Friday 15 October 2010


I read of people with bipolar affective disorder disorder who see it as a gift. It's part of their chemistry, it's who and how they are, it's something that gives changes and makes things different, with difference from the herd not always being bad. I've yet to meet such folk, my patients tend to see bipolar disorder as a wretched nuisance.

One bloke, though, quite appreciates it. He'd rather not have it, hating the periods of low mood when he describes how melancholia descends and remorselessly harrows him for months on end, but he does like the rest of it. Most of the time he's a naturally cheerful disposition, our team's unclear if this is because we're holding him on average a little on the high side, or if he's one of life's cheery souls.

In any case, he's normally buoyant and optimistic and outgoing. He has no family but has a good number of good friends.

Dr Zorro talked of music. The Jobbing Doctor spoke of music, too.

My patient speaks of music. He loves to play, plays a few instruments, and is decent at this. Friends think he's okay, he describes how folk amiably listen whilst chatting or sharing wine or whatever on an evening. All pleasant enough. I can't play any instrument competently so envy his aptitude, to pick something up and create melody and rhythm and emotion in instruments he plays. He sounds good to me, too, when he's played for me.

What's different is when he's high. When he's high he plays music and it's divine. His friends enthusiastically agree. He has insight into this too, reckoning that his music, when he's high, is genius. He's not that grandiose either, it really is in a wholly different league. Home visits when he's high are a source of both dismay (finding seeing him manic) and raturous joy, as he enthusiastically plays the most incomparable music I've heard.

Monday 11 October 2010

Paternalistic Healthcare

I started to think this through previously, but derailed into a post about my experiences of GP training and reflection on how clinical focus shifts at different stages of our training and our careers.

My thoughts were on training, particularly my GP training, because one of the teams I work with has recently had animated debate on the topic of paternalistic healthcare. As in, telling patients what they should do.

I work in a world where mostly there're shades of grey. Most folk working in mental illness suss out there's not a magical dichotomy between mentally well and mentally ill, but there's a continuum. No matter how biomedical or psychosocial in their outlook, most folk I work with see medication as not the only treatment/panacea for everything or as useless to all patients all of the time. Whether it's diagnosis or treatment, we're comfortable with managing uncertainty within accepted frameworks. We do shades of grey quite well.

Apart from on this one, it seems.

How paternalistic should we be? It was argued that it's also a continuum and we should be more paternalistic or less paternalistic, taking into account patient factors. Some felt no, we shouldn't be paternalistic at all and that family or IMCAs should take on this role.

If someone's bewildered and all at sea, it was argued that the least restrictive/most proportionate response, acting in their best interests, would be to offer choices to them and if they were unable to make a choice to steer them to what's a good idea. A nurse had an example of a patient they'd seen who was clinically depressed (unable to think, thought they'd been back from their daughter's house 3 days when it had been 9 days, unable and unwilling to eat or drink, demotivated and not leaving the house for weeks, seeing no hope for the future and wanting to be dead).

Depression had caused marked cognitive distortions. After the nurse and I saw him one day, the nurse saw him the next day and again talked through ways of helping him. The patient couldn't make a choice, the nurse met me and arranged for an orodispersible antidepressant so the only choice the patient had to make was whether to take it or not. 2 weeks later things had improved a lot, 4 weeks later he's almost back to normal. The response to medication was unusually good but that wasn't the point, it was that the patient was started on medication through being jollied along into this by his nurse (and indirectly by me, from discussing medication the day before then providing a prescription for him).

A lady with dementia, she's now in respite care, a lot. When at home our support worker takes her out at least once a week. This gives her husband a break but also gives her opportunity for stimulation and lets us get the measure of her functional level/what she can or can't readily do any more. The support worker can get her to do anything. She'll get into her car, pop to the shops, sit and have coffee or something to eat, play a game of bingo or dominoes or snap, have a bath, anything. With respite care or home care or the sitting service we're told she's a "challenging lady" who won't do anything and "is resistive to care."

The support worker and a nurse went to the care home and watched how they treated her. Usually we'd not send two staff but there was a need for a nurse to do some formal Dementia Care Mapping as part of future teaching with that care home anyway. The staff feedback and documentation was interesting. It was clear that carers were offering the lady lots of choices and open comments.

"Do you want to play a game of card?"
"What would you like for lunch?"
"Do you want a drink of tea?"
"You okay there, love?"
"Do you fancy joining the [activities] group this afternoon?"

She sat in the care home, declining everything, "No, I'm alright love, leave me be."
Things were offered and she'd either decline to opt in, or care home staff would see her as not keen to engage so would pass over her. Mostly she was ignored.

Why was she fine with the support worker but not with care home staff? It was a difference of approach. Our support worker would, in her bright and cheery way, suggest, "Come and . . . " or "Come on, let's . . ." and she'd go with the flow and join in.

Rather than choices, to offer direction was helpful. Not for all things, all the time, but there seemed to be a place for directive comments. The lady would never opt in to play a game, but if you said, "Come and have a game of snap with Betty and me," she'd happily walk over and sit down and talk and play. Without being "told" to come and do it, if just offered "Do you want to play snap?" she'd always decline, as she would almost any choice offered to her.

Some of our team illustrated compelling cases where being paternalistic, with some people, some of the time, is a good thing.

Managers will be having a fit.

Friday 8 October 2010

Dementia Care

I'm sure everyone's been gripped by the NICE review and preliminary guidance on the NICE Technology Appraisal (TA 111), released yesterday. It goes on, at length, here. Reading the runes, it's likely to be refreshed from preliminary guidance into national NICE guidance in February 2011 which then has significant implications. Implementation and use of Technology Appraisals in clinical care has to be funded and can't be denied solely on cost grounds.

I'm rather relieved, therefore, that in my corner it isn't going to make a significant difference. Does the review of TA 111 matter, than? It was released in September 2007, updated in August 2009, now refreshed in October 2010 for update in February 2011. Does this document have any use or meaning? It will, helpfully, to a lot of other Trusts.

Microsoft Word tells me the preliminary guidance is 21 824 words. There's a lot of it.

I like it.

It's at variance with some folks' wishes who aren't keen on early diagnosis, since the guidance now invites treatment of mild dementia, rather than waiting 'til you're moderately demented before starting medication. This makes sense to me. The medication typically holds a person at their level of cognition for couple of years. Is is better to be held at a level where MMSE is 24/30 or where MMSE is 14/30? There're exceptions (where insight is a curse and distress blessedly diminishes as the ability to forget becomes more intense) but usually it's desirable (and desired by patients/carers) to keep someone at their best, rather than wait for a decline then keep them at that level.

This is what my colleagues and I've done for years. Our local Alzheimer's Society, PCT, Area Prescribing Committee, GPs and Trust Medicines Management Committee uncharacteristiclaly all agreed a care pwathway and funding such that folk with dementia access treatment on diagnosis, irrespective of severity/MMSE. All my patients with mild dementia have been having the drugs for years.

No changes there, then. Speaking with colleagues in other Trusts, it will open up a huge amount of work for them, with literally hundreds of people who've mild dementia who will be entitled to medication and aren't currently on it needing review and discussion and (often) medication initiated, titrated, reviewed then continued under Shared Care.

I don't prescribe a lot of memantine, using it with just a few patients, so the guidance there won't change my world. Opening up memantine so it can be used in the NHS (outside of clinical trials) isn't a change for me, since I am prescribing it already.

Over 20 000 words saying I can practice as I am.

That's the sort of guidance I can stand to receive!

Tuesday 5 October 2010

Vitamin B

Folks with memory problems have some B vitamins checked before ever reaching my door. Vitamin B12 (and folic acid, and LFTs showing albumin levels) evidence nutrition, or lack of nutrition.

If patients have evidence of vitamin deficiency, it's usually treated by their GP before I assess the patient, so assessment of mood and cognition is looking at contributing mental health problems, not nutritional deficits impacting on their wellbeing.

Recently patients' carers have been asking me about vitamin B preventing/slowing Alzheimer's disease. It's not something I know a lot about. I know a lot about Alzheimer's disease, the risk factors, the pathology that develops within the brain, the evidence of psychological interventions and the evidence of medication's efficacy and effectiveness. I know that about 8% of patients referred to me with dementia have something else instead, so routinely find physical health problems presenting with cognitive impairment.

In all this thinking and sleuthing stuff out, I was perturbed that vitamins could have great benefit to my patients but none of my colleagues knew of this, no current teaching articulated this, no past training covered this and no journal articles and updating continuing professional development taught this. My pharmacist colleagues knew naught of this, either. Perplexing.

I spent a few hours finding what I could. A pharmacist did the same. We met up and compared notes. We'd not found anything illuminating.

I chanced upon another blog today for the first time, which helpfully fisks the rubbish being tossed around in some main stream media. It's heartening that it's not just me and my clinical team that's not wondrously excited by vitamin B.

When patients ask about it, I'm indifferent. It's cheap, it's water soluble (so, unless really really trying hard, if you take too much it is dissolved in our urine and we just wee it out) but it's also not convincingly beneficial. If it's taken with minerals (like iron) then it's not that hard for folk with dementia to poison themselves.

It's not crystal therapy or colour healing. Not quite. It could have some sensible contribution beyond placebo effect. If people want to take vitamin B, all well and good. But it's not something my GPs or I'm prescribing for folk with dementia, yet.

Monday 4 October 2010

The past

When I trained as a GP there was consistent recognition of the book "The Doctor, his Patient and the Illness" by Michael Balint. Given that Balint's work involved GPs and psychiatrists meeting up and chewing over discussions of patients the GPs had been seeing, the themes and processes were right up my street. Although I enjoyed working in GP land, having swapped to psychiatry I still find the work equally appealing.

Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.

A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.

As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.

On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.

"The past is a foreign country; they do things differently there."
- L P Hartley

Friday 1 October 2010


I was surprised.

When the National Dementia Strategy was published in February 2009, although it wasn't a vision of perfection, it had good content and importantly also had cash attached to it. Strategic Health Authorities were given millions to implement the strategy. Not just "these are good ideas" or "do more, and now start doing it right" but instead a sensible strategy with sensible amounts of cash to resource it.

I was pleased.

Okay, okay, in my corner our Trust didn't get a penny more, but had (and still have) to deliver on objectives, so are being asked to do more and mroe without anything extra. But across Primary Care and the Local Authority and care homes, new money has been thrown at it and has helped patients. Mostly with Continuing Care funding, it seems.

I am still pleased.

That was February 2009. Time moves on. 1 year 8 months on and it's all gone quiet, with no enthusiasm to tackle dementia and the focus has moved elsewhere. No no no. This week the Department of Health published another document, following on from the National Dementia Strategy, called Quality outcomes for people with dementia : Builing on the work of the National Dementia Strategy. Okay, it's not the snappiest title for a document, but what's the document about? Read it on the DoH website, here.

It only came out this week, on the 28th September, so I've only just got around to reading it, thinking about it and forming a view. It contains 9 desired outcomes for people with dementia, which are clear and meaningful and realistic. It gives explanation of how theese outcomes can be delivered without oodles of prescriptive mandates and This Is What Thou Shalt Do edicts. Even the appendix, Annex 1, gives genuinely helpful descriptors for what the 9 outcomes/improvements for patients with dementia mean, in a nutshell.

First there's a National Dementia Strategy with a clear, over arching vision for health and social welfare that had millions attached to it, that we got. Then there's a follow up document a year and a half on, maintaining focus and contributing useful outcomes.

I remain pleased. Pleased and very pleasantly surprised.