I've had a number of folk who I've seen who ride horses. That wasn't the reason for referral to my door, it's a benign enough past time and not a behaviour that generally merits treatment. Although I recall an A&E Consultant lecturing on how there were more accidents per mile when horse riding than when motor racing. Her point of contention was that horses were more perilous than Formula One racing and children/young adults jaunting along on a hack was oft times seen in far too cavalier a manner.
There're some reasons p'raps to support a ride in the great outdoors. Leave the urban sprawl and, where I work, we're blessed by verdent landscapes pretty much on our doorstep. Getting out and about can be therapeutic.
Kaplan's work in 1995 (The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169-182) was progressed in 2005, with consideration of such restorative environments. This has been advanced in 2008 with exploration of natural versus urban environments and consequences of this upon cognition.
Being outdoors and exposed to nature seems to be good for our brains.
The evidence of exercise on cognition and neurogenesis is compelling. Growing new brain cells as we get older, what's not to like?! So I should enthuse over folk striding out to be at one with nature.
I'm contracted to do really rather varied work. Unfortunately a number of folk I've worked with have had significant riding accidents. One teenager smashed up her pelvis spectacularly, changing overnight her opportunities and possible futures, as mobility and fertility are eclipsed in a blink. A number of back injuries, necessitating referral on for surgical intervention. Large numbers of exacerbation of existing painful backs. I fear the A&E Consultant had the truth of it, horses are not without their risks.
What's been surprising is the role of psychological therapy, physiotherapy and pharmacotherapy when combined. Looking at acceptance (and mindfulness, with mostly a CBT model) whilst also optimising function, looking at nociceptive/neuropathic analgesics and attending to mood disorder has yielded pretty good outcomes. Well, both evidenced functional outcomes and patient questionnaires post discharge suggest outcomes are good, which is heartening.
Through this, duloxetine seems to have been helpful. It's licensed for the treatment of diabetic neuropathy in the UK, and fibromyalgia in the USA, so is a reasonable treatment for pain. It's also licensed for the management of major depressive disorder and generalised anxiety disorder. Depression is a straight 60mg dose, so no titration or adjustments, meaning you know you're on the perfect dose from day one. Neuropathy may need titration from 60mg to 120mg, so is simple to manage too. Treating low mood, anxiety and pain, with a once a day drug, with just 2 strengths of dose so it's straightforward to get patients on the optimal dose, I guess it's unsurprising we're seeing decent outcomes. It's not miraculous. Often it doesn't work. But for some folk, some of the time, it's really been a rather helpful adjunct to their care.
Wednesday, 25 May 2011
Monday, 23 May 2011
Improvement
I've a gentleman who lived in a flat, alone, for a decade. What was curious was that he never left it. His son did all his shopping for him. His GP and dentist managed him through home visits. He'd elected to be housebound. We never knew him, then.
He moved in with his son because his son couldn't keep visiting all the time. He was was confused. He thought he had paid tens of thousands for a penthouse to be built for him. He heard spirits talking to him, from animals. He spoke to photographs of the children, because they spoke with him. Voices told him bad things. He felt worried, suspicious, afraid, insecure. He took no medication because his GP, who he saw in the living room every day, told him not to. He ate little since he knew his son was poisoning his food. He never bathed because the water was tainted and would hurt his skin, transforming it. His son thought all this was odd, asked for help, we became involved.
His son and a community psychiatric nurse invested endless hours with him. He was started on olanzapine velotabs which he took haphazardly, but then reliably. 5mg initially, then 10mg once a day. He got better.
He's now well, happy, laughing and engaged with his son and family. He's been to the shops, to town, to appointments with his son.
From being tormented and housebound to being happy and active.
A good result.
He moved in with his son because his son couldn't keep visiting all the time. He was was confused. He thought he had paid tens of thousands for a penthouse to be built for him. He heard spirits talking to him, from animals. He spoke to photographs of the children, because they spoke with him. Voices told him bad things. He felt worried, suspicious, afraid, insecure. He took no medication because his GP, who he saw in the living room every day, told him not to. He ate little since he knew his son was poisoning his food. He never bathed because the water was tainted and would hurt his skin, transforming it. His son thought all this was odd, asked for help, we became involved.
His son and a community psychiatric nurse invested endless hours with him. He was started on olanzapine velotabs which he took haphazardly, but then reliably. 5mg initially, then 10mg once a day. He got better.
He's now well, happy, laughing and engaged with his son and family. He's been to the shops, to town, to appointments with his son.
From being tormented and housebound to being happy and active.
A good result.
Friday, 20 May 2011
Shambling
I was reading through a lot of guidance today that's been published by the National Institute of Health and Clinical Excellence (NICE) since I've been drawn into doing some work on quality standards and care pathways and stuff. It's not an organisation directly controlled by the government, but it's funded by it. Sort of independent, but sort of State organised.
I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.
When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.
Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.
It's quite a formal organisation. Proper. Seemly.
In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.
Geeeenius!
I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.
When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.
Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.
It's quite a formal organisation. Proper. Seemly.
In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.
Geeeenius!
Wednesday, 18 May 2011
Confusion
I saw a lady last year, referred to me for assessment and management of her dementia. She was confused, her Addenbrookes Cognitive Examination (ACE-R) was poor, her functional level had declined (with constricted activities of daily living).
Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.
Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.
A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.
History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.
It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!
Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.
Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.
A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.
History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.
It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!
Sunday, 15 May 2011
NHS Review
I was reading the weekend papers with Mrs Shrink. Whilst she was musing over a lass who's gone all gaga, I was taken by the front page news, "NHS review chief: health reforms are unworkable."
Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.
The final report's due out at the end of the month.
The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .
. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.
Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.
Hurrah!
Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.
The final report's due out at the end of the month.
The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .
. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.
Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.
Hurrah!
Tuesday, 3 May 2011
Leave
I'm back after a bit of a holiday. Lots of people have enjoyed a break through the glorious sunshine we've been enjoying. I'm mindful when emails bounced back with "Out of office" messages, or when trying to sort out meetings, just how many people are away at the moment.
With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.
At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.
What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.
What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.
I wonder how many people noticed . . .
With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.
At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.
What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.
What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.
I wonder how many people noticed . . .
Tuesday, 19 April 2011
Complementary Medicine
I can't recall who linked this YouTube video, it wasn't found by me. I chanced upon it on a blog which, to my shame, I can't recall. My wife thinks I read too many blogs. Meh.
Anyway, watch this :
"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."
Brilliant.
Anyway, watch this :
"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."
Brilliant.
Monday, 18 April 2011
Art. Allegedly.
My wife persuaded me to see some art she was interested in. An effort for the poor lass, since my interest in culture seldom exceeds the remits of what's grown within a petri dish.
I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.
A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.
Apologies for the images, they looked a lot sharper on my mobile 'phone!
Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.
I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.
A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.
Apologies for the images, they looked a lot sharper on my mobile 'phone!
Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.
Tuesday, 12 April 2011
Diagnostic Formulation
The acute medical ward referred a patient to me, for urgent assessment.
The patient had been perfectly well until 2 weeks ago when she experienced left sided weakness and slurred speech that she and her husband have been very worried about. She'd become confused. The medical team referred her to me "with dementia" to sort it all out.
She's had a stroke.
The history, clinical course, clinical examination and structural brain imaging yield a diagnosis of a stroke.
She was perfectly well a fortnight ago. She does not have dementia.
The medical team (well to be fair, a junior doctor on the medical team) assert otherwise. She thinks I'm being unhelpful, not curing this woman or taking over her care "to manage her dementia." I explain she's not got dementia. The junior doctor continues to assert that she does.
I'd love to do this :
The patient had been perfectly well until 2 weeks ago when she experienced left sided weakness and slurred speech that she and her husband have been very worried about. She'd become confused. The medical team referred her to me "with dementia" to sort it all out.
She's had a stroke.
The history, clinical course, clinical examination and structural brain imaging yield a diagnosis of a stroke.
She was perfectly well a fortnight ago. She does not have dementia.
The medical team (well to be fair, a junior doctor on the medical team) assert otherwise. She thinks I'm being unhelpful, not curing this woman or taking over her care "to manage her dementia." I explain she's not got dementia. The junior doctor continues to assert that she does.
I'd love to do this :
Monday, 11 April 2011
Care Pathways
I've been throwing in my 2p worth to discussions 'bout how care pathways could be constructed. I was invited on whim. Folk thought I may know what was happening, what best practice guidance is and what could work. All that is true. They also thought that the discussions could then generate a care pathway so patients could receive services according to their oft repeated mantra of, "the right care, in the right place, at the right time, by the right person."
Mmmm.
One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.
Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.
The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.
Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.
Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.
Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.
Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.
The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.
Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .
Mmmm.
One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.
Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.
The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.
Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.
Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.
Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.
Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.
The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.
Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .
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