Teaching session for GP registrars. Dr Mohinder Kapoor Consultant Psychiatrist. TOPICS. RISK ASSESSMENT & MANAGEMENT DEMENTIA MOOD DISORDERS. Primary care: Older people are high users of primary care time and resources High prevalence of Dementia & Depression Public Health
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Older people are high users of primary care time and resources
High prevalence of Dementia & Depression
Older people over-represented in many care settings
More treatments available
e.g. anti-dementia drugs etc, with cost implications
Treatment outcomes affected by psychiatric illness…
Current estimate is there are 700,000
dementia sufferers in UK
Expected to double to 1.4 m in 30 years
Total cost of dementia in the UK - £17 billion per annum
Tripling £51billion pa in 30 years
population prevalence over 65(dementia (total) sufferers)
2010 32,100 1605
2015 36,600 1830
2020 39,800 1990
Common but not inevitable part of aging
Most of us will (or do) experience dementia directly or through someone we care about
2 thirds of people with dementia live in their own homes in the community
Quality of life is as much related to the richness of interactions and relationships as to the extent of the brain disease
20-40% of people with dementia receive a formal diagnosis
Often too late
At a time of crisis
Too late for effective intervention
Dementia (meaning "deprived of mind") is a serious cognitive disorder.
Dementia is a word for a group of symptoms caused by disorders that affect the brain.
Memory loss is a common symptom of dementia. However, memory loss by itself does not mean you have dementia. It is characterized by three main symptomatic domains, as shown below.
Activities – inability to perform activities of daily life
Behaviours – psychiatric symptoms/behavioural disturbances
Cognition – neuropsychological impairments
Behaviour changes, non-fluent aphasia
Apraxia, agnosia, Fluent aphasia
Parkinsonian features , Hallucinations
Focal neuro signs
80 year old presents with his wife to the GP. His wife is concerned because she has noticed a gradual impairment of his memory. His family has noted him to have ‘changed’ in himself. He denies any problems with his memory. He seems to be more disorientated at home.
What is his most likely diagnosis?
What would be your management plan?
Progressive, Irreversible condition
S-T memory affected first
Amnesia, Aphasia, Apraxia, Agnosia
Behavioural, personality and psychiatric symptoms
5% of people over age of 65
Depletion of Acetylcholine implicated
Other NT’s involved- 5HT, NA, glutamate
Changes in dementia
Neuropsychiatric: Personality and Behavioural Changes
MMSE-screening test, not diagnostic, 24/30 further investigations may be required
Bloods- FBC, ESR, LFTs, Renal Function tests, TFTS, blood sugar, B12 and folate, Urine C&S, ECG, CXR
CT/MRI if any significant history or positive findings or suspect infarct or SOC
75 year old man with sudden impairment of memory is taken to Emergency department by his. He was noted to have ‘slumped in his chair’ at home a week ago but recovered shortly after. He seems to be more confused at night time
What is his most likely diagnosis?
What would be your management plan?
Unequal distribution of deficits in higher cognitive functions and other relatively spared
Focal brain damage
CBV disease evident
Abrupt onset/stepwise progression
Vascular risk factors
Evidence suggests that vascular dementia can co-exist with Alzheimer’s Disease leading to diagnostic confusion and mixed forms of dementia.
Vascular lesions may also contribute to the severity of AD [Snowdon, 1997].
Neuroimaging studies showing cerebrovascular disease – infarcts or deep white matter ischaemia – support the diagnosis of vascular dementia.
60 year old woman presents to the emergency department with her daughter. Her daughter is worried because she is having increased number of falls with fluctuations in her alertness. Over the past few days, she has become increasingly agitated as she is experiencing visual hallucinations of elves playing the piano in her house. She has a resting tremor
What is your differential diagnosis?
What would be your management plan?
Fluctuations in cognition with alterations in attention and alertness
Recurrent vivid visual hallucinations
Motor features of Parkinsonism
Possible repeated falls, syncope neuroleptic sensitivity
Summary of evidence
When can prescribing of antipsychotics be justified
Assessment prior to prescribing
Choice of drugs
How long to treat
Risks associated with Antipsychotic Treatment
CSM 2004 - apparent 2-3 fold increase risk of cerebrovascular event in people with dementia prescribed olanzapine & risperidone. Not recommended.
2005- increased mortality rate (1.6-1.7fold) also with ‘typicals’ or conventional antipsychotics due to heart failure, sudden death, pneumonia)
No evidence to say any antipsychotic is safer than another
150 000 people given antipsychotics unnecessarily
Only 1 in 5 gain benefit
Cause of extra 1 800 deaths per annum amongst elderly
Benefit does not extend beyond 3 months
NICE/SCIE guideline 42
Offer a pharmacological intervention in the first instance ONLY if the patient is severely distressed or there is an immediate risk of harm to the person or to others.
possible undetected pain or discomfort
side effects of medication
behavioural and functional analysis
Discussion about risks and benefits
with patient and or carer
Assessment of cerebrovascular risk factors
Consider the effect of co-morbid conditions such as depression
Based on the current evidence in relation to prescribing antipsychotic drugs in dementia we recommend an ongoing prescription of no more than 3 months as the evidence suggests there can be serious adverse effects from antipsychotic drugs for patients with dementia. In addition these drugs may become ineffective after this time . We suggest you review medication after three months with a view to gradually withdrawing the antipsychotic over 1-2 weeks. You should then review the patient’s progress and only consider a further short term prescription if the target symptom for which medication was prescribed recurs on discontinuation. If you need further advice about prescribing please contact Dr …...Team leader ….... Pharmacist………
NICE key priorities
Key priorities continued
Aim to keep elderly person in own surroundings as long as possible
Continuing care and support to relatives/carers
Treat any underlying physical disorders that can lead to acute confusional states
Early dementia, also known as mild cognitive impairment, involves problems with memory, language, or other cognitive functions. But unlike those with full-blown dementia, people with mild cognitive impairment are still able to function in their daily lives without relying on others.
Becomes more common with age
Frequently losing or misplacing things
Frequently forgetting conversations, appointments, or events
Difficulty remembering the names of new acquaintances
Difficulty following the flow of a conversation
Intact activities of daily living
Risk of developing AD: 0.2% in general population as compared to 6% in MCI (65-69); 4% in general population as compared to 25% in MCI (85-89)
The number of patients with mild cognitive impairment (MCI) who progress to dementia is at least half of what it was previously believed to be, new research suggests. A large meta-analysis showed that the cumulative risk over 10 years ranged between 30% and 50%, depending on whether the studies that were analyzed used a definition of MCI that included subjective memory complaints.
Until now, the prevailing opinion was that the progression rate from MCI to dementia was about 10% per year, or a 100% conversion to dementia over 10 years.
This research suggests that instead of always being an invariable transitional state between normal aging and dementia, MCI is a condition in which some patients stay static and some even improve
Excessive anxiety and worry about a number of events or activities, which occur more days than not for at least 6 months
Person finds it difficult to control the worry
At least 3 additional symptoms from a list of 6:
restlessness or feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind going blank
Anxiety generalised and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. "free-floating")
Dominant symptoms variable but include complaints of:
12-month prevalence in general population is 3.1%1
Lifetime prevalence in general population is 5.1%1
Prevalence of anxiety disorders in the UK is estimated at 17-95 per 1,000 people depending on age2
Most frequent anxiety disorder in primary care3
Mean 1-month prevalence 7.9%4
Affects women more than men, especially in midlife3
Lifetime prevalence in those over 45 years old: 3.6% (men) vs. 10.3% (women)3
12-month prevalence ratio 1:2.2 males:females5
Social disability as severe as with chronic physical diseases4
Low remission rates6
Symptoms wax and wane at different times3
Often co-occurs with other psychological disorders and physical conditions7
1. Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355–64; 2. Kings Fund 2011. Paying the Price: The cost of mental health care in England to 2026; 3. Wittchen H-U. Depress Anxiety 2002;16:162–71; 4. Maier W, et al. Acta Psychiatr Scand 2000;101:29–36; 5. Vesga-López O, et al. J Clin Psychiatry 2008;69:1606–16; 6. Yonkers KA, et al. Br J Psychiatry 2000;176:544–9;
7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.
Lifetime prevalence (%)
Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355-364.
Mental disorder recognisedbut generalised anxiety disorder not diagnosed
Mental disorder not recognised
Specific generalised anxiety disorder diagnosis
Based on a sample of 17,739 patients
5.3% with generalised anxiety disorder (DSM-IV)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4thed, criteria
Wittchen H-U. J Clin Psychiatry 2002;63(Suppl 8):24–34.
Nervousness, irritability and worrying1
Difficulty concentrating or mind going blank1,2
Restlessness, tension and inability to relax1
Intolerance of uncertainty3
Poor assessment and response to problems3
e.g. nausea, diarrhoea, irritable bowel syndrome3–5
Insomnia and difficulty falling asleep1,4
Dizziness, light headedness1,2
Pain and muscle tension, aching and soreness1,2,4
Tachycardia, palpitations, sweating2,4
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition
ICD-10, International Classification of Diseases, 10th revision.
However, full diagnosis should be confirmed using DSM-IV or ICD-10 diagnostic criteria
1. Kroenke K, et al. Ann Intern Med 2007;146:317–25; 2. Spitzer RL, et al. Arch Intern Med 2006;166:1092–7; 3. Zigmond A, Snaith RP. Acta Psychiatr Scand 1983;67:361–70.
Severity of illness2
Possible interactions withconcomitant medications1
Risks of deliberate self-harmor accidental overdose2,3
SSRI, selective serotonin reuptake inhibitor ; SNRI, serotonin norepinephrine reuptake inhibitors; *Review effectiveness and side effects of pharmacological therapy every 2–4 weeks; during the first 3 months of treatment and every 3 months thereafter; **Not licensed for the treatment of GAD in the UK; †Not licensed for the treatment of GAD in the UK except for escitalopram and paroxetine
NICE. Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults. Clinical Guideline 113, January 2011.
Please refer to local Summary of Product Characteristics before prescribing
Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive symptoms
persistent sadness or low mood;and/or
loss of interests or pleasure
fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
poor concentration or indecisiveness
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
not depressed (fewer than four symptoms)
mild depression (four symptoms)
moderate depression (five to six symptoms)
severe depression (seven or more symptoms, with or without psychotic symptoms)
symptoms should be present for a month or more and every symptom should be present for most of every day
Loss of interest
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.
Risk Assessment & Management
Why is risk my business?
What kinds of risk do I need to consider?
What time frame do I need to consider?
Risk of suicide?
To be able to complete it using a scenario
“The likelihood of an event happening with potential harmful or beneficial outcomes for self and / or others . . .
. . . Possible behaviours include suicide, self-harm, aggression and violence, and neglect; with an additional range of other positive or negative service user experiences”
Psychiatric patients more at risk than general population
Recent studies/ surveys: National Service Framework for Mental Health (1999); Our Healthier Nation (1997);National Confidential Inquiry Homicide & Suicide (2001); Avoidable Deaths (2006 http://www.medicine.manchester.ac.uk/suicideprevention/nci/)
Dictates significant components of overall management plan
Direct self harm
Harm to others
Accidental self harm
Harm to property
Risk of harm to children
Road deaths per annum =
Annual suicide rate for people with mental health problems =
People killed annually by intoxicated drivers =
??% of people with Schizophrenia will actually succeed in committing suicide
Annual homicides committed by people with a mental health problem = ?? to ??
You are ?? times more likely to be attacked or killed by someone WITHOUT a mental health problem.
Road deaths per annum = 4,000
Annual suicide rate for people with mental health problems = 1,000
People killed annually by intoxicated drivers = 400
15% of people with Schizophrenia will actually succeed in committing suicide
Annual homicides committed by people with a mental health problem = 35 to 40
You are 13 times more likely to be attacked or killed by someone WITHOUT a mental health problem.
Current/short term risk
Long term/historical risk
1% people with deliberate non-fatal self harm will kill themselves in following year - 100x risk of general population
10% all deliberate self harmers eventually commit suicide
attempt premeditated and prepared for
Precautions taken to avoid intervention
Attempt in isolation
Attempt timed to minimise discovery
Suicidal intent communicated prior to attempt
Final acts in anticipation of death, egg. will
Violent, active methods used or more lethal drugs
Person’s belief re drugs
Person stated aim was to kill self
Person regrets surviving
No action taken to obtain help after event
Numerous suicide attempts with apparent intention to die
Attempts on their life
Significant life events
Expressing high levels of distress
Believe no control over life
Use of violent methods
Helplessness or hopelessness
Misuse of drugs and/or alcohol
Family history of suicide
Major psychiatric diagnosis
Expressing suicidal ideas
Hope that things will turn out
Get pleasure out of life
Feel hopeful from day to day
Able to face each day
See point in it all
Ever despair about things
Feel it is impossible to face each
Feel life is a burden
Wish it would all end
Wish self dead
Why feel this way, e.g. be with dead person
thought s of ending life and how persistent
Specific method contemplated
Ever acted on thoughts
What stopped them
Feel able to resist thoughts
How likely to kill self
Able to give reassurance , e.g. until next appointment
Circumstances likely to make situation worse
Willingness to turn for help in a crisis
Previous incidents of violence
Previous use of weapons
Misuse of drugs and/or alcohol
Male gender, under 35 years of age
Known personal triggers
Expressing intent to harm others
Previous dangerous impulsive acts
Paranoid delusions about others
Violent command hallucinations.
Signs of anger and frustration
Sexually inappropriate behavior
Preoccupation with violent fantasy
Admission to secure settings
Denial of previous dangerous acts.
Inability to engage in treatment plan
History: from patient, informant history, eating habits, security, financial affairs,
MSE: self care, cognitive functioning
Informal support networks
Previous history of neglect
Failing to drink/eat properly
Difficulty managing physical health
Living in inadequate accommodation
Lacking basic amenities ( water/heat/light)
Pressure of eviction/repossession
Lack of positive social contacts
Unable to shop for self
Difficulty maintaining hygiene
Experiencing financial difficulties
Difficulty communicating needs
Denies problems perceived by others
Clinical diagnosis: depression, mood disorders, schizophrenia, organic conditions
Perceived support from formal and informal networks
What’s on your radar?
All clinical decisions
Every clinical situation
Dynamic variable: think of short and long term risk
Enhanced by using multiple sources of information, often incomplete
Identify cause of risk from information
What is the risk?
What is the magnitude of the risk?
What is the imminence of the risk?
Who is at risk?
What are the factors to increase risk?
What are the factors to decrease risk?
David Hargreaves, 2006
Risks of any action, or no action, e.g. to
admit to hospital
detain under Mental Health Act
allow periods of leave
liaise with family members
manage illicit drug misuse
manage alcohol misuse
What is positive risk management?
“Positive Risk-Taking is not negligent ignorance of the potential risks. Nobody, especially service users benefits from allowing risks to play their course through to disaster. Positive Risk-Taking is about collaborative working, based on the establishment of trusting relationships, whereby service users can learn from their experiences, based on taking chances just like anyone else. It is about understanding the consequences of different courses of action; making decisions based on a range of choices, and supported by adequate and accurate information. It is about knowing that support is available if things begin to go wrong, as they occasionally do for all of us. Positive Risk-Taking is also about explicit setting of boundaries, to contain situations that are developing into potential catastrophic circumstances for all involved.”
Weighing up the potential benefits and harm of one choice over another
Collaboration with service user and practitioner essential
Focus on positive attributes within service user
Identifying the potential risks involved when following a clearly defined course of action, with the expressed aim of achieving specific positive gains
Positive risks need to be measured, defensible, intelligent, documented
Supportive management and policy
Quality clinical supervision
Consensus within the team
Monitor for early warning signs
Agreed crisis and contingency plans
Document decisions reached
Support for service users and carers
Culture of learning rather than failure.
Admission to hospital
Periods of leave
Liaison with families
Discharge from service
Medication reduction /withdrawal/self management
“controlled” self harm
Dealing with own finances
Building a social network
Moving on from day care facilities
Going away on holiday
FACE risk assessment
Sainsbury risk assessment tool
The patient is a 37 year old single woman who is currently cohabitating with an alcoholic male friend. She consumes alcohol, but is not dependent, and smokes cannabis to excess with likeminded friends who follow an ‘alternative lifestyle’.
She has a six year history of continuous auditory, visual and somatic hallucinations, worsening with alcohol and cannabis. She is erratically compliant with medication, which improves her symptoms. History of depression with psychotic symptoms in the past. Took an overdose and hit her neighbour last year thinking he was a spy who worked for MI5. This led to her being detained under section 2 of the MHA. Recently 3 months ago took an overdose of 30 paracetamol tablets with alcohol. She lost her parents in a car accident nearly a year ago. Her parents were very supportive and lived locally. Has a younger brother and sister who are the only family members she has and when well she keeps in touch with them and engages well with them.
At times of deterioration in her mental health, her self care and living skills decline, such that she fails to shop for herself, keep her flat clean or attend to her personal hygiene. At the time of her last hospital admission, she argued with 2 MHA assessment teams, that if she wanted to live in squalor with no electricity or running water, then this was her choice.
Currently feeling down, with poor appetite and loss of weight. She is unemployed and is on benefits. Has mentioned to her friend that she doesn’t want to live anymore and she might buy some tablets from the market and take them on her parent’s death anniversary. 2 weeks ago cut her wrists when she was under the influence of alcohol. Last week pushed a stranger on the street thinking he was spying on her. Police arrested her and released her without charging her. Has hit her male friend who has also hit her back. Her friend is concerned about her. Not engaging with CMHT.
She is currently non-compliant with medication and has obtained a dog whom she does not exercise and who defecates in the corner of the room .
Relationship of risk to mental disorder
Short and long term risks
Have a systematic approach in your clinical practice