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The Royal College of Psychiatrists Improving the lives of people with mental illness

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07/11/2013 14:59:30

Delirium – A New Surge For Thought


Delirium – A New Surge For Thought

Time is mind

People rush for heart attacks and say time is myocardium. We act fast with strokes, as time is brain. Why don't we have the same attitude to delirium? It's an acute brain failure that people have to act on quickly to reverse and prevent. In the surge of delirium time is mind.

 

Occam's razor approach

Perhaps it’s not as reductive as that. The multitude of causes, the ambiguity of diagnosis and the dearth of ownership amongst one branch of clinicians give rise to the lack of cohesive research into this condition.

 

Delirium is one of the most under researched areas in medicine yet one of the most common neuropsychiatric presentations.

 

I'm frustrated by the Occam's razor approach that clinicians have when dealing with it. All too often the simplest explanation is rightly or wrongly pinned as the cause. The benefit of thorough investigation, adequate management and long term effects seem to be frequently ignored.

 

Someone with delirium is very unwell. What's more important than your cognition and mental faculties? I shudder to think about the glial toxicity, metabolic dysregulation and the secretion of neurotoxins into a brain that was previously firing on all cylinders.

This etiologically nonspecific organic cerebral syndrome characterised by the seemingly rigid wording of it’s ICD-10 definition allows clinicians to hide behind the umbrella terms of vague, subjective concepts. They forget about its true cause, pathology and downstream effects.

It has concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe. Great.

 

 

Subtleties of brain demise

So it’s easy to distinguish delirium from everything else then? We seem to be glossing over the subtleties of brain demise.

 

Someone with delirium is very unwell. What's more important than your cognition and mental faculties? I shudder to think about the glial toxicity, metabolic dysregulation and the secretion of neurotoxins into a brain that was previously firing on all cylinders. Our current investigative strategies aren’t enough.

 

The cost to the individual may seem to be subtle yet is sinister. And that’s not even thinking about the economic effects

We know delirium accelerates cognitive decline and physical decline.  Mice pumped with neurotoxins have worse Alzheimer's disease compared to without. The one-year mortality of patients who have delirium post hip-replacement is high. The list is ever expanding.

 

Refocusing our perspective is necessary. One should think that delirium will lead to aggregated insidious harm. Perhaps the term post delirium brain injury is a necessary addition to our medical terminology. The cost to the individual may seem to be subtle yet is sinister. And that’s not even thinking about the economic effects.

 

One American insurance company put total healthcare costs arising from delirium at $150 billion per year. The NHS doesn't yet have the right clinical coding infrastructure to account for delirium incidences and costs. Perhaps the plethora of synonyms for delirium doesn’t help either. Is it acute brain failure, limbic encephalitis, a rapid clouding of consciousness or an acute confusional state?

 

 

Paving the way

What is clear in all of this is that an aging population paves the way for research into this fascinating constellation of deleterious effects on the brain.

 

Molecular research is needed to see if a final cause pathway or potential biomarkers can be identified. Functional imaging of brain structures would be ideal, but difficult. Delirious mice might shed light into potential therapeutic options. Risk stratification scores that predicted future likelihood and early prevention may be key. None of this yet exists.

 

One thing is certain. New surges of thoughts into combating delirium are urgently needed.  


Advances in Psychiatric Treatment 

 

08/08/2013 16:26:17

You can leave your hat on


All heads turn in my direction

Advances: trainees

It is often very early on in any post that I undertake that my passion for mental health reveals itself.

As many of my colleagues do not share this passion, when the task of dealing with a patient that does suffer with mental health issues alongside their physical health issues, all heads turn in my direction.

To be fair, I’m happy to ‘take one for the team’. We all have likes and dislikes, strengths and weaknesses, and I am happy to shoulder the burden when it comes to the complex mental health needs that can arise in the acute medical setting. Who am I kidding? I love it!

 

Further investigation

One such situation arose recently following the admission of a 17 year old boy to the medical admissions unit. ‘John’* was not very happy about being discharged from the inpatient mental health unit that he had been at for a number of weeks. The situation escalated and the police were called.

Upon their arrival, ‘John’ was witnessed to have a tonic-clonic seizure. With no previous diagnosis of Epilepsy, he was brought to A&E, where he was witnessed to have a second seizure and thus admitted for further investigation.

I came to know of ‘John’ at handover on Friday morning.

Upon clerking, ‘John’ had revealed to the night SHO that he was hearing voices instructing him to harm himself. As he was still awaiting medical investigations, ‘John’ would not be seen by the mental health team. I was asked therefore to review him later in the day and refer him as appropriate.

 

...never leave your pen unattended, always accept the offer of a hot drink and nurses get very twitchy at 5 o’clock on a Friday if planned discharges fall through

‘John’ had no information about his own mental health. He denied any formal diagnosis or medication, and was unsure of his follow-up arrangements. We contacted his previous mental health team, in an attempt to obtain a collateral history, but were unable to get through to a member of staff familiar with his care. Messages were left, and we awaited further correspondence.

Things weren’t adding up. On the one hand, I had a young man who must have been reviewed by a senior psychiatrist very recently, if the decision had been made to discharge him from inpatient services. On the other however, this was my first encounter with him, and I had very little information with which to make a decision. I discussed the situation with a senior colleague, and decided that we had no choice but to involve the crisis team, even if it was simply to collate more information.

In the meantime, I was faced with facilitating the safe discharge of a young man with no fixed abode or registered GP, awaiting social placement who reported experiencing complex auditory hallucinations; second person voices that were instructing him to take his own life. As if the case wasn’t convoluted enough, this was complicated further by the fact that ‘John’ was miles away from his previous residence and thus care worker who was trying to place him into a new address.

Oh and, 5 o’clock was approaching. On a Friday.

 

Interesting curiosities

There are many interesting curiosities that I have learnt during my time in medicine: never leave your pen unattended, always accept the offer of a hot drink and nurses get very twitchy at 5 o’clock on a Friday if planned discharges fall through.

I was soon approached by the nurse co-ordinator requesting an update about ‘John’. I explained the situation and that we may have to delay his discharge as we waited for the crisis team. Not quite the answer she was expecting. The focus of nursing handover surrounding ‘John’s’ care were his physical needs; working diagnosis and pending investigations. They were blissfully unaware of any of his previous or potential mental health needs.

I proceeded to explain the passage of events, correspondence I had made, and information I was awaiting, only to be met with a look of utter disappointment. “You’ve got the wrong hat on”, followed by a somewhat despondent explanation of the aims of the medical admissions unit, an overconfident statement of ‘John’s’ mental wellbeing topped with a condescending “when you’ve been in the job as long as I have, you get to know these things.”

 

In my idealist mind I had hoped that I was entering a health service that valued holistic patient care, working towards upholding health as a complete state of physical, mental and social wellbeing. It seems however that this is not the case.

The feelings of disappointment were soon reciprocated.

I left the conversation feeling bruised, not by her discourtesy, but by her obstructive approach. We may well have excluded any urgent medical cause for ‘John’s’ seizures, but it was my responsibility as the discharging doctor to be sure that ‘John’ was not a risk to himself or others.

 

Disenchantment

Fortunately, there was a happy ending for ‘John’. The mental health unit returned my call and reassured me that these hallucinations were known to them, and that ‘John’ had community follow-up arranged for the following week. His care worker, also came through at the last minute, with a temporary placement into which we could discharge him and so the nurse co-ordinator got her way after all and my conscience could rest knowing that I was discharging my patient with a number of safety nets in place.

The feelings of success were short-lived however, overpowered instead by feelings of disenchantment. In my idealist mind I had hoped that I was entering a health service that valued holistic patient care, working towards upholding health as a complete state of physical, mental and social wellbeing. It seems however that this is not the case. Rather, I find myself surrounded by super-specialists and managers preoccupied with turfing patients between services.

We are more concerned with who is responsible for a patient rather than who is looking after the patient, and I find this more often than not, when dealing with patients with simultaneous physical and mental health needs.

There are clearly financial and political reasons involved in this divide, but there are also personal factors much closer to the front-line.For example, nurses no longer receive general training. Newly qualified general nurses often only have 4-6 weeks of mental health exposure, as do medical students- the majority of whom will not undertake a foundation post in psychiatry.

This plants a seed of fear in the workforce when dealing with mental health. We all fear the unknown as it is, let alone when the unknown can potentially pose a risk to one’s safety.

Furthermore, as juniors, we look to our seniors for support and expertise – themselves even more distant from their psychiatric training. How therefore can we expect to provide holistic healthcare to patients if there is such limited shared expertise? Or do I actually have the wrong hat on after all?

 

*Patient and clinical details have been altered in the interests of patient confidentiality.


Advances in Psychiatric Treatment 

 

08/08/2013 10:28:28

MUS, CFS, ME etc – definitive diagnosis or loaded label?


Umbrella terms

Advances: trainees

Over a set of recent night shifts in Liaison Psychiatry I met several patients in the Accident and Emergency Department whom, when asked about their past medical history, listed conditions such as ‘Functional disorder’, ‘functional illness’, ‘Somatoform disorder’, ‘somatic symptoms’, ‘medically unexplained symptoms’, as well as more specific diagnoses that many doctors categorise under these umbrella terms, such as irritable bowel syndrome, tension headache, and chronic fatigue syndrome.

Some simply listed these terms as facts, diagnoses they had been given and accepted. Others had more emotional responses to such terms, telling me they had been ‘labelled’ as ‘mad’, ‘crazy’ or ‘a liar’ by being given these terms for symptoms they experienced as very disabling and very real.

Interestingly, in many of the handovers I was given by A and E doctors, these terms were read off the notes accompanied by a ‘knowing’ look or even comments such as ‘that says it all’.

 

The big, unsolvable question

This got me thinking about the big, perhaps unsolvable question of ‘what are these symptoms and what do they mean?’ but also about the more practical questions of which terms should we be using and when, and how should we describe these to patients?

Firstly, the list of ways to describe symptoms that we don’t know the cause for appears to be endless and I’m sure there are readers who can give the textbook definitions and list the differences between each of these terms, but, other than for passing an exam or appearing clever to other psychiatrists, how much does this really mean? If other medical colleagues don’t use the terms consistently and they are ‘loaded’ terms rather than factual how useful can they be?


Many people want a diagnosis, as they link this with a reassurance of sorts, in that they feel if they have a diagnosis, at least they don’t have the other hundred conditions they have been worried about and maybe read about on the internet.

Catch-all term

To me, ‘medically unexplained symptoms’ seems to be the clearest way of describing a pain or other symptom that cannot currently be explained by medical science. It’s a ‘catch-all’ term that means what it says – the problem the person is experiencing cannot be explained by medicine.

There are many reasons why the problem can’t be explained, and just a few possibilities may include:

  • that we don’t have the diagnostic equipment to diagnose the problem at this early stage and it will present clinically when more advanced;
  • we don’t yet have the investigations to diagnose the problem at all but had the same person presented 20 years from now perhaps we would have a diagnostic test;
  • the doctor is missing the clinical signs; the problem is presenting atypically; t
  • he problem is relapsing and remitting and at the times of examination has not been present;
  • the pain or symptom is real and experienced by the person but we don’t have a ‘test’ for pain and we don’t know the underlying cause;
  • the pain or symptom is not real and is being used for some social gain.

I also prefer the definition ‘medically unexplained symptoms’ as this term makes it clear that the person is experiencing one or more symptoms which have not been diagnosed as a specific illness, whereas ‘disorder’ and ‘syndrome’ imply a fixed diagnosis. I think that this is important because we need to make it clear to the patient that unfortunately we cannot give them a concrete diagnosis.

 

Unique skills

Many people want a diagnosis, as they link this with a reassurance of sorts, in that they feel if they have a diagnosis, at least they don’t have the other hundred conditions they have been worried about and maybe read about on the internet.

I think this is where we need to use our unique skills as doctors in striking a balance between offering appropriate tests to rule out potential conditions, keeping in mind the risk-benefit balance, and not getting talked in to giving a clinically inappropriate test that the person may understandably want to rule out a tiny possibility of a very rare condition which is currently in the media limelight.

We can also use this as an opportunity to educate patients about the appropriate checks they need to keep on their symptoms, and when they should access medical care again if the problem doesn’t go away or worsens and what this can mean.

We are also in a unique position to reassure the person to whatever degree is appropriate and explain that a ‘diagnosis’ is not always the end of the story, and, actually, the body and mind are more complex than that and signs and symptoms can evolve and change, and hopefully we can help them to begin to live and cope with this degree of uncertainty.


...we should try to see these patients as people for whom we can offer clinical help and advice and although we can’t give a ‘diagnosis’, perhaps we can give them a lot more by attempting to enable them to live with this uncertainty and manage their symptoms.

We may also have to break the perhaps unpopular news to them that medicine does not have any further solutions at present, and painkillers, antidepressants, or sleeping pills will not help, and they are going to have to learn alternative coping strategies to address and manage the symptoms. We may have to add the bad news that the symptoms may not go away and this may be a lasting problem that cannot be ‘cured’, and instead requires adaptations in order for them to continue working and living their life.

Treading this very careful path between giving accurate and thorough clinical input, without over-investigating, and giving appropriate reassurance, without dismissing or ignoring symptoms, while at all times maintaining the patients’ trust, is something that I think doctors, and psychiatrists in particular, are in a unique position to do.

This is something that can’t be found on the internet, can’t be done by a computer programme, can’t be done after a day of training referring to a ‘patient journey pathway’, and can’t be done by someone who is more interested in filling in a ‘risk assessment form’ than interacting with the patient and engaging with the unavoidable clinical uncertainties and risks medicine entails.

 

Patients as people

So perhaps instead of the feelings of despair that many doctors appear to get when they see these terms written in the notes, we should try to see these patients as people for whom we can offer clinical help and advice and although we can’t give a ‘diagnosis’, perhaps we can give them a lot more by attempting to enable them to live with this uncertainty and manage their symptoms.

What do other readers perceive as the role of psychiatrists and other doctors in managing these patients?

Do you think a ‘label’ or ‘diagnosis’ is a help or a hindrance to people getting better, and do you give one?


Advances in Psychiatric Treatment 

 

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The Trainee Editor of this blog is Howard Ryland.

 


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