I'm surprised!
The readers of Mental Nurse have voted for favourite mental health blogs and have voted for this as their favourite Psychiatrist's blog.
Given the number of popular psychiatrist blogs, more established ones, more frequently updated ones, newer ones, more evidence based ones and almost all of them look nicer/are better presented, and more popular blogs (with me tumbling through 2010 from number 2 to number 15 now) I'm very surpised (and of course pleased) that folk rated my musings.
So, a big thank you for being so kind!
Now, get on to Mental Nurse and rummage around some really good top quality blogs!
Friday, 31 December 2010
Liaison Psychiatry
It's stopped.
Bank Holidays must have something to do with it. I can't really fathom it, since that local acute Trust has a massive pressure on beds and is keen as mustard to move patients on.
Yet despite having hundreds of patients within their hospitals who've dementia, delirium and major mental illness, spread over a number of sites, with difficulty in managing and effecting safe discharge for these patients, I've not been swamped by liaison referrals. They've literally hundereds of patients with mental health problems on their wards. Often they find them very very difficult to manage on the ward and to plan discharge for. What with capacity assessments, Best Interest Meetings, Continuing Care needs there's usually process they want support with, before we even get to advice on clinical care.
With pressure on beds you'd expect there's be squillions of referrals to my door, trying to speed up the assessment, diagnosis, management or discharge planning for these patients.
Over 5 consecutive days I had 0 referrals. Not one. We usually have referrals every day. It's utterly unheard of.
Long 4 day Bank Holiday weekends. My fear is that no routine or important work gets done, only urgent/emergency work's attended to. These patients with physical and mental health needs, within the acute Trust, have unusually had no Liaison Psychiatry input in to their care for almost a week. Junior doctors and on-call staff haven't been considering their mental health needs and referring for specialist input.
Bank Holidays seem dangerous. This surely can't be good for patient care . . .
Bank Holidays must have something to do with it. I can't really fathom it, since that local acute Trust has a massive pressure on beds and is keen as mustard to move patients on.
Yet despite having hundreds of patients within their hospitals who've dementia, delirium and major mental illness, spread over a number of sites, with difficulty in managing and effecting safe discharge for these patients, I've not been swamped by liaison referrals. They've literally hundereds of patients with mental health problems on their wards. Often they find them very very difficult to manage on the ward and to plan discharge for. What with capacity assessments, Best Interest Meetings, Continuing Care needs there's usually process they want support with, before we even get to advice on clinical care.
With pressure on beds you'd expect there's be squillions of referrals to my door, trying to speed up the assessment, diagnosis, management or discharge planning for these patients.
Over 5 consecutive days I had 0 referrals. Not one. We usually have referrals every day. It's utterly unheard of.
Long 4 day Bank Holiday weekends. My fear is that no routine or important work gets done, only urgent/emergency work's attended to. These patients with physical and mental health needs, within the acute Trust, have unusually had no Liaison Psychiatry input in to their care for almost a week. Junior doctors and on-call staff haven't been considering their mental health needs and referring for specialist input.
Bank Holidays seem dangerous. This surely can't be good for patient care . . .
Tuesday, 21 December 2010
Mental Capacity Act 2005
I'm blessed with fantastic colleagues. It's really the only reason I'm working where I am. The staff really are fantastic.
Colleagues outside of the NHS are more variable in their competence. Some social workers are fantastic. I've a lot of time for social workers, they do a hard job with little meaningful support/team work. One disadvantage of this culture is that social workers are pretty idiosyncratic animals. They all work differently, with sometimes very different attitudes and consequently very different interventions (or lack of interventions).
This variability in social work bemused me . . . shouldn't it be a needs led service? Shouldn't what the patient (erm, client, to them) needs define what activities the social worker undertakes/the content of their care schedule? No, it all falls down to the quirks of the individual social worker (or assessment officer) in my corner, and the attitude/whim/habits they possess. Patients get very different responses and outcomes depending which area team social worker picks up their case.
What's more muddling is their response to change, including legislative changes such as the Mental Capacity Act 2005.
A social worker today said they didn't know it, she hadn't had what she thought was enough training on it, she didn't use it and it was "still new" so it didn't matter. 3 of her colleagues thought similarly. New? Still new?! It was drafted in 2005 and implemented in 2007, we've been using it for years!
Good grief.
But those individuals ignore it, don't do formal capacity assessments or Best Interest meetings/decisions or the like. Instead they refer such nonsense to their Team Leader (who has to do it all) because when she says they have to do it, and it's the law, they just tell her she's, "going off on one, again," and shrug and move on.
I'm not sure we've the ideal system, locally, for embedding current best practice within Local Authority social work teams . . .
Colleagues outside of the NHS are more variable in their competence. Some social workers are fantastic. I've a lot of time for social workers, they do a hard job with little meaningful support/team work. One disadvantage of this culture is that social workers are pretty idiosyncratic animals. They all work differently, with sometimes very different attitudes and consequently very different interventions (or lack of interventions).
This variability in social work bemused me . . . shouldn't it be a needs led service? Shouldn't what the patient (erm, client, to them) needs define what activities the social worker undertakes/the content of their care schedule? No, it all falls down to the quirks of the individual social worker (or assessment officer) in my corner, and the attitude/whim/habits they possess. Patients get very different responses and outcomes depending which area team social worker picks up their case.
What's more muddling is their response to change, including legislative changes such as the Mental Capacity Act 2005.
A social worker today said they didn't know it, she hadn't had what she thought was enough training on it, she didn't use it and it was "still new" so it didn't matter. 3 of her colleagues thought similarly. New? Still new?! It was drafted in 2005 and implemented in 2007, we've been using it for years!
Good grief.
But those individuals ignore it, don't do formal capacity assessments or Best Interest meetings/decisions or the like. Instead they refer such nonsense to their Team Leader (who has to do it all) because when she says they have to do it, and it's the law, they just tell her she's, "going off on one, again," and shrug and move on.
I'm not sure we've the ideal system, locally, for embedding current best practice within Local Authority social work teams . . .
Tuesday, 9 November 2010
Complicated
Another rant, I'm afraid.
First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.
The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.
The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.
I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.
They weren't.
On face value, with the problem in front of us, it was all very simple indeed.
It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.
Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.
Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).
I was perplexed.
Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.
We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.
They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.
Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.
First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.
The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.
The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.
I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.
They weren't.
On face value, with the problem in front of us, it was all very simple indeed.
It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.
Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.
Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).
I was perplexed.
Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.
We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.
They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.
Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.
Wednesday, 3 November 2010
Slap
Is it wrong to want to slap someone? There's a dark cloud.
There's an irrational, unwanted, non EBM collusion that in older adults you prescribe medication by, "starting low and going slow."
No, I don't really know what that means, either. It was never taught to me in pharmacology lectures at medical school. Nobody in conferences speaks of subtherapeutic prescribing, unless you're in a homeopathy class, presumably. And then, well, frankly it's just water so dose becomes singularly uninteresting to me.
But for proper drugs, doesn't an effective dose matter?
Really, in all the pharamcological and therapeutics conferences, CPD events, reading and training I don't hear folk saying, "Take the patient research, the evidence based medicine, the product SPC and of course just ignore it all . . . halve the starting dose to well below what the BNF has as a minimum, keep 'em on that subtherapetic dose for ages and then maybe titrate up to the minimum dose months later . . . since boy and girls, we much start low and go slow."
Nonsense.
Older adults with mental health problems are vulnerable adults. I'd absolutely advocate minimum therapeutic doses, if medication's indicated at all. Most of the time medication's not got a major role to play. When it is used, it's therefore important that it's used effectively and that it works.
Depression is serious. An older adult, being depressed, is harmful. Evidence shows permanent neuronal cell death arising from depression, so each day depressed is a day that a little bit more brain dies.
We know that a metaanalysis of antidepressants confirmed that the drugs aren't any more effective than placebo in mild, moderate or severe depression, with benefits only being realised in very severe depression (as described here). If an older adult is clinically depressed, either it's mild/moderate/severe and arguably medication's seldom used, or it's very severe and medication's used effectively. It's hard to argue to use medication ineffectively.
Why do some folk, who are otherwise sensible and rational and effective doctors, therefore prescribe subtherapeutic doses of antidepressants which don't work (surprise, surprise) then refer them, perplexed, to my door, time and time again? I know why it is, because I asked them. It's because they're harrowed by drug reps whittering on about "start low and go slow" in older adults. Bastards. It means my patients are getting shabby care for no good reason, what so ever, but Big Pharma has lots of FP10s which have to be dished out for months "because you have to go slow" before then the meaningful prescribing can start.
Why should anyone with depression, which is severe enough to need medication, be on citalopram 10mg once a day? The BNF has the minimum starting dose as 20mg once a day. It kindly guides us into evaluating at 3-4 weeks to titrate up to 40mg and kindly specifies that in folk over 65, 40mg is the maximum dose. Brilliant. Crystal clear. For folk over 65, you're on 20mg od and if after 3 to 4 weeks you need more, you're on 40mg od. Why oh why are 10mg or 30mg prescribed, then? Drug rep waffle seems to be cited as the only cause, and worryingly is more powerful in effecting change in practice than the crystal clear/precise BNF is in directing appropriate prescribing.
Gah.
Olanzapine also is used in timid doses. I don't want high dose presribing, this year my appraisal portfolio evidences just 2 patients under my care received above BNF doses of medication at any time. I'm not after high dose use. I just don't want subtherapeutic or irrational use. Olanzapine's blood level is roughly halved in smokers, with many of my older adults in the deprived areas I cover being smokers. Yet there's a zeal for homeopathic starting doses, which are continued ineffectively for months, to "start low and go slow."
Whoever it is, in 2010, that's going around and poisoning doctors' minds away from evidence based medicine, pharmaokinetics/pharmacodynamics, product testing and the licence/Summary of Product Characteristics and BNF prescribing details, they're harming patient care. Those folk whittering on about this "start low go slow" notion, I want their evidence base or I want to slap them. Or reporting them to APBI may placate me and rid us of such pernicious counsel. There's a dark cloud, but there's a silver lining.
There's an irrational, unwanted, non EBM collusion that in older adults you prescribe medication by, "starting low and going slow."
No, I don't really know what that means, either. It was never taught to me in pharmacology lectures at medical school. Nobody in conferences speaks of subtherapeutic prescribing, unless you're in a homeopathy class, presumably. And then, well, frankly it's just water so dose becomes singularly uninteresting to me.
But for proper drugs, doesn't an effective dose matter?
Really, in all the pharamcological and therapeutics conferences, CPD events, reading and training I don't hear folk saying, "Take the patient research, the evidence based medicine, the product SPC and of course just ignore it all . . . halve the starting dose to well below what the BNF has as a minimum, keep 'em on that subtherapetic dose for ages and then maybe titrate up to the minimum dose months later . . . since boy and girls, we much start low and go slow."
Nonsense.
Older adults with mental health problems are vulnerable adults. I'd absolutely advocate minimum therapeutic doses, if medication's indicated at all. Most of the time medication's not got a major role to play. When it is used, it's therefore important that it's used effectively and that it works.
Depression is serious. An older adult, being depressed, is harmful. Evidence shows permanent neuronal cell death arising from depression, so each day depressed is a day that a little bit more brain dies.
We know that a metaanalysis of antidepressants confirmed that the drugs aren't any more effective than placebo in mild, moderate or severe depression, with benefits only being realised in very severe depression (as described here). If an older adult is clinically depressed, either it's mild/moderate/severe and arguably medication's seldom used, or it's very severe and medication's used effectively. It's hard to argue to use medication ineffectively.
Why do some folk, who are otherwise sensible and rational and effective doctors, therefore prescribe subtherapeutic doses of antidepressants which don't work (surprise, surprise) then refer them, perplexed, to my door, time and time again? I know why it is, because I asked them. It's because they're harrowed by drug reps whittering on about "start low and go slow" in older adults. Bastards. It means my patients are getting shabby care for no good reason, what so ever, but Big Pharma has lots of FP10s which have to be dished out for months "because you have to go slow" before then the meaningful prescribing can start.
Why should anyone with depression, which is severe enough to need medication, be on citalopram 10mg once a day? The BNF has the minimum starting dose as 20mg once a day. It kindly guides us into evaluating at 3-4 weeks to titrate up to 40mg and kindly specifies that in folk over 65, 40mg is the maximum dose. Brilliant. Crystal clear. For folk over 65, you're on 20mg od and if after 3 to 4 weeks you need more, you're on 40mg od. Why oh why are 10mg or 30mg prescribed, then? Drug rep waffle seems to be cited as the only cause, and worryingly is more powerful in effecting change in practice than the crystal clear/precise BNF is in directing appropriate prescribing.
Gah.
Olanzapine also is used in timid doses. I don't want high dose presribing, this year my appraisal portfolio evidences just 2 patients under my care received above BNF doses of medication at any time. I'm not after high dose use. I just don't want subtherapeutic or irrational use. Olanzapine's blood level is roughly halved in smokers, with many of my older adults in the deprived areas I cover being smokers. Yet there's a zeal for homeopathic starting doses, which are continued ineffectively for months, to "start low and go slow."
Whoever it is, in 2010, that's going around and poisoning doctors' minds away from evidence based medicine, pharmaokinetics/pharmacodynamics, product testing and the licence/Summary of Product Characteristics and BNF prescribing details, they're harming patient care. Those folk whittering on about this "start low go slow" notion, I want their evidence base or I want to slap them. Or reporting them to APBI may placate me and rid us of such pernicious counsel. There's a dark cloud, but there's a silver lining.
Monday, 1 November 2010
Weather
Walking through the hospital grounds this morning, beneath bright sunshine, the grounds are a riot of colour. Trees shifting through golds, browns, yellows and vibrant reds.
I love Autumn.
I love Autumn.
Friday, 15 October 2010
Music
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.
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.
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!
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.
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.
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