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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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teaching session for gp registrars
Teaching session for GP registrars
  • Dr Mohinder Kapoor
  • Consultant Psychiatrist
topics
TOPICS
  • RISK ASSESSMENT & MANAGEMENT
  • DEMENTIA
  • MOOD DISORDERS
why is old age psychiatry important
Primary care:

Older people are high users of primary care time and resources

High prevalence of Dementia & Depression

Public Health

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…

Why is old age psychiatry important?
dementia across uk
Dementia across UK

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

figures for calderdale
Figures for Calderdale

population prevalence over 65 (dementia (total) sufferers)

2010 32,100 1605

2015 36,600 1830

2020 39,800 1990

facts about dementia
Facts about dementia

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

epidemiology
Epidemiology
  • Incidence rates approximately doubles with each decade over 60
  • Prevalence of AD was 3% in 65-74 (Evans et al. 1989).
  • In the 75-84 year cohort the figure was 18.7%
  • 1 in 50 aged 65-70 have dementia
  • In the 85-94 the figure rose to 47.2%.
  • Currently 700,000+ people in the UK
  • 18,500 (2.5%) aged under 65
  • Fewer cases in ethnic minorities
  • Risk in learning disability
early diagnosis
Early diagnosis

20-40% of people with dementia receive a formal diagnosis

Often too late

At a time of crisis

Too late for effective intervention

overview of dementia
Overview of dementia

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

socioeconomic impact
Socioeconomic Impact
  • 150,000 people thought to be in residential/nursing home care in UK
    • require 24 hour care
    • approximate cost £20,000 per year
  • Assuming 50% suffer from AD - total cost of AD residential care is >£1 billion
  • The annual cost of treating and caring for people for AD in the UK is £5 billion.
ad and other dementias
AD and other dementias
  • Direct and indirect costs
  • Treatment costs
  • Financial and emotional costs to family
  • Great need for effective well organised systems of service delivery
  • Elderly overlooked in planning mental health and other services
  • Older people in community suffer from untreated depression/dementia
  • May lead to premature institutionalisation
slide14

Dementia defined

  • “a syndrome due to disease of the brain usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement.”
  • not a disease in its own right
  • deterioration in intellectual functioning and social behaviour
  • presents in a variety of ways:
  • causal condition
  • individual concerned
  • does not affect the brain uniformly
slide15

Dementia syndromes

  • Categorised by:
  • their nature
  • degenerative – Alzheimer’s disease, Frontotemproal dementia, Lewy Body Disease, Progressive supranuclear palsy, Huntington’s disease
  • vascular – multi-infarct
  • traumatic – head injury
  • infective – AIDS, prion diseases
slide16

Dementia syndromes

  • Or, categorised by:
  • their site
  • cortical – Alzheimer’s disease – cognitive changes most notable
  • sub-cortical – Parkinson’s – neurological and physical symptoms
  • multi-focal – prion diseases – severe cognitive and physical problems
risk factors ad
Risk factors (AD)
  • Age
  • Inherited risk
  • Female
  • Head injury
  • Educational attainment
  • Smoking (protective)
  • Metal ions
slide18

Relative frequency

  • Alzheimer’s disease 55%
  • Vascular dementia 20%
  • Lewy body dementia 15%
  • Others 10%
  • questions re diagnosis of Alzheimer’s
  • pure AD rarely seen in clinical practice
slide19

Dementia

Early-amnesia

Yes

No

Behaviour changes, non-fluent aphasia

Apraxia, agnosia, Fluent aphasia

Parkinsonian features , Hallucinations

Focal neuro signs

FTD

AD

DLBD

VAD

dementia1
Dementia

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?

alzheimer s disease
Alzheimer\'s Disease

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

slide22

Clinical features

  • Amnesia- recent memories initially affected
  • Aphasia- Language problems
  • Agnosia- difficulty recognising and naming objects e.g. autoprosopagnosia
  • Apraxia- difficulties in complex tasks
  • Visuospatial difficulties
slide23

Clinical features

  • Functional impairment- often most impact on individual- e.g. finances, dressing/personal hygiene
  • Mood disorders
  • Psychosis- delusions and hallucinations
  • Personality change- “living bereavement”
  • Other behavioural manifestations
slide24

Symptoms

  • Problems remembering:
  • ‘’When I try to remember things, it goes further away from me’
  • Find it hard to find the right words:
  • ‘I don\'t put the right word in the right place’
  • Can\'t understand what people are saying:
  • ‘A direct question brings me up short’
  • Have problems recognising people:
  • ‘I knew him from somewhere, but I couldn\'t remember where’
  • Find it more difficult to complete tasks and solve problems:
  • ‘Cooking has become more difficult. I have problems working out what comes next’
  • Find it harder to concentrate:
  • ‘My mind wanders sometimes’
slide25

Changes in dementia

  • often subtle onset
  • only recognised after diagnosis
  • memory, language, behaviour, personality
  • symptom under-reporting, lack of self-awareness
  • gradual loss of self or ‘personhood’
slide26

Neuropsychiatric: Personality and Behavioural Changes

Personality Changes

Behavioural Changes

  • indifference
  • lack of concern
  • decreased interest
  • reduced affection
  • poor motivation
  • agitation
  • depression
  • delusions
  • hallucinations
  • stubbornness
  • resistance to care
  • suspicion
  • abusive language
  • hiding articles
  • outbursts
  • restlessness
  • wandering
  • sundowning
  • catastrophic reactions
alzheimer s disease diagnosis
Alzheimer\'s disease-diagnosis

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

slide28

Drug therapies

  • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine
  • Memantine
  • Vitamin E, ginko biloba
  • NSAIDs
  • Simvastatin
  • Antidepressants
  • Antipsychotics
dementia 2
Dementia (2)

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?

vascular dementia
Vascular Dementia

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

clinical issue differentiation of diseases
Clinical issue: differentiation of diseases

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.

dementia 3
Dementia (3)

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?

lewy body dementia
Lewy body dementia

Fluctuations in cognition with alterations in attention and alertness

Recurrent vivid visual hallucinations

Motor features of Parkinsonism

Possible repeated falls, syncope neuroleptic sensitivity

prescribing antipsychotics in dementia
Prescribing Antipsychotics in dementia

Summary of evidence

When can prescribing of antipsychotics be justified

Assessment prior to prescribing

Choice of drugs

How long to treat

slide36

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

dh report on antipsychotics in the management of dementia nov 2009 prof sube banerjee
DH report on antipsychotics in the management of dementiaNov 2009 Prof Sube Banerjee

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

when are antipsychotic justified
When are antipsychotic justified

NICE/SCIE guideline 42

NOV 2006

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.

Psychosis

Severe agitation

assessment before prescribing
Assessment before prescribing

physical health

depression

possible undetected pain or discomfort

side effects of medication

individual biography

environmental factors

behavioural and functional analysis

check list
Check list

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

slide41

Principles of prescribing

  • Identify target symptom
  • Aim to reduce agitation or aggression without sedation
  • Start low go slow
  • Avoid high doses and combinations.
  • Time limited with regular review (3 mthly or as needed).
prescribing follow up
Prescribing follow up

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………

slide44

Management: carers

  • Support for the family
  • Practical advice to enhance/compensate for memory deficits- “memory training”
  • Education
  • Advice on communication
  • Self help groups
  • Financial and legal help
  • Practical support from social services etc.
national audit office
NATIONAL AUDIT OFFICE
  • Half of people not diagnosed
  • Lack of training and awareness
  • “not uncommon” for GPs to dismiss dementia as “normal effects of aging”
  • Specialist services were patchy
  • Support from CMHTs “varied considerably”
  • Many CMHTs have no social worker
  • 2/3 of people with dementia are cared for in the community with carers losing employment/pensions/lower earning and depression
  • Access to home care restricted
slide46

NICE key priorities

  • Non discrimination
  • Valid consent
  • Carers
  • Coordination and integration of care
  • Memory services
slide47

Key priorities continued

  • Structural imaging
  • Behaviour that challenges
  • Training
  • Mental health needs in acute hospitals
dementia diagnosis
Dementia-Diagnosis
  • History and informant history
    • Mode of onset/course/pattern of impairment
    • Behavioural disturbance-wandering/aggression
    • Co-morbid depression
  • MSE
  • Geriatric depression scale to rule out depression
dementia2
Dementia

Biopsychosocial approach

Aim to keep elderly person in own surroundings as long as possible

Continuing care and support to relatives/carers

Memory clinics

Treat any underlying physical disorders that can lead to acute confusional states

dementia3
Dementia
  • Alzheimer’s- Acetyl-cholinesterase inhibitors-
  • MMSE between 10-20
    • Dose reviewed regularly
  • Treat other co-morbid conditions
  • Anxiety and depression- antidepressants
  • Paranoia and hallucinations-Antipsychotics
  • Behavioural symptoms-antipsychotics,
  • SSRI’s and mood stabilisers
  • Insomnia with hypnotics
dementia management
Dementia-management
  • Psychoeducation
  • Psychological input
    • Behavioural methods, memory aids
  • Day hospitals
  • MDT/CPN/OT/Physiotherapists/Dietician
  • Social services- care assessment of needs and carers assessment
  • Voluntary organizations- Alzheimer\'s soc.
  • Long-term placement
what is mild cognitive impairment or early dementia
What is mild cognitive impairment or early dementia?

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

symptoms of mild cognitive impairment
Symptoms of mild cognitive impairment

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

normal memory loss v mci
Normal memory loss v MCI

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)

most cases of mild cognitive impairment do not become dementia
Most Cases of Mild Cognitive Impairment Do Not Become Dementia

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.

most cases of mild cognitive impairment do not become dementia1
Most Cases of Mild Cognitive Impairment Do Not Become Dementia

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

conclusions
Conclusions
  • Common
  • Important
  • Challenging
  • Community mental health resources
  • Treatments directed at memory syndrome and behavioural complications
  • Supporting families
  • Pursuing the least restrictive options
  • Complex problems to health and social care
  • Permeates all aspects of hospital care
  • Go beyond stereotypes of ageing
what is generalised anxiety disorder

DSM-IV-TR definition

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

irritability

muscle tension

sleep disturbance

ICD-10 definition

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:

persistent nervousness

trembling

muscular tension

sweating

lightheadedness

palpitations

dizziness

epigastric discomfort

What is generalised anxiety disorder?
how common is generalised anxiety disorder
How common is generalised anxiety disorder?

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

Prevalence

Most frequent anxiety disorder in primary care3

Mean 1-month prevalence 7.9%4

Primary care

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

Gender

Frequently chronic3

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

Course

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 of generalised anxiety disorder increases with age
Lifetime prevalence of generalised anxiety disorder increases with age

12

Male

10.3%

10

Female

8

7.2%

7.1%

6.6%

Lifetime prevalence (%)

6

4.7%

4.6%

3.6%

3.6%

4

2.5%

1.5%

2

0

15–24

25–34

35–44

≥45

Total

Age (years)

Wittchen H-U, et al. Arch Gen Psychiatry 1994;51:355-364.

generalised anxiety disorder is often not recognised in primary care
Generalised anxiety disorder is often not recognised in primary care

Mental disorder recognisedbut generalised anxiety disorder not diagnosed

Mental disorder not recognised

28%

38%

34%

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.

generalised anxiety disorder symptoms overview
Generalised anxiety disorder symptoms overview
    • Most people with generalised anxiety disorder experience a combination of symptoms:
      • psychological1–3
      • physical1,2,4
      • behavioural5
  • Often the worry is out of proportion to the likelihood of the event1
  • Symptoms can:
      • vary widely between different individuals
      • wax and wane6
      • become more persistent with age7
psychological symptoms associated with generalised anxiety disorder
Psychological symptoms associated with generalised anxiety disorder

Nervousness, irritability and worrying1

Anxiety1,2

Psychological

symptoms

Difficulty concentrating or mind going blank1,2

Restlessness, tension and inability to relax1

Intolerance of uncertainty3

Poor assessment and response to problems3

physical symptoms associated with generalised anxiety disorder
Physical symptoms associated with generalised anxiety disorder

Gastrointestinal symptoms

e.g. nausea, diarrhoea, irritable bowel syndrome3–5

Insomnia and difficulty falling asleep1,4

Physical

symptoms

Dizziness, light headedness1,2

Pain and muscle tension, aching and soreness1,2,4

Tachycardia, palpitations, sweating2,4

screening for generalised anxiety disorder
Screening for generalised anxiety disorder

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition

ICD-10, International Classification of Diseases, 10th revision.

  • Several self-report questionnaires are available to assist doctors in the detection of generalised anxiety disorder and depression:
    • GAD-2 – quick screening tool for generalised anxiety disorder1
    • GAD-7– screens for generalised anxiety disorder2
    • Hospital Anxiety and Depression Scale (HADS) – screens for anxiety and depression3

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.

before prescribing pharmacological therapy for generalised anxiety disorder
Before prescribing pharmacological therapy for generalised anxiety disorder

Age1

Severity of illness2

Tolerability1

Previous treatmentresponse1,2

Consider…

Cost1,2

Co-occurringdisorders2,3

Possible interactions withconcomitant medications1

Risks of deliberate self-harmor accidental overdose2,3

Patient preference1,2

nice 2011 guidelines for the management of generalised anxiety disorder
NICE 2011: Guidelines for the management of generalised anxiety disorder

STEP 2

STEP 1

STEP 3

STEP 4

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

what is depression
What is depression

Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive symptoms

Key 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:

disturbed sleep

poor concentration or indecisiveness

low self-confidence

poor or increased appetite

suicidal thoughts or acts

agitation or slowing of movements

guilt or self-blame

continued
Continued

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

overlap in symptoms between generalised anxiety disorder and depression
Overlap in symptoms between generalised anxiety disorder and depression

Generalised anxietydisorder

Depressed mood

Apathy

Withdrawal

Loss of interest

Worthlessness/guilt

Weight loss

Suicidality

Anticipatory anxiety

Uncontrollable worry

Irritability

Muscular tension

Tension pains

Physical symptoms

Fatigue

Poor concentration

Sleep disturbances

Restlessness

Agitation

Major depressivedisorder

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington DC: American Psychiatric Association; 2000.

depression aetiology
Depression: aetiology
  • Similar to <65
    • Genetic reduced effect
    • Biochemical amine theory: no consensus
    • Life events
      • Elderly have more of them
      • Bereavements
      • Physical disability & illness
      • Loss of roles/activities
depression prevalence
Depression prevalence
  • Higher than <65
  • 10-20% community prevalence
  • Up to 33% in general hospitals
    • May not be recognised as presents differently
  • Treatable
  • Adverse impact
    • Increased mortality – relative risk 1.6
    • Reduced quality of life
depressive presentations in older patients
Depressive presentations in older patients
  • More somatic complaints
  • Reduced expression of sadness
  • Overlap with physical illness
  • Recent onset of neurotic symptoms
  • “Trivial” self-harm
  • Pseudo-dementia
  • Depression superimposed on dementia
  • Accentuation of personality traits
  • Conduct disorder (behavioural problems)
  • Late onset alcohol dependence syndrome
depression detection
Depression: detection
  • History, examination, informant etc
  • Screening tools
    • Geriatric Depression Scale
      • GDS-30, 15, 10, 8, 5, 1
    • Hospital Anxiety and Depression Scale
      • HAD
    • Brief Assessment Schedule-DEP
      • BAS-DEP
depression treatment
Depression treatment
  • Full range should be available
    • Biological
    • Psychological
    • Social
  • For medication, consider:
    • Side effects
    • Interactions
    • Efficacy
    • Concordance
self harm and suicide
Self harm and suicide
  • 25% of suicides are older people
    • male, living alone, unmarried, physical illness, depression, previous self harm
  • 90% have significant depressive symptoms
  • 60% have physical illness
  • Must be seen by psychiatric services
introduction
Introduction

Definition

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

04/04/2012

risk training.MK/2012

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definition of risk
Definition of Risk

04/04/2012

risk training.MK/2012

79

“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”

(Morgan, 2000)

why is risk my business
Why is risk my business?

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

04/04/2012

risk training.MK/2012

80

what kinds of risk do i need to consider
What kinds of risk do I need to consider?

Direct self harm

Harm to others

Self neglect

Alcohol/drug misuse

Vulnerability/exploitation

Accidental self harm

Harm to property

Arson

Sexual offending

Risk of harm to children

04/04/2012

risk training.MK/2012

81

uk statistics
UK Statistics:

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.

uk statistics1
UK Statistics:

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.

what time frame do i need to consider
What time frame do I need to consider?

Current/short term risk

Long term/historical risk

04/04/2012

risk training.MK/2012

84

risk of suicide
Risk of Suicide

Actuarial 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

04/04/2012

risk training.MK/2012

85

slide86
How do I assess risk? I: Suicide iiMore the self harm resembles the following characteristics, greater risk:

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

Suicide note

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

how do i assess risk i suicide iii risk checklist
How do I assess risk? I: Suicide iii: Risk checklist

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

Separated/widowed/divorced

Expressing suicidal ideas

Unemployment/retired

Considered/planned intent

how do i assess risk i suicide iv assessment
How do I assess risk? I: Suicide iv: Assessment

Interview sequence:

Hope that things will turn out

well

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

day

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

how do i assess risk ii safety to others i risk checklist
How do I assess risk? II: Safety to others I: Risk checklist

Forensic history

Previous incidents of violence

Previous use of weapons

Misuse of drugs and/or alcohol

Male gender, under 35 years of age

Early maladjustment

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.

Poor compliance

Inability to engage in treatment plan

how do i assess risk iii self neglect i sources of information
How do I assess risk? III: Self Neglect i: sources of information

History: from patient, informant history, eating habits, security, financial affairs,

MSE: self care, cognitive functioning

Informal support networks

how do i assess risk iii self neglect i risk checklist
How do I assess risk? III: Self Neglect i: Risk checklist

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

Insufficient/inappropriate clothing

Difficulty maintaining hygiene

Experiencing financial difficulties

Difficulty communicating needs

Denies problems perceived by others

what causes risk
What causes risk?

Clinical diagnosis: depression, mood disorders, schizophrenia, organic conditions

Social circumstances

Alcohol misuse

Drug misuse

Perceived support from formal and informal networks

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risk management
Risk Management

What’s on your radar?

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principles of working with risk
Principles of working with Risk

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

Screening tools

risk rules iii 6 questions
Risk Rules III: 6 questions

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 in clinical management decisions
Risks in clinical management decisions

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

breach confidentiality

alter medication

manage illicit drug misuse

manage alcohol misuse

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what is positive risk management

What is positive risk management?

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Or ?

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positive risk taking i
Positive Risk Taking i

“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.”

positive risk taking ii principles
Positive Risk Taking ii: principles

Weighing up the potential benefits and harm of one choice over another

More empowering

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

positive risk taking iii essential requirements
Positive Risk taking iii: Essential requirements

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.

positive risk taking iv some examples
Positive Risk Taking iv: some examples

Admission to hospital

Periods of leave

Home treatment

Police arrest

Home visiting

Liaison with families

Discharge from service

Medication reduction /withdrawal/self management

Work opportunities

Independent living

“controlled” self harm

Dealing with own finances

Building a social network

Moving on from day care facilities

Going away on holiday

should i use screening tools
Should I use Screening Tools?

YES!

FACE risk assessment

Sainsbury risk assessment tool

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clinical example
Clinical example

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.

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clinical example contd
Clinical example: contd

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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 .

in conclusion
In Conclusion:

Relationship of risk to mental disorder

Short and long term risks

Have a systematic approach in your clinical practice

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