't wholly wrapped up in it and just wanted to do something that didn't need lots of hard exams at the time. Yes, at that time junior doctors were that frazzled.

I've nothing but respect for GPs, they do an incredibly diverse and difficult job and, as evidenced, they're better men and women than me, being able to stick it out and work in such a system.

So I swapped over in to hospital medicine and trained in psychiatry, which I knew when doing GP training that it was where I'd want to be. Patients I saw were not just similar to patients I'd see as a GP. They were identical.
"I'm tired all the time, doctor."
"I feel run down."
"I think I may have something serious, I ache a lot more and can't do as much."
"I've headaches all the time which won't go away."
Instead of 10 minute consultations, I had an hour. Time to explore the issues in detail and then work through things as I'd wish. I was home. I got to do a lot of medical stuff and in training worked with physicians. I had to revisit exams, but was lucky, getting through membership exams at the first attempt. This let me continue in to higher specialist training, specialising in old age psychiatry but also continuing to work in a subspeciality as a physician. I passed all my exams and training and was appointed as a Consultant Psychiatrist and as a Consultant in a medical subspeciality seeing folk of all ages. This leaves me being more medical than many psychiatrists.

It's noteworthy that this career path, with the valuable experience I gained through each and every post I did, is no longer an option for todays junior doctors. They have to decide promptly on one career path, have to start on it straight away and have to choose a career that has vacancies (so may have no choice at all, ending up being a pathologist or GP when they wanted to be a cardiologist or orthopaedic hand surgeon).

In old age psychiatry I get to work with older adults, which I prefer. They're often a disadvantaged group with few folk improving their lot. There's an affable and courteous nature to consultations that's very agreeable. There's a stoicism that arises from having coped with everything life's thrown at you for 60, 70, 80 years or whatever, so dealing with the problems of the here and now can be childs play compared to some of the past adversity that folk have had to manage. Almost always, there's a lot that can be done to improve things. There's usually physical comorbidity to improve upon. There's usually a drug regimen that can be rationalised and improved. Sometimes mental health problems can be improved upon, invariably even if we can't change/fix the condition we can help folk cope with them better. Usually their world (the environment, their relationships, their wealth, the richness of their social contact) can be improved significantly. I work in well resourced teams (a rare privilege in old age psychiatry) with sensible managers who've always given me what I've asked for (a very rare privilege in old age psychiatry) so have a service that I think is great. Community services have enough staff to see everyone as often as needed (daily, sometimes), in-patient wards are new and bright and spacious and everyone's got their own room. It's the service I'd want for my parents or my wife or myself.

For me, I get to work in an area of medicine that I thrive within, working with older adults over the long haul improving their mental wellbeing through addressing their psychiatric conditions as well as looking at medical and psychosocial interventions. The service has been shaped so that delivery's exactly how I'd wish it to be. I work with great teams. I'm working long hours but thoroughly enjoying it, I'm not frazzled any more, I choose to do so rather than need to do so.
At the end of the day, for my patients and the lives I touch, and follow through on, I see the difference that I make.

Much goodness.

Tuesday 3 June 2008


Do you have Integrated Pathways of Care (an IPOC) or Integrated Care Pathways (ICP) as protocols, governance frameworks, audit tools and clinical records all rolled in to one?

I used to write on blank paper. Life was simple.

Now we've care pathways for oodles of things. Each has its own booklet to fill in with squillions of boxes. Have you documented that you've assessed capacity in the Capacity box? Have you signed and dated this? Have you initialled and dated the "discussed managed choice" bit and listed what options were proffered? Have you recorded biochemical indices before initiating an antipsychiotic? Have you commented on the ECG you then invariably undertook, since the patient's on an antipsychotic?

I can see the point of them. They focus in on what one version of best practice is, lists every single element of this, then guides you through each and every step which you document, laboriously.

Much of the paperwork is redundant (do I really need a list of approved abbreviations for each care pathway in each set of filed documentation each time it's started?) making them lengthy. Case notes have increased in size appreciably.

But, not just case notes. I see a patient in their home, do I start care pathway documentation in the community? I guess I probably should. Hang on, then, how's my CPN going to follow it up since she won't have my written medical notes (since the CMHT have their own electronic records). What about day hospital attendance when things are fiddled with? Or in-patient episodes? Gah, the care pathway isn't one record with continuity and contemporaneous documentation at all then, is it?

What if a patient has, say, hypomania? They're admitted informally and receive help. But the documentation becomes hideous. We've a care pathway for the admission, a care pathway for the antipsychotic, a care pathway for the mood stabiliser, a care pathway for the discharge. We've care pathways for ECT. Each care pathway requires, at length, that every element of every step of care is documented, timed/dated and signed.

I hate it.

Not the framework, per se, more the compartmentalised documentation. I look at an antipsychotic pathway then find in the notes the one for lithium use, then the admission one with physical comorbidity and medication and so on, information's scattered all over the place. That, above all else, is what I loathe about care pathways. This fixation with form and process loses the context and detail.

What's it like for the person, today compared to yesterday? What's changed, in terms of how they're now able to sit having a fag in the garden and chatter to folk about what lumpy custard we had at lunchtime (when last week behavioural repetoire was much more constricted). What does their nearest and dearest reckon's changed? Where does it allow us to document that, now, there's a desire to choose ones own clothing when offered a choice? There're lots of bits to document suicidality, but nowhere does it allow documentation of ataxia and falls risks, or dysthmic changes and feeling hacked off and irritable, or consequences such as delirium or akathisia causing wandering at 5.00am in a night dress across and along a main road.

Information is now incomplete since only what's requested is documented and other (more relevant) information is no longer documented. Information is fragmented, being compartmentalised in to different areas. Information is factual and procedural and specific, so lacks context.

Having started using care pathways a year or so ago, I've managed to avoid them totally this year. We're in to June now, half way through, and nobody's told me off yet. Hopefully I can get away with it for another few decades, eh?