Thursday 17 July 2008


Let me take you through a scenario.

A lady with hypertension, diabetes and atrial fibrillation develops dementia and is seen by her GP. Her GP takes a thorough history, speaks with relatives for informant history, undertakes a physical examination then blood tests and excludes acute confusional states. Her relatives are at their wits end because the lady is screaming all the time, thoroughly confused, urinated inappropriately in public at a garden centre last weekend, gets lost so wanders around questing to find something that looks familiar and can't remember to take any tablets.

The GP thinks the lady may have dementia and refers her on to me.

I see her at her home, with a mental health nurse. The nurse and I also take a thorough history and mental state examination and examine relevant things. I go through concentration and attention span, orientation, registration, recall, language, praxis, executive information processing and decision making. Her pulse, which was irregularly irregular. Her shaking (but normal gait) that was almost certainly benign essential tremour. Her eyes, she looked a bit icteric but it was probably the gloom of her room and the colour of her faded curtains. The nurse chats with her about function and changes and how she's feeling she's coping whilst I speak her family in the next room about her dementia.

Explanation, advice, social care input and psychoeducation. CT imaging excludes atrophic changes but confirms vascular dementia.

Family say that home care manage to prompt her to take most of her medication most of the time but she's still wandering across roads and getting lost, fiddling in the kitchen, shouting at people and has no idea of social norms. Because her speech and presentation is well preserved, with vascular damage just compromising a few cognitive domains (particularly frontal lobe function, so judgement and personality are affected), she doesn't present to the general public as ill, she just seems abrasive and frankly delinquent.

An antipsychotic is considered and discussed with family. Risks are explicit and bluntly stated. Perceived benefits are explained with realistic goals thought through. A drug is started. Her behavioural and psychological symptoms of dementia (BPSD) are abolished. No wandering. No fiddling. No urinating inappropriately. No shouting. She is undistressed and happy. Family are happy.

She is reviewed by the nurse and myself over many weeks. The dose of medication if adjusted. Side effects are looked for, but thankfully aren't present. Benefit continues, with abolition of all intrusive symptoms and mitigation of risks. Hurrah.

All problems have been sorted out. She no longer needs the specialist input of a Foundation Trust's mental health team. She's no symptoms, no risks, no problems. All is good. She's discharged back to her GP's care, who's delighted we've sorted everything out.

She's on an antipsychotic. The GP declines to prescribe the antipsychotic. The Area Prescribing Committee have the drug green lighted, so the GP can freely prescribe it. The PCT has no commissioned dementia care service with our Trust to prescribe for these patients, they expect the GPs to prescribe. The patient doesn't get their drugs. The patient has symptoms of BPSD again and it all turns pear shaped. The family complain about the GP. The General Medical Council is notified and the GP is taken to task. The GP's patient had a condition, treatment was started under specialist care, it was evidenced that this drug worked for this patient, risks and benefits were considered with the patient and family, the drug was monitored over time and when the patient was seen to be stable the GP didn't continue this care. Prescribing was rational and appropriate.

The GMC in 2006 published the booklet Good Medical Practice detailing what doctors must and should do. In "Good Clinical Care," section 3 (c) it says the in providing care you must, "provide effective treatments based on the best available evidence."

For this patient, the evidence is that the antipsychotic is effective. For a GP not to prescribe is therefore a serious matter for the GMC.

An interesting scenario, eh? And, uniquely, I can't take credit for this vignette. The patient symptoms are from my work this last few weeks but the GP bit was described to me by a lawyer, she saw this as an untenable position for a GP to maintain. Interesting times. Oh, for the record, the lawyer earns more than I do ;-)


Jobbing Doctor said...

This is an interesting vignette, and as a experienced practising GP I would be willing to prescribe this drug, particularly with the support of a psychogeriatrician like yourself.

The waters have been muddied, however, by the attitude of certain professionals who take it upon themselves to pontificate on antipsychotic prescribing in dementia, and that makes a lot of us GPs somewhat nervous.

We have discussed this before!

Cockroach Catcher said...

Our PCT is now pushing for our GP clinic to go down the Polyclinic route and we want to object. As the government cleverly pass the money matter to PCTs and there may be a few who value their knighthoods and so on we are in for a very rough ride. In older times would the GP be so stubborn as to refuse to prescribe? A consultant certainly earns less than the sort of lawyer you are talking about and nowadays less than the GPs that we deal with, where is it going to lead us? Is the PCT indeed dodging the whole issue when they may have an agenda that is driven by money?

That consultants and GPs are divided by the present government is a sad state of affair. I do not personally have a solution but I feel that the way forward would be to separate public health care with private health care completely. All doctors either do public work or private ones. Psychiatry is a big problem because of the chronicity and there is not much money to be made by any private concern. We will in the end suffer, Virgin or otherwise.

The Cockroach Catcher

ditzydoctor said...

hullo shrink! :D may i pls have your email? :D

Anonymous said...

Clearly the GP is a donut.

GP refers to you for advice which you gave then decides to go against your specialist advice.

There is more to say the GP should continue the script than against.

And I think your vignette deliberately identifies just about the most extreme grey area of BPSD care - completely plausible - but how likely?

In such a scenario the ending would be far more convaluted than "..and that's that" - and would hopefully result in the patient receiving the medication but the processes around it being changed (either permanently or on an as-required basis)