Monday 27 June 2011

General Practice

I was out at a local Chinese restaurant with Mrs Shrink, after a fatality within the oven in our kitchen wrote off a nutitious evening meal, 'less your idea of nutritious involves burnt unidentifiable charcoal clumps.

Out we went. We ordered lots of nibbly things. Very nice they were, too.

The owner kept looking at me. I couldn't think why. He came over to thank me for treating his daughter, in the 1990's sometime, when I was working out in GP land. Apparently I'd diagnosed her skin condition correctly as eczema, I'd given her the right creams and oils and she'd been cured.

He remembered that. He remembered me and what I'd done for his child. Patients do that, with GPs. The current NHS changes invite discourse on what GPs do that's important, what GPs do that's delegable, what GPs do that can be displaced to other services. This contact stirred thoughts that, frankly, that's all missing the point. The gentleman approached me 2 decades on to offer his gratitude because that consultation and care within General Practice had rich meaning to him. It mattered. And that's the bottom line . . . what GPs do makes a difference to peoples' lives, is valued and deeply meaningful.

Thursday 23 June 2011


Back from holiday and there's always mountains of stuff to sort. Busy busy busy. But the nuisances and inconveniences pale against that adversity that some patients endure. A number of patients presented with different backgrounds causing the same presentation and experience of wishing to die in an active intentional elective manner. Indulge me in merging details of several patients into one vignette.

A patient's got severe COPD and is breathless just sitting around doing nothing. He's got lungs full of coal dust. He's got knackered joints all over, he struggles to mobilise at all now. He's scalded himself, dropping cups of tea on himself through arthritic and somewhat numb hands (his GP reckons past machine use has caused vibration white finger). He's long standing angina, blood pressure and mild heart failure, he's getting older and renal function's starting to decline too but a recent diagnosis of Parkinson's Disease clinched it.

He described how he reckoned he'll get iller, frailer, more dependant, physically and mentally deteriorate and explained he'll die, "buggered, a cabbage." Those were his words. Grim. He'd been a proud man, proud of his working class roots and life, grafting to earn everything and asking nothing from anybody. When he came into hospital he'd not even allowed his family to look after his dog, he asks nothing and puts nobody out. Except inadvertently a social worker, who sorted kennels.

He feels it's not right for him to lose his dignity and independance, he's wishing to end it all before it comes to that. He's not awfully cheerful but he's not clinically depressed. Specifically, he's not mentally disordered (within the meaning of the MHA 1983) and he's a capacitated adult (within the meaning of the MCA 2005). His psychological wellbeing's not cheery, but there's no frank psychiatric condition to attend to. Mental wellbeing's supported, protective factors are explored, support's considered that may engender more hope and help him endure over the longer term. Or maybe it won't.

Killing himself won't be a happy ending for me. Or for his family. But it may be the ending he wants and needs, in the way and time he chooses. I don't want it to happen, but it's not my choice. I can't have a happy ending every time . . .

Wednesday 1 June 2011

Antipsychotics in Dementia

Dementia is a gruesome disease.

It robs you of your dearest memories, your personality and sense of self, your vocabulary and communication, function and what you can do, and life. Unlike cancer, there's no drug or surgery or intervention that we have which can prolong life/delay death by even one day.

Broadly dementia is said to cause both cognitive problems (changes in memory and thinking) and non-cognitive problems (behavioural and psychological symptoms of dementia, BPSD).

Cognitive changes can be managed, fairly successfully, most of the time. Non-drug strategies (practical support, carer interactions and psychological interventions) make a huge difference. I'm not amazingly sold on Cognitive Stimulation Therapy as the bees knees (that NICE advocate in their clinical guideline CG 42), but a host of simple practical suggestions can help non-demented and demented folk alike, like these. Acetylcholinesterase inhibitors have significant benefits to most folk with Alzheimer's Disease (and related dementias) most of the time. We can't stop cognitive change over time, but we can manage the symptoms of it and the impact of it, fairly well, most of the time.

What's much more problematic is managing the non-cognitive BPSD part. Wandering without purpose day and night, mood changes and frustrations with anxiety or utter unconsolable despair, shrieking and screaming in public, disinhibition trying to kiss strangers and masterbating in public, suspicion of partners/carers with consequent hostility and violence. Much harder to manage than cognitive changes such as forgetting a hairdresser's appointment.

Our weekly carers' support group rarely focuses on cognitive problems, mostly it's BPSD that takes carers to their knees, it's BPSD that they need help managing. Without the intensity of the BPSD they miraculously could (and usually do) cope well in truly dismal circumstances.

Delusions, with paranoid persecutory thoughts, mood disturbance and seemingly irrational beliefs, how can these be managed?

In America the FDA have said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

This can be harsh.

You can have psychosis, this can torment the patient and torment the carer, you've antipsychotics to treat the psychosis but you don't. Kind of galls me, that.

The reasoning behind the FDA's reticence to entertain antipsychotic medication in dementia care is sound. It's not homeopathy, it's proper medicine that has proper benefits but also proper risks/side effects (like ramping up risks of a stroke in the next year by 2%). The medications can cause significant harm.

Originally work was mostly focussed on risperidone and olanzapine since there was sufficient research to evidence consequences of use in dementia care (both good and bad), with such medication evidencing great benefit as well as great risk. Subsequent research shows older adults in care homes experience similar risk from which ever antipsychotic drug you use. They all have side effects and can cause harm, it's just some are more likely to cause a heart attack, others more likely a stroke, but the over all risks are pretty comparable.

Knowing that the medication has a modest risk:benefit ratio and can cause significant harm, such medications need to be carefully considered and used judiciuously. Careful consideration of what the issue being treated is, what the target symptoms are, what the level of symptom burden is before treatment, what it is after introducing medication and is there objective gain through the medication's use? The time necessary and sophistication of assessment, reasoning/rational prescribing practice, carer input/management of frequently incapacitated adults (with respect to the treatment decision and valid consent), initiation, titration and evaluation of medication is usually outwith the scope of Primary Care or acute hospitals and sits better within mental health services for older people.

With that in mind, and seeing the grim consequences for patients and carers of not treating BPSD and dementia related psychosis, I'm increasingly aligning with this view, ". . . that antipsychotics may be justified using a palliative model."

Evidence Based Medicine (EBM) informs the discussion but to then elect to use antipsychotic medication, for some patients, some of the time, that somehow feels much more humane.